National Health Care for the Homeless Council, Inc.
Full Text Guideline
Recommended Clinical Practice Adaptations
- Focus primarily on fostering a therapeutic alliance at the initial encounter, recognizing that this may be the only opportunity to engage a homeless patient in ongoing care. Use the initial visit as a critical opportunity to engage the patient and establish trust.
- Ask about physical and mental health (including history of traumatic brain injury/substance use), history of chronic pain, and living situation (including residential stability).
- Defer the physical examination to the second visit, if needed, or keep the initial exam focused on the area of concern. Perform serial focused exams (as tolerated), if needed. Look for evidence of occult alcoholism or addiction.
- Practice trauma-informed care during the physical examination and in all patient encounters, recognizing that individuals who are homeless are likely to have experienced some form of previous trauma.
Assessment, Screening and Diagnostic Testing
- Assess every chronic pain patient for substance use and mental health issues. Based on prevalence of behavioral health issues in the patient population served as well as provider and staff resources and experience, weigh benefits and costs of using standardized screening tools.
- Use urine drug tests (UDT) as an additional tool in initial assessment for substance use disorders and in the ongoing evaluation of patient outcomes. Use UDT and pill counts carefully and strategically to monitor treatment adherence and to minimize diversion, misuse, and abuse for patients on chronic opioid therapy (COT). Use a universal precautions approach to initial and ongoing assessment of all patients with persistent pain, particularly those receiving opioid analgesics.
Plan of Care
- Jointly identify indicators of functional improvement with the patient to help determine whether the plan of care is "working." Develop a plan emphasizing holistic treatment with multiple modalities; assure patient understanding of the treatment plan; modify in response to functional change or if problems arise.
- Determine the patient's stage of change and how behavioral health problems are contributing to chronic pain. Include a behavioral health care plan in the plan of care.
- Plan for safe storage of medication and adaptation of prescribing/dispensing practices, as needed.
- Review fundamental concepts of chronic pain management at every visit.
- Consider group visits as a vehicle for patient education; develop a core curriculum for all patients supplemented by special groups for those with higher needs.
- Educate providers about prescribing opioid analgesics to homeless persons with substance use disorders and adaptation of prescribing/dispensing practices, as needed.
- Emphasize setting reasonable, attainable, short-term self-management goals while working toward long-term goals. Use motivational enhancement techniques to help patients resolve ambivalence about behavioral change.
- Select treatment based on context and available resources (e.g., street/shelter, bare-bones poorly resourced health center, full-service ambulatory clinic with access to specialists, well-equipped hospital/medical respite program).
- Encourage early and ongoing non-pharmacologic treatment. Address psychosocial needs.
- Choose non-opioid pharmacologic interventions based on etiology of pain, co-morbid conditions, medications, and other factors, some of which are more common among homeless people.
- Apply other guidelines cited in this document on use of opioids for chronic pain, with particular attention to identifying psychosocial factors that may complicate their use for homeless persons; structure monitoring and follow-up to address those factors.
- To promote successful use of opioid analgesics by homeless patients, use a written treatment plan, patient provider agreement/informed consent (assuring that patients understand them), a multidisciplinary care team, and a consistently nonjudgmental approach to behaviors outside treatment plan.
Associated Problems, Complications
- Monitor functional status closely and investigate any decline, which has a broad differential diagnosis but may indicate active substance abuse.
- Use a nonjudgmental approach to explore behaviors outside the treatment plan, which may indicate diversion or misuse of medications, and a harm reduction approach when addressing them. Recognize that a more structured treatment plan and/or discontinuation of opioids is/are sometimes indicated.
- Determine frequency of follow-up based on stability of the patient and his/her living situation and risk of misuse. For patients with comorbid behavioral health issues who are receiving COT, more frequent visits with random urine drug tests may be necessary. In general, opioid prescriptions should be of shorter duration (1 month or less) to help reduce risk of diversion/overdose/loss of medications.
- At each visit, assess for behaviors outside the treatment plan, including a psychosocial assessment. Consider causes related to homelessness — missed appointments due to competing priorities or unexpected events (e.g., in jail, delayed by another appointment), stolen medications (e.g., assault, theft in shelter).
- Refer homeless patients to medical respite/convalescent care facilities and facilitate entry into permanent supportive housing, to reduce problems and complications associated with chronic pain.
Recommended Programmatic Adaptations
Service Delivery Design
Optimum design includes the following:
- Use integrated care and multidisciplinary clinical teams.
- Given the challenges and risks of opioid analgesics, the central role of behavioral approaches in chronic pain management, and the benefits of non-pharmacologic interventions, develop and utilize strategies for effective pain management other than or in addition to chronic opioid therapy. Consider combining opioids with non-opioids for synergistic or additive effects.
