Motivational Interviewing and Recognizing our powerlessness as physicians PART ONE CMG Opiate Scrips The top 7 CMG providers each have an average of 425 currently active opiate prescriptions written in the past two years outstanding ID: 760135
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Slide1
How To Write Fewer Opiate Prescriptions
Motivational Interviewing and
Recognizing our powerlessness as physicians
PART ONE
Slide2CMG Opiate Scrips
The top 7 CMG