Last Thursday at the Health Care for the Homeless Policy Symposium and Conference, I gave a presentation entitled “Pain Points for the Community Health Center: Integration of Addiction-Informed Pain Management Services into Primary Care.” I opened the presentation with a story about one of my patients: quadriplegic and using a wheelchair due to gunshot wounds, the patient was suffering with bedsores that went all the way to the bone. His catheter, he explained, had been blocked for some time. I asked how he managed to urinate and he responded that the urine was leaking out from his back. I was incredulous; it seemed impossible physiologically. But after an examination, I discovered the patient’s fistula, and I came to the tragic conclusion that the man was right. While this story may seem shocking and atypical to many people, to those of us who work with vulnerable populations, this is, as one audience member put it, “just another Tuesday for us.”
As providers, we often ask ourselves how to treat pain of this magnitude. Our patients’ pain goes beyond the simple broken ankle or sore back: many have been touched by violence, sexual and physical abuse and other hardship. A history of substance abuse, in particular, presents a challenge: concerns about relapse while on chronic opioid therapy, confusion among “drug-seeking” behaviors and addiction, and a lack of evidence-based guidelines for management of pain in patients with history of substance abuse, make treatment a delicate balancing act. The use of opioids for chronic pain management is especially controversial, with some providers fearing addiction that may lead to other drug abuse, like heroin, along with incentive for theft or sale on the street. Some believe that the risks override the potential for pain relief that opioids provide.
At Brightpoint Health we are committed to reducing our patients’ pain and suffering, improving their quality of life, and minimizing their risk of adverse effects, including addiction. However, we believe that reducing pain and suffering includes providing opioids for patients with a history of substance abuse when appropriate, and in a highly structured setting. As a leading nonprofit provider of high-quality health care and social support services, we serve over 40,000 New Yorkers, of whom approximately 75% have a history of substance abuse. To ensure our patients receive the right treatment, Brightpoint has integrated specialty pain management into its services to help us make what can sometimes be a difficult call. As my colleague Carol Murphy outlined in her presentation, “Using an Integrated Care Team to Improve Treatment Adherence in a Substance Using Population,” our pain management specialist works with primary care, behavioral health and our health home to form an integrated care team that monitors, supports and retains patients in their care continuum.
To determine the right course of treatment for a pain patient, Brightpoint staff use a comprehensive risk assessment and objective and subjective screening tools. We monitor the 4 A’s: Analgesia (pain relief), Activities of daily living, Adverse effects, and Aberrant behavior (patient behavior that raises the possibility of abuse) throughout treatment. Brightpoint’s addiction-informed integrated pain management services aim to address patients holistically and enhance quality of life.
Other monitoring tools I use include toxicology screening for all patients, pill counts, consultation with I-STOP and one-on-one patient meetings with our pain management specialist. All monitoring is further supported by consistent communication across a patient’s integrated care team.
At the end of the presentation, an audience member posed a question to me: “Is there any sort of ‘holy grail’ of correct pain treatment for our patients?” “Nope,” I replied, met with empathetic laughter from the audience. While there is no one simple answer to such a multifaceted problem, we do know that person-centered integrated care produces better health outcomes. Brightpoint delivers addiction-informed integrated pain management services to our patients with dignity and respect, ultimately enhancing their quality of life.