Over the past year, Massachusetts physicians have increasingly taken advantage of a consultation service to assist them with challenges involved in treating patients with chronic pain, substance use disorders, or the particularly vexing combination of the two.
A hotline similar in concept to a longstanding Massachusetts service to help pediatricians with questions on child mental health issues, the Massachusetts Consultation Service for Treatment of Addiction and Pain (MCSTAP) launched in January and has seen a steadily growing volume of inquiries. MCSTAP's medical director tells Addiction Professional that the content of the calls tells him that most doctors want not to refer their complex patients elsewhere, but to possess tools enabling them to work more effectively with them.
“Most are looking to talk; it's not as much for referral,” says Christopher Shanahan, MD, MPH, an assistant professor of medicine at Boston University. “They want the hand-holding.”
Many of these physicians have had longstanding professional relationships with the patients they are inquiring about, Shanahan says, so they would not simply give up on these cases.
The Massachusetts state government is funding the service through a contract with the Massachusetts Behavioral Health Partnership, a unit of behavioral health services company Beacon Health Options.
Data from an analysis of 93 individual callers from the service's inception through September found that around one-third were repeat callers (either regarding the same patient or a different patient). Just over half the calls have been from physicians, with one-quarter from nurse practitioners and the rest from a wide combination of providers.
Forty-eight percent of the calls have concerned chronic pain, 30% have focused on substance use disorders, and 19% have addressed a combination of the two, Shanahan says. He hopes that if physicians begin to grow more comfortable with topics around substance use disorders, more will be inclined to treat the illness rather than immediately seek referral options.
How service works
A caller to MCSTAP (833-724-6783) during the available business hours on weekdays between 9 am and 5 pm speaks with a resource specialist, who then relays the nature of the inquiry by text to whichever of the service's 10 physicians is on call at that time. Shanahan says all of the physicians have primary care practice experience, mostly in traditional settings.
The consulting physician tries to get a quick read on how much time the inquiring provider has, so the conversation can be tailored to the time available. “I teach my docs to find out if the patient is there at the time,” Shanahan says.
Providers are encouraged to call back when necessary. “These [patients] are projects. They're not one-and-dones,” he says.
Callers with a focus on pain issues often ask questions about opioid titration and tapering, or advice on how to manage patients who have been on high doses of long-acting opioids. Callers with a focus on substance use disorders might ask about buprenorphine or naltrexone induction, for example.
Shanahan says there remains much misunderstanding about aspects of medication treatment in the medical community, such as the mistaken notion that a patient on buprenorphine should be taken off the medication in preparation for surgery and the post-operative medications that may have to be prescribed.
Spreading the word
At the outset the service was fielding two to three calls a week, and the volume has been slowly climbing. Shanahan says similar services are available in a handful of other states, including Maryland and Ohio. Most offer some combination of a hotline and broader provider education.
MCSTAP has been getting the word out mainly through talks to doctors' groups, hospital organizations and specialty group practices. The Massachusetts Medical Society recently endorsed the service and encouraged all primary care physicians in the state to make use of it. The growing interest level from a diversity of providers clearly demonstrates the degree to which patients with pain and/or substance use disorders touch every level and specialty within the health care system.