Optimizing Opioid Therapy for Patients with Behavioral Health Disorders

According to the CDC, chronic pain is a risk factor for suicidality.^1,2,3 Studies indicate several additional factors as potential predicators of increased suicide risk in chronic pain patients, including depression, anger, unemployment/disability, harmful health habits, challenging personal and family history, sleep problems, poor perceived mental health, and multiple chronic pain conditions. Newly identified psychosocial factors, including pain catastrophizing, hopelessness, and perceived burdensomeness also appear to be associated with suicidality.² On a positive note, many suicide risk factors can be addressed through an individualized chronic pain management program.²

Overdose on pain medications is the number one plan for chronic pain patients contemplating suicide.³ Given the access many chronic pain patients have to large quantities of opiates, it is essential to understand suicide risk factors of opioid prescribing in chronic pain patients.²

Allegation

The FP negligently failed to manage the patient’s pain and behavioral health issues, resulting in suicide.

Case File

The patient was a long-term patient of an FP who treated her depression and anxiety. Her health history was otherwise unremarkable. However, in February 2016, the patient injured her back. Her FP referred her to an orthopedic surgeon (OS), who diagnosed her with degenerative disc disease and prescribed oxycodone to relieve her back pain. In January 2017, however, the OS refused to continue prescribing oxycodone, because he felt the patient had developed an OUD. The OS referred her to a pain management specialist, who switched her from oxycodone to morphine for pain management.

In February 2017, the patient begged her FP to prescribe something for breakthrough pain. Because the patient seemed desperate for relief, the FP gave the patient meperidine injections every few weeks at the patient’s request. However, in July 2017, the pain management specialist asked the FP to stop giving the patient meperidine injections. At the patient’s next appointment, when she requested an injection, the FP refused. That evening, the patient overdosed on a combination of prescription opioids and other medications and died. She left a suicide note indicating she could no longer live with her back pain. The patient’s husband filed a wrongful death lawsuit against the FP and pain management specialist, contending they negligently failed to manage her pain and behavioral health issues, which resulted in suicide.

Discussion

A major obstacle to defending this claim was the incomplete medical records. In addition to the general documentation problems, experts could not support the FP’s care of the patient for a number of reasons, including:

• Prescribing psychiatric medications without a treatment plan or behavioral health assessments
• Failing to assess the patient for suicide risk
• Injecting meperidine without consulting the OS or pain management specialist, performing diagnostic examinations, or conducting any pain assessments
• Failing to integrate the patient’s behavioral health and pain treatment or coordinate her treatment

Had an integrated treatment plan been created and followed, a comprehensive approach to managing the patient’s pain and depression might have been used, and her suicide might have been averted.

Risk Reduction Strategies

Depression can play a crucial role in suicide risk for patients with chronic pain.² Studies indicate that chronic pain can trigger and exacerbate existing depression, and that depression can cause and worsen pain.^4,5 Opioids alone may cause depression in certain patients.⁶ Consider the following risk management strategies for optimizing safe outcomes when treating chronic pain patients with comorbid behavioral health disorders:^3,5,7

• Assess the patient’s behavioral health and suicide risk.
  • Select assessment instruments that fit the structure and time constraints of the practice.
    • There are many suicide risk assessment tools, e.g., Suicidal Behaviors Questionnaire-Revised (SBQ-R), Columbia-Suicide Severity Rating Scale (C-SSRS), and SAFE-T with C-SSRS.
    • A number of different tools are available to assess a patient’s level of depression. Studies indicate that, in primary care, the Patient Health Questionnaire (PHQ-9) detects depression with sensitivity around 90% and specificity ranging from 77% to 88%. The Initiative on Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) consensus group on measuring emotional functioning in chronic pain trials recommended the Beck Depression Inventory (BDI) and the Profile of Mood States (POMS).³
  • Monitor and treat the patient’s behavioral health disorders as an element of pain management.
  • Refer to a behavioral health professional when appropriate.
    • Document the referral and confirmation that the consultant has agreed to provide care to the patient.
    • Have follow-up mechanisms in place to ensure that patients have accessed referred services.
    • Request treatment updates from the behavioral health consultant.
    • Make facilitating communication with consultants part of the treatment plan.
  • Have a suicide prevention plan ready as part of the treatment plan.
    • Refer patients with suicidal ideation to inpatient treatment when appropriate.
  • Consider the patient’s suicide risk before tapering or discontinuing pain medications.
  • Coordinate the patient’s pain management and behavioral healthcare management unless another clinician has been designated to do so.
  • Document suicide and behavioral health assessments and mitigation.

It’s important to note that proposing risk reduction strategies for pain management comes with the acknowledgement that some primary care practices may face limited referral options, insurance coverage for various pain management modalities, and clinician time to manage cases. It is important to realize, however, that lack of resources, insurance, options, etc. are not valid defenses to medical negligence. Primary care physicians cannot abdicate responsibility to address a patient’s complaints of pain — keeping in mind that addressing pain does not mean curing pain. Expectation management is important for all pain management patients, but crucial for legacy patients (patients who have been on long-term opioid therapy) in practices with limited resources. If a particular patient’s pain management is outside a physician’s scope, or resources cannot be accessed, the physician has to communicate that clearly and compassionately. A physician can state the needed care is “past my area of expertise and I need help managing your condition in the safest way possible.”

Appropriate documentation of efforts to accomplish pain management in a manner consistent with the standard of care is a crucial aspect of liability risk management in difficult circumstances. At a minimum, medical record documentation should include efforts to coordinate care and refer to specialists, the results of those efforts, and patient response to those efforts, as well as conversations with patients about waiting periods for specialty care referral and what can and cannot be done in the meantime.

References

1. Centers for Disease Control and Prevention. “Risk and Protective Factors.” Page last reviewed: August 5, 2022.

2. Mélanie Racine. “Chronic Pain and Suicide Risk: A Comprehensive Review.” Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2018 Dec 20;87(Pt B):269-280. DOI: 10.1016/j.pnpbp.2017.08.020.

3. Martin D. Cheatle. “Depression, Chronic Pain, and Suicide by Overdose: On the Edge.” Pain Medicine. 2011 Jun; 12(Suppl 2): S43–S48. DOI: 10.1111/j.1526-4637.2011.01131.x.

4. Jiyao Sheng, Shui Liu, et al. “The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain.” Neural Plasticity. 2017;2017:9724371. DOI: 10.1155/2017/9724371.

5. Robert J. Gatchel, Jeffrey Dersh, et al. “Psychological Disorders and Chronic Pain: Are There Cause-and-Effect Relationships?” In D.C. Turk and R.J. Gatchel, (Eds.), Psychological Approaches to Pain Management: A Practitioner’s Handbook. 3rd Ed. New York, NY: Guilford Publications; 2018. 33–52.

6. Graham Mazereeuw, Mark Sullivan, et al. “Depression In Chronic Pain: Might Opioids Be Responsible?” Pain. 2018;159(11):2142-2145. DOI: 10.1097/j.pain.0000000000001305.

7. Substance Abuse and Mental Health Services Administration. “TIP 54: Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders.” U.S. Department of Health and Human Services. Treatment Improvement Protocol (TIP) Series. Publication ID: SMA13-4671. 2012.