Difficult Conversations about Opioids

[101N]

The attached is an excellent resource for PCP who plan to have a difficult conversation about opioids. Thanks to Group Health for this.

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[chibadriver]

This is great! I am just developing a presentation for my referring PCPs now, I will post when complete.

 

[thecentral09]

The attached is an excellent resource for PCP who plan to have a difficult conversation about opioids. Thanks to Group Health for this.

Thanks for sharing. T

 

[epidural man]

I learned a great line from someone here on SDN (sorry I can't remember who said it - you deserve props though).

They use it with regards to fibromyalgia, but I now use it with opioids.

"I am so sorry. I find I'm not very good at getting patients to respond to opioids. When I give them out, patients never get better at it, and they always seem to want to increase dosages. Because of my failures, I just decided I shouldn't even try any more, since I'm not good at it." Haha. I love it. How can a patient complain about that? Put the failure on you - not them.

 

[hello1234!]

I'm always interested to see advise about pain management. The number of new pts I get that are on benzos, narcotics, and muscle relaxers (the holy trinity) is high. I still can't get over the number of new pts I get that are over 65 and take norco with their ambien at night ... .

 

[Aether2000]

When prescribing opioids, you have the power to say no. If they are taking stupid combinations from other physicians, then you can tell them either stop drug x or drug y- if not, you will stop prescribing opioids. Usually they comply. Check the PMP thereafter monthly.

 

[101N]

I think we've lost the power to say no over the past 30yrs. The graph below is from the 2014 CMS data for PCPs who refer to my clinic. The Y axis is the % of all Rx'ers - sums
to 100% - and the X axis is the decile they fall into from 10% to 90% for their specialty. To be clear, a 10% percentile Rx's is in the lowest 10% opioid prescribing for their specialty
and a 90% percentile is in the highest 10% for their specialty. If the data were normal you would expect a bell distribution. The profound skew to the right illustrates a
a cultural problem. (Note none of these folks have explicit financial incentives to prescribe this way. They don't do injections, aren't subject to PG, and they don't
own their own UDS lab.)

I just watched Dr. Feelgood: healer or dealer. Hurwitz's narcissism is palpable in the language he uses to describe his prescribing - innovative, "I beat the medical board.", etc -
and I think a lot of the people who skew far to the right in the Rx'ing also suffer from that flaw. They have some weird god complex that is beyond simple COI.

 

[drusso]

I think we've lost the power to say no over the past 30yrs. The graph below is from the 2014 CMS data for PCPs who refer to my clinic. The Y axis is the % of all Rx'ers - sums
to 100% - and the X axis is the decile they fall into from 10% to 90% for their specialty. To be clear, a 10% percentile Rx's is in the lowest 10% opioid prescribing for their specialty
and a 90% percentile is in the highest 10% for their specialty. If the data were normal you would expect a bell distribution. The profound skew to the right illustrates a
a cultural problem. (Note none of these folks have explicit financial incentives to prescribe this way. They don't do injections, aren't subject to PG, and they don't
own their own UDS lab.)

I just watched Dr. Feelgood: healer or dealer. Hurwitz's narcissism is palpable in the language he uses to describe his prescribing - innovative, "I beat the medical board.", etc -
and I think a lot of the people who skew far to the right in the Rx'ing also suffer from that flaw. They have some weird god complex that is beyond simple COI.

Bingo. Did anyone ever REALLY believe that doing injections, earning a satisfaction score, or maintaining continuity of care ancillary services created COI for RX'ing opioids? That was all population-based Kabuki and fake news conjured to advance a political agenda to control doctors. Think it through: You sink a million dollars into starting a business or adding an ancillary and you're going to throw it away on an addict?

In my experience, only a small number of problem prescribers are sociopathic. The vast majority are just "over their heads," and often have boundary issues in number of other areas in their life--family/marriage, business, community, etc.

 

[EruditeDoc]

It would be optimal if those PCPs who are "in over their heads" would just send the patient's too us straight away without prescribing 120 pills of narcotic! There are so many people I see that I would have never started on this class of medications in the first place

 

[DOctorJay]

Erudite,
That is the exact message I delivered to my referring PCPs at a meeting where I reviewed the new CDC guidelines. Almost all of these patients now come to me on tramadol instead of oxy. I'm doing a lot of initial work ups that I didn't used to do and ordering more therapy first as the PCPs aren't even doing that now but at least I'm not getting nightmares anymore.