- Ensure that all clinical service providers know the basics of chronic pain management and have appropriate skills to work with persons experiencing homelessness, including trauma-informed care.
- Develop policies and procedures to improve treatment effectiveness, clinic safety, and satisfaction of staff and patients, including patient registries and case review mechanisms to promote appropriate tracking and follow up, identify/address repeated behaviors outside the treatment plan, and provide support for staff.
- Develop relationships with outside partners and/or hire/train staff to provide services – e.g., pharmacy or program that can dispense medications weekly or more often, addiction medicine specialist, pain clinic, cognitive behavioral therapist, physical/occupational therapist, acupuncturist.
Outreach and Engagement
- Focus on the pain, not the pill. Where pain medicines are sought, explore the patient's expectations, experience, and potential to benefit.
- Consider using a member of the care team other than the primary care provider (behavioral health counselor, acupuncturist, panel manager, occupational therapist, nurse, social worker, case manager) as the primary contact person for the patient, to lower potential access/communication barriers.
Standards of Care
- Adapt clinical practices to optimize care for patients who are homeless or at risk of becoming homeless, considering the recommendations contained in this guide.
- Integrate service with advocacy to improve access for homeless people to a broader range of interventions for chronic pain management. Address structural causes of homelessness. Involve service providers and recipients in advocacy.
Transitions of Care
From hospitals to medical respite/recuperative care:
- Confirm that long- and short-acting pain medications are prescribed by the hospital discharge team, and that at least a 7-day supply of medication is dispensed to the patient at discharge.
- Coordinate appropriate follow-up care for community provider(s) who will be prescribing medication before accepting the patient into a medical respite program following hospital discharge.
Evidence Supporting the Recommendations
The practice adaptations recommended in this document are based on a comprehensive review of published reports and consensus opinion of clinicians with expertise in homeless health care, treatment of chronic pain, and addiction medicine.
The primary sources for these recommendations are six sets of guidelines for chronic noncancer pain management (see the "Adaptation" field for full citations).
Implementation of the Guideline
An implementation strategy was not provided.
Foreign Language Translations
Staff Training/Competency Material
Benefits/Harms of Implementing the Guideline Recommendations
Appropriate evaluation and management of non-malignant pain in homeless adults
Adverse effects from opioid medications include falls, oversedation, overdose requiring emergency services, drug-drug interactions, constipation, itching, nausea/vomiting, mental cloudiness, sweating, fatigue, and drowsiness.
See the table "Non-opioid Medications for the Management of Chronic Pain" in the original guideline document for additional cautions regarding non-opioid medication use in specific populations.
Rating Scheme for the Strength of the Recommendations
- The information and opinions expressed in the guideline are those of the Advisory Committee on Adapting Clinical Practices for Homeless Patients, not necessarily the views of the U.S. Department of Health and Human Services, the Health Resources and Services Administration, or the National Health Care for the Homeless Council, Inc.
- The recommendations in this document specify what experienced clinicians know works best for patients experiencing homelessness, with the realistic understanding that limited resources, fragmented health care delivery systems, and loss to follow-up often compromise adherence to optimal clinical practices. We hope these recommendations provide helpful guidance to health care professionals serving adults with chronic non-malignant pain who are homeless or at risk of homelessness, and that they will contribute to improvements in both quality of care and quality of life for these patients.
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
The development of these guidelines included a literature search of PubMed using the following key words:
- homeless + health
- chronic pain
- homeless + pain
- pain + stress
- stress + homeless
The timeframe of the literature search was approximately September 2009 to June 2011.
References were also identified through online searches of current pain guidelines, bibliographies of relevant reports and publications from the National Health Care for the Homeless Council (www.nhchc.org). References cited in the guidelines were ultimately selected by the advisory committee. Selection was based on the judgment of these experienced homeless services providers regarding the validity, significance, and usefulness of the publications to clinicians whose patients include individuals who are homeless or at risk of homelessness.
This guideline is adapted from 6 primary sources.
Chronic pain management for homeless and other marginalized people was identified as a Network training priority in 2008. A literature review revealed knowledge gaps in this area and responses to a survey of homeless services providers conducted in 2010 revealed both knowledge and practice limitations. The 101 participants in this survey were from 26 states in the U.S. and one province in Canada. Results showed that these providers were uncomfortable prescribing opioid analgesics for pain, lacked access to nonpharmacological pain interventions, and lacked resources for optimal pain management. (A report of survey results can be found on the National Health Care for the Homeless [HCH] Council website at www.nhchc.org.) In 2011, an advisory committee comprised of 16 health and social service providers experienced in chronic pain management for underserved populations was convened to develop clinical and programmatic recommendations for the care of homeless adults with chronic non-malignant pain. These recommended practice adaptations reflect their collective judgment about optimal pain management interventions for this population.
