Coordination of Care, Reduction of Polypharmacy Can Simplify a 'Complex Patient'

LAS VEGAS—Properly managing complex patients can save time and money, and help patients, according to Darren McCoy, FNP-BC, CPE.

“Complex patients are those patients who worry you the most,” explained McCoy to attendees of PAINWeek 2014: patients who are taking high doses of opioids, which you may have started or are ‘inheriting,' or who have multiple and interacting pain issues that can “feed” off each other, as well as social problems, mental health issues, or time-consuming personality issues.

Complex patients' care “take time, and time is money,” he said.

“Primary care physicians identified 26% of their patients as ‘complex,'” he noted. “In younger patients, issues like mental health and substance abuse were the complicating factors; in older patients, multiple disease processes, medical decision-making, and coordination of care made them more complex.”

In most cases, these are not “bad people,” McCoy emphasized, “but rather bad situations which could have been avoided.” Difficult situations can include unreliable transportation issues or painful conditions that feed off one another like an old traumatic injury affecting gait and causing mechanical back pain, he explained. Or family members might resist “quite reasonable” treatment plans involving, for example, multiple hydrocodone tabs each day.

Polypharmacy is another complicating factor. “It's not unusual to see a patient who is taking 10 to 20 different meds a day,” McCoy noted. “Reducing the number of different medications a patient is taking is one of the easiest way to simplify care.”

Problems can also be systems-of-care related: a pain clinic may close, or a patient's prior provider may have retired, for example. Complex patients may have been dismissed from a prior practice after missing a drug test or pill count.

Comorbid illnesses can contribute to a patient's case complexity, as well. For example, sleep apnea limits the relative safety of benzodiazepines, sedating antidepressants like trazodone, and opioids.

“Problems may affect a given patient's ability to take advantage of a variety of pain therapies,” McCoy added. “Open wounds and urinary or fecal incontinence? No aquatic physical therapy. Recent MI or stents, or anticoagulants limit interventional options.”

Ultimately, pain management “involves addressing the intimate, dynamic interaction of physiologic processes like nerve damage or inflammation, and emotion, as modulated by social/behavioral context,” he said. “Not just what hurts, but why and when.”

Reducing the number of medications and reducing dose are two opportunities for simplifying treatment, he said. But unfortunately, there is no single, simple formula for learning how to manage complex patients.

"Look for mentors,” McCoy advised. “There are not a lot of them, but roughly 4,000 physicians in the US are board-certified in the specialty of pain medicine. If you are completely new to practice or at least just getting involved with pain management as part of your practice, reach out to them and see if you can arrange a few days to ‘shadow' them.”

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