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[101N]

A Psychologist's Advice for Dealing With Difficult Patients

ORLANDO — Anthony J. Mariano, PhD, a clinical psychologist in the department of psychiatry and behavioral sciences at the University of Washington and the Veterans Affairs Puget Sound Health Care System, in Seattle, gave a lecture at the annual meeting of the American Academy of Pain Medicine (AAPM) titled “Practical Advice for Real-World Practice: Facilitating Self-Management in Challenging Patients.”1 Dr Mariano sought to address a common question voiced by pain physicians: should they reinstate opioid treatment in patients successfully taken off these medications?

The answer is: it depends on the patient, on whether he/she has a history of substance misuse, on the patient's functioning, and whether he/she is actively involved in his or her own pain rehabilitation. “This is the primary directive of opiate prescribing. No matter the answers to those other questions, safety always trumps pain relief,” said Dr Mariano. “So the answer is, if you can't use opioids safely, if you can't guarantee appropriate risk mitigation, you shouldn't do it.”

Why is it so difficult for us to follow through with recommendations? According to Dr Mariano, ”What ends up happening to the average provider in the real world, trying to help people, [is that they] find themselves alone in the room with a patient who is overwhelmed and overwhelming the provider, and the only choice left for the provider seems to be to give up, give in, and get these medications. They are caught between what they think they should do and what they find they really can do.”

To get out of such situations, what should healthcare providers (HCPs) say? Providers need to be aware of their own reactions during this difficult process. Dr Mariano identified 6 common situations and sought to provide advice for each scenario.

1. Negotiations and false hope. When patients are engaging in such promises in order to get HCPs to prescribe opioids, Dr Mariano advises providers to self-monitor in order to determine whether such behaviors by patients were successful in the past. It is important to tell patients that learning self-management strategies is a difficult process. The goal for HCPs is to develop a plan that is safe, make sense medically, and is sustainable. Patients would say: “Of course I want to get off these medicines, I just need a few more for a little while longer.” But increasing doses to take people down later is nonsensical; it only worsens the issue, says Dr Mariano. It is important in these situations that clinicians normalize the situation, recognize that they are asking a lot from patients, and communicate to their patients that they are willing to help them in any way possible, other than continuing the treatment for which the risks outweigh the benefits.
2. Appeals and ethical confusion. A patient may say: “It is your job to help me. Why won't you give me what I need to find some relief?” or: “I shouldn't have to suffer like this, nothing else works. What am I supposed to do?” Dr Mariano asks, "What are the provider's professional and ethical obligations in such situations?" In some instances, the patient will even “absolve” the HCP, saying: “I don't care about the risks, why should you? I need these pills to survive.” Dr Mariano responds, "These are your responsibilities, not your patients'. Your duty may be to wean this person, as your duty is not to harm.” Avoid taking complete responsibility for urgent and complete pain relief in a patient who is not going to engage in what we know is far more important: being actively engaged in dealing with other life problems. “The bottom line is, there are patients we can't help,” he added.
3. Blame and guilt. The patient comes and says: “How can you take away the only thing that helps me? You're ruining my life!” or: “I was doing just fine, now I can't do anything.” This brings up the “guilt scale.” Here, HCPs need to be careful when assuming that patients are stable. Providers need to help their patients identify problems other than pain, and try to get them the help they need. Patients may refuse to consult other specialists and insist that all of their problems are caused by pain, but the clinician's responsibility is to get patients the treatment that they need vs the treatment that they want.
4. Accusations and anger. Sometimes, patients accuse their HCP of being responsible for all their problems: “You're the reason I'm drinking! The only reason I'm drinking is because you won't give me enough Percocet.” It is very easy and natural to respond defensively in such situations; however, it is not helpful. “The key is this: don't argue,” says Dr Mariano. “I don't think you need to try to convince the patient…What I like to say to patients in that situation is: ‘You're an adult, you're making choices, but those choices really limit the options that we have, as safety has to come first.'” If a person has problem with substance abuse, taking them off opioids is not synonymous with refusing to help this person. On the contrary, refusing to prescribe opioids in that situation is refusing to continue harming them. Another group of patients may be misusing, while having poor expectations as to the kind of relief they can get through medications. These patients are not looking for drugs — they are looking for relief. And they may say: “I'll take what I need, and I need to use more medicines, because you are not giving me enough.” In these situations, it is helpful to explain to people that medications do not work equally well for everybody, to provide them with realistic expectations, and to frame the issue by pointing to the fact that some people do not respond to opiates.
5. Threats and fear. Some patients start threatening their provider: “I'm going to go over your head, I'm going to call your boss, the Senator ... I'm going to file a complaint with the State Medical board…” Although it is easy to feel intimidated in that situation, Dr Mariano recommends HCPs acknowledge the fact that there is coercion and seek advice from pain specialists, “because you know you're not going to get in trouble if you document your rationale and show that you are seeking advice from your colleagues.” Should a patient threaten suicide, consultation with a mental health professional is imperative.
6. Challenge and doubt. The average practitioner has very little training in pain, and even less in the specifics of prescribing. “If you're in a situation where you doubt your own expertise, where you doubt whether it is correct to take a certain patient off their medications, you're going to react very strongly to patients who challenge your competence or whether you care.” Here, the key is seek prompt consultation, as it is important to believe that you are doing the right thing when a patient believes you are doing the wrong thing. Dr Mariano recommends telling patients to consult the Veterans Affairs or Centers for Disease Control websites, so as to get them to realize the HCP is not not making this up.

“The key is not to get frustrated and give up, because these patients need our help more than ever,” Dr Mariano adds. So that saying ‘no' is more a process of safety and of patient education and support. “It is important to help patients understand that you are not refusing pain treatment. You made a logical decision, you are going to work with them, you are not abandoning them, and you are going to help them with their withdrawal symptoms. You need to help them understand non-opioid options.”

So, when tapering, “be very clear about the rationale — safety is your major concern — and be very specific about the process. Let the patients know about what is going to happen, and then follow through on it. And then, be empathetic but not apologetic, because bad care is not an option,” concluded Dr Mariano.

 

[NJPAIN]

I worked with Tony Mariano at the Seattle VA. He is a master at dealing with difficult patients. Great advice.


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[neutro]

one way to deal with difficult patients is to protocolize everything and before you meet them, i.e. make them fill out questionnaires, put the onus on them to get the medical records and ideally have UDS results available prior to your evaluation [done by pcp]. then review, and go in with a game plan.
cut them off if they start being tangential, which happens 100% of the time. be stern, and offer your plan.
if they disagree, walk out and give them a list of other pain doctors in the area.

i cannot win against these people. not many people can. there are other patients waiting that i can help.
so that is the approach i have taken.

 

[bronchospasm]

The initial visit is key. If you spend 5 minutes educating patients on multidisciplinary approach and shift responsibility from pills are going to help me to " I am going to help myself". Brief list of side effects of opioids including drug addiction, only helps 25-30% etc. Also address psych component after PHQ 9 and ORT. No evidence for long term opioids.

For the difficult patients, I give them all this information, ask them to think about it and call to schedule a follow up if they are interested. 90% of the time they continue their journey elsewhere.

In the long run, these patients drain me and to keep my sanity, I have to limit how many of these patients I can let in my practice.

 

[Gauss]

one way to deal with difficult patients is to protocolize everything and before you meet them, i.e. make them fill out questionnaires, put the onus on them to get the medical records and ideally have UDS results available prior to your evaluation [done by pcp]. then review, and go in with a game plan.
cut them off if they start being tangential, which happens 100% of the time. be stern, and offer your plan.
if they disagree, walk out and give them a list of other pain doctors in the area.

i cannot win against these people. not many people can. there are other patients waiting that i can help.
so that is the approach i have taken.

this is pretty old school and similar to how we used to behave in addiction med back in the 80's and 90's. There is plenty of data in the treatment of alcoholics to prove that your strategies will continually fail. Boundaries and rules are not in dispute, but if you want people to change (even addicts) you'll need to evoke that response from within them. That's the basis of motivational interviewing

 

[neutro]

this is pretty old school and similar to how we used to behave in addiction med back in the 80's and 90's. There is plenty of data in the treatment of alcoholics to prove that your strategies will continually fail. Boundaries and rules are not in dispute, but if you want people to change (even addicts) you'll need to evoke that response from within them. That's the basis of motivational interviewing

we are not talking about alcoholics. we are talking about difficult patients that are sent to us inappropriately in interventional pain practice. these people will not imrpove from interventional pain modalities. hence there is no point in wasting our time on them. hence offering our plan and walking out.