Published cost analyses were reviewed.
External Peer Review
Internal Peer Review
The guideline developer's Advisory Committee identifies, in the original guideline document, the clinicians who reviewed and commented on the draft recommendations prior to publication.
These recommendations of the Healthcare for the Homeless (HCH) Clinicians' Network were approved by the Advisory Committee on Adapting Clinical Practice for Homeless Adults with Chronic Non-Malignant Pain, whose members have expertise in homeless health care, treatment of chronic pain, and addiction medicine.
Identifying Information and Availability
Wismer B, Amann T, Diaz R, Eisen D, Elder N, Ho C, Hwang S, Johnston M, Joslyn M, Kertesz S, Kushel M, Preston C, Solotoroff R, Thompson L, Silva F, Smith S, Zevin B, Meinbresse M, Post P, editor(s). Adapting your practice: recommendations for the care of homeless adults with chronic non-malignant pain. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2011. 119 p.
This guideline is adapted from the following primary sources:
- Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al.; American Pain Society-American Academy of Pain Medicine (APS-AAPM) Opioids Guidelines Panel. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. Journal of Pain. 2009;10(2):113-130. http://www.jpain.org/article/S1526-5900%2808%2900831-6/fulltext
- Berland DW, Rodgers PE, Green CR, Harrison RV, Roth RS; University of Michigan Health System (UMHS) Clinical Care Guidelines. Managing Chronic Non-Terminal Pain – Including Prescribing Controlled Substances. http://www.med.umich.edu/1info/fhp/practiceguides/pain.html
- Institute for Clinical Systems Improvement (ICSI). Assessment and Management of Chronic Pain. 2009. http://www.icsi.org/guidelines_and_more/gl_os_prot/musculo-skeletal/
- Labby D, Koder M, Amann T; prepared for CareOregon, Inc. Opioids and Chronic Non-Malignant Pain: A Clinician's Handbook. 2003. http://www.careoregon.org/Res/Documents/Providers/Opioids_Pain_Management.pdf
- U.S. Department of Veterans Affairs, Department of Defense (VA/DoD). Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010. http://www.healthquality.va.gov/Chronic_Opioid_Therapy_COT.asp
- Washington State Agency Medical Directors' Group (AMDG), Washington State Department of Labor and Industries. Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. 2010. http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf, http://www.agencymeddirectors.wa.gov/opioiddosing.asp
Note: In general, treatment recommendations found in these standard practice guidelines are not restated in this document except to clarify a particular practice adaptation or to emphasize practices that are especially important in homeless health care.
National Healthcare for the Homeless Council, Inc.
Advisory Committee on Adapting Clinical Practice for Homeless Adults with Chronic Non-Malignant Pain
Advisory Committee Members: Barbara Wismer, MD, MPH (Chair), Physician, Internal & Preventive Medicine, Tom Waddell Health Center/Homeless Programs, San Francisco Department of Public Health, San Francisco, California; Ted Amann, MPH, RN, Director of Healthcare, FQHC Project Director, Central City Concern, Portland, Oregon; Rachel Diaz, MSW, LAc, LICSW, CDPT, Social Worker, Acupuncturist, Chemical Dependency Specialist, Former Acupuncture Program Manager, Evergreen Treatment Services, Seattle, Washington; David C. Eisen, LAc, MSW, OMD(am), Executive Director, Acupuncturist, Quest Center for Integrative Health, Portland, Oregon; Nancy C. Elder, MD, MSPH, Medical Director, Health Care for the Homeless, Program/Cincinnati Health Network, Associate Professor and Director of Research, Department of Family & Community Medicine, University of Cincinnati, Cincinnati, Ohio; Cheryl J. Ho, MD, Medical Director, Valley Homeless Healthcare Program, Santa Clara Valley Health & Hospital System, San Jose, California; Stephen Hwang, MD, MPH, Research Scientist & Staff Physician, General Internal Medicine, Saint Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Meredith Johnston, MD, Staff Psychiatrist, Health Care for the Homeless, Inc., Baltimore, Maryland; Matthew Joslyn, MD, Staff Clinician, Boston Health Care for the Homeless Program, Boston, Massachusetts; Stefan Kertesz, MD, MSc, Associate Professor, Preventive & General Internal Medicine, University of Alabama, Birmingham, Alabama; Margot Kushel, MD, Associate Professor of Medicine in Residence, General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, California; Charles Preston, PhD, Lead Psychologist, Valley Homeless Healthcare Program, Santa Clara Valley Health & Hospital System, San Jose, California; Frank Silva, RPh, Pharmacist, Albuquerque Health Care for the Homeless, Inc.; Frank Roland, RPh, PharmD Candidate 2011, University of New Mexico, Albuquerque, New Mexico; Shannon Smith, RN, MSN, CNL, Coordinator, San Francisco Sobering Center & Medical Respite Program, San Francisco Department of Public Health/Housing and Urban Health, San Francisco, California; Rachel Solotaroff, MD, Medical Director, Central City Concern, Assistant Professor of Medicine, Oregon Health & Science University, Portland, Oregon; Lisa Thompson, DNP, PMHNP-BC, Psychiatric Nurse Practitioner, Colorado Coalition for the Homeless, Denver, Colorado; Barry Zevin, MD, Physician Specialist, Lead in Addiction Medicine, Tom Waddell Health Center, San Francisco Department of Public Health, San Francisco, California; Molly Meinbresse, MPH, Program and Research Specialist, National Health Care for the Homeless Council, Nashville, Tennessee; Patricia A. Post, MPA, Editor, Adapting Your Practice series, HCH Clinicians' Network, National Health Care
The Heath Care for the Homeless (HCH) Clinicians' Network has a stated policy concerning conflict of interest. First, that all transactions will be conducted in a manner to avoid any conflict of interest. Secondly, should situations arise where a member is involved in activities, practices or other acts which conflict with the interests of the Network and its Membership, the member is required to disclose such conflicts of interest, and excuse him or herself from particular decisions where such conflicts of interest exist.
