The Contract You tell me whats ailing you and I will give my full attention to fixing it What if the patient doesnt know whats ailing them What if the patient withholds important information ID: 756394
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Slide1
How to Write Fewer Opiate Scrips Part 2Slide2
The Contract
“
You tell me what’s ailing you, and I will give my full attention to fixing it.”
What if the patient doesn’t know what’s ailing them?
What if the patient withholds important information?
What if there is no described syndrome or illness that fits the patient’s condition?
What if my patient doesn’t like me?
And, the BIG ONE,
What if I can’t really fix what’s wrong?Slide3
The Contract
Patients see us as quite powerful.
“My lawyer can tell me that
I’ve been sued, my accountant can tell me that I’m broke, but only you can tell me that I’m going to die.”
As a consequence, it is in the patient’s interest to place us on a pedestal.
If the provider is powerful, fear is reduced.
This can feel pretty good.
But it can trap us into trying to meet an unattainable standard.
What happens when we “fail?’Slide4
The Dopaminergic Mesolimbic System
PFC= Prefrontal Cortex
NA=Nucleus
Accumbens
VTA= Ventral Tegmental Area
A = Amygdala
C = Caudate NucleusSlide5
Limbic Survival
Dopamine flows when we are:
Warm
Dry
Well-fed
Safe
Satisfied
Happy
“I can still feel the pain; it just doesn’t bother me as much.”Slide6
Chronic Pain
Over time, opiates produce
a weaker and weaker dopaminergic response.
The hippocampus and amygdala have long since decided that taking a pain pill is necessary to avoid truly unimaginable pain.
This explains why a patient with chronic pain will very often answer “10” when asked to rate their pain.
Pain becomes the dominant force in that patient’s life.Slide7
Chronic Pain
Thus, we are faced with a patient who has decided
that to be without pain medicine is to face a horrible fate.
A patient who, because of suffering intermittent opiate withdrawal, has daily evidence that they’re right about this.
Here we sit trying to limit opiates.
This is an automatic adversarial relationship wherein we can, in the short term, make our patient feel worse.Slide8
Why All of This Can Feel SO Bad
Our patient is still in pain
We haven't helped.
The patient may well be angry.
The doctor may well be angry.
The insurance company may withhold prescription payment.
We are trying to treat a mesolimbic problem with a strategy that is doomed to fail.Slide9
There is No Easy Fix
We must admit that we are powerless over our patient’s pain.
We must allow the patient to see the world differently.
We must allow the patient to regain control over their life.
We must acknowledge that only the patient can achieve true pain control.Slide10
Shifting the Locus of Control
“I don’t know what to
do,
you’re
the Doctor.”
“How can you tell me that it’s too early for my refill; can’t you see I’m in pain?”
“Taking more and more oxycodone is bad for you.”
“Your Vicodin is probably not doing much of anything for your pain anymore.”
All that the Morphine ER is doing is keeping you out of narcotic withdrawal.”Slide11
Shifting the Locus of Control
"What have you found (other than narcotics) that helps your pain?”
“You will never be pain-free.”
“This pain you’re having is part of who you are now.”
“Right now, the
pain is controlling you. You need to learn how you can control it.”Slide12
The Physician’s Role
Expert informer and teacher.
Emotional supporter and cheer leader.
Reliable helper who’s in for the long haul.
Reliable
l
imit setter.Slide13
Don’t Waste Your Time
“It seems pretty clear that I am not helping
you. You will need to find someone who can better meet your needs.
“I don’t want to be a part of making you worse.”
“I’m so sorry that you are suffering so much.”
“I’m sorry that I’m not able to help.”
“I’m sure that you can find another practitioner who will give you the opiates that you want.”
“This is as good as it gets.”Slide14
Motivational Interviewing
Listen,
don’t talk.
Let the patient set the agenda.
You may be surprised
at how much shorter the visit will be.
Don’t EVER argue.
Admit your powerlessness.
“Oh, well, what
do
you
think
you can do?”
Stop explaining.
Don’t assume that your ideas are what are most important.Slide15
Motivational Interviewing
Stop trying
to help.
Just listen and try to understand your patient better.
Take your nose out of the computer screen and try to stay in the moment.Slide16
MOTIVATIONAL INTERVIEWING
FREE publication that is a complete textbook on motivational interviewing.
https://store.samhsa.gov/shin/content//SMA13-4212/SMA13-4212.pdf
Geared toward addicts but perfectly applicable to diabetics, smokers, etc.Slide17
Who to taper
The four main opiate side-effects:
“Are
you constipated?”
“Do you get headaches”
“How are you sleeping?”
“How’s your sex life?”Slide18
Who to taper
The
patient has to be at least contemplative.
“How are you feeling?”
“How much longer do you think you’re going to live?
“Do you want to spend the rest of your life this way?”Slide19
Opiate Tapering Tips
Make sure that you know all sources of opiates and benzodiazepines for
your patient.
Prescription Drug Monitoring Program (PDMP)
Make sure that you know how many of each prescription that the patient has stashed away.
“Bring in all your bottles.”
Count the individual pillsSlide20
Opiate Tapering Tips
Ask the patient how much they want to cut down.
Don’t cut by more than 10%
and no more frequently than every two weeks.
Prescribe the
exact number
of pills that you two agree on.
Let your patient know that they can use more than agreed on so long as they call you before they run out of pills.
And they will run out since you prescribed the exact number needed to get to their next appointment.
Let your patient know that if they get prescriptions from another practitioner, you can no longer help them.Slide21
Opiate Tapering Tips
See the patient frequently, especially
at first.
If the patient can’t commit to frequent visits or keeps changing appointments, don’t waste your time.
Always ask the patient by how much they want to cut down.
You will almost always have to caution them that their goal is too aggressive.
Emphasize that they are in control of the taper.
As long as the amount is going down, it’s all good.
Taper more slowly as the overall
amount becomes smaller.