 

[Gauss]

we are not talking about alcoholics. we are talking about difficult patients that are sent to us inappropriately in interventional pain practice. these people will not imrpove from interventional pain modalities. hence there is no point in wasting our time on them. hence offering our plan and walking out.

you are a pain specialist, so you better get used to seeing patients with pain regardless of whether or not they need interventions. If you are not multimodal/multidisciplinary, then you are not helping very many people

 

[Ducttape]

or maybe he is just an interventionalist....

 

[neutro]

you are a pain specialist, so you better get used to seeing patients with pain regardless of whether or not they need interventions. If you are not multimodal/multidisciplinary, then you are not helping very many people

1. Its a bad habit to tell others how to practice.
2. The protocols are in place to determine if patients are good candidates for injections. If the patient marks their pain like their body hair distribution, then we have a problem. FM and diffuse patients are not good candidates for injections, unless they have a localized problem amenable to that. The diagnosis itself is controversial. They are not themselves interested in injections either. They are interested in playing the victim role and using FM diagnosis as an excuse for disability/opioids/legitimizing their psychiatric issues. These patients are offered education, CBT, PT/aquatherapy, weight loss, opioid wean (TO BE DONE BY CURRENT PHYSICIAN - typically their PCP) and recommendation for cymbalta/lyrica. Rheum eval as per PCP.
This can be achieved without spending 70 minutes during first visit as long as we go in prepared and have documents to review prior to eval.

 

[bronchospasm]

this is pretty old school and similar to how we used to behave in addiction med back in the 80's and 90's. There is plenty of data in the treatment of alcoholics to prove that your strategies will continually fail. Boundaries and rules are not in dispute, but if you want people to change (even addicts) you'll need to evoke that response from within them. That's the basis of motivational interviewing

Absolutely, and we are pain specialists not dumping grounds for other iatrogenically created legal drug addicts. Call it what you may ??

Big believer of and Agree with the multimodal approach. But how long can we keep playing counsellor/ psychologist/ social worker.?

Difficult patients are difficult for a reason. They are usually mismanaged. Most of these patients should not be on narcs to begin with.

After years of Norco 10 QID, when they show up at your office, good luck even getting them to therapy or to see a psychologist.

It is easy to jump on the compassion bandwagon, truth is that there is really no solution to this problem. Other than limiting primary care to prescribe pain medications.

After many such battles, I have chosen to distance myself from these situations. Again, others may choose to continue these unending battles. But I need to preserve my sanity and avoid burnout

 

[DrCommonSense]

1. Its a bad habit to tell others how to practice.
2. The protocols are in place to determine if patients are good candidates for injections. If the patient marks their pain like their body hair distribution, then we have a problem. FM and diffuse patients are not good candidates for injections, unless they have a localized problem amenable to that. The diagnosis itself is controversial. They are not themselves interested in injections either. They are interested in playing the victim role and using FM diagnosis as an excuse for disability/opioids/legitimizing their psychiatric issues. These patients are offered education, CBT, PT/aquatherapy, weight loss, opioid wean (TO BE DONE BY CURRENT PHYSICIAN - typically their PCP) and recommendation for cymbalta/lyrica. Rheum eval as per PCP.
This can be achieved without spending 70 minutes during first visit as long as we go in prepared and have documents to review prior to eval.

How many of them actually are willing to do ANY of that stuff though?

My experience is less than 5% are willing to do that. They just go on to the next doc until they can find someone to prescribe narcotics and talk bad about the previous physician.

 

[DrCommonSense]

Absolutely, and we are pain specialists not dumping grounds for other iatrogenically created legal drug addicts. Call it what you may ??

Big believer of and Agree with the multimodal approach. But how long can we keep playing counsellor/ psychologist/ social worker.?

Difficult patients are difficult for a reason. They are usually mismanaged. Most of these patients should not be on narcs to begin with.

After years of Norco 10 QID, when they show up at your office, good luck even getting them to therapy or to see a psychologist.

It is easy to jump on the compassion bandwagon, truth is that there is really no solution to this problem. Other than limiting primary care to prescribe pain medications.

After many such battles, I have chosen to distance myself from these situations. Again, others may choose to continue these unending battles. But I need to preserve my sanity and avoid burnout

Also, good luck with your "patient satisfaction" score when you are filled with patients placed on higher dosages of narcotic meds for INAPPROPRIATE reasons that you are trying to wean off while using CBT/PT/Acupuncture/Chiropractic/etc to give them "high value" care.

All I get are arguments followed up by complaints to their primary care doctor saying I lack "compassion"