It is the policy of the National Health Care for the Homeless Council to require authors of its educational publications to disclose financial relationships with relevant commercial entities and to identify and resolve any related conflicts of interest. The authors reported no such relationships or conflicts of interest. The content of this document is educational and based on clinical experience or rigorous scientific evidence. It was developed independent of commercial influence.
This is the current release of the guideline.
Electronic copies: Available in Portable Document Format (PDF) from the National Health Care for the Homeless Council, Inc. Web site.
Print copies: Available from the National Health Care for the Homeless Council, Inc., P. O. Box 60427, Nashville, TN 37206-0427; Phone: (615) 226-2292
Case studies are available in the original guideline document.
A variety of tools and forms, including patient consent forms in several languages, mental health and substance abuse screening tools, nursing assessment forms, and a drug formulary, are available in the appendices to the original guideline document.
This NGC summary was completed by ECRI Institute on December 6, 2011. This summary was updated by ECRI Institute on June 2, 2016 following the U.S. Food and Drug Administration advisory on Opioid pain medicines.
All material in this document is in the public domain and may be used and reprinted without special permission. Citation as to source, however, is appreciated. Suggested citation: Wismer B, Amann T, Diaz R, Eisen D, Elder N, Ho C, Hwang S, Johnston M, Joslyn M, Kertesz S, Kushel M, Preston C, Solotoroff R, Thompson L, Silva F, Smith S, Zevin B, Meinbresse M, Post P (Ed.). Adapting Your Practice: Recommendations for the Care of Homeless Adults with Chronic Non-Malignant Pain, 128 pages. Nashville: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc., 2011.
Chronic non-malignant pain
Advanced Practice Nurses
Allied Health Personnel
Emergency Medical Technicians/Paramedics
Health Care Providers
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
- To provide helpful guidance to health care professionals serving adults with chronic non-malignant pain who are homeless or at risk of homelessness, and that they will contribute to improvements in both quality of care and quality of life for these patients
- To enhance understanding of optimal chronic pain management among experienced homeless services providers and among primary care providers who are less experienced in the care of homeless and other marginalized people
- To facilitate adherence to these standards in the care of impoverished, displaced persons with multiple medical and psychosocial problems
Adults with chronic non-malignant pain who are homeless or at risk of homelessness
- Fostering a therapeutic alliance with the patient
- History, including physical and mental health (history of traumatic brain injury/substance abuse), history of chronic pain, living situation
- Physical examination with trauma-informed care, including initial exam, comprehensive and serial, focused exams, and physical origin of pain
- Assessment, screening and diagnostic testing, including urine drug testing
- Establishment of patient-centered goals and treatment regimens
- Reviewing concepts of pain management
- Patient education program and self-management practices
- Educating providers about prescribing practices
- Non-pharmacologic treatment, including cognitive behavioral therapy (CBT) and acupuncture
- Pharmacologic treatment, including use of opioids and non-opioids
- Monitoring functional status
- Nonjudgmental approach to behaviors outside the treatment plan
- Follow-up care
- Quality of life
- Functional status
- Opioid use/misuse
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.
- March 22, 2016 – Opioid pain medicines: The U.S. Food and Drug Administration (FDA) is warning about several safety issues with the entire class of opioid pain medicines. These safety risks are potentially harmful interactions with numerous other medications, problems with the adrenal glands, and decreased sex hormone levels. They are requiring changes to the labels of all opioid drugs to warn about these risks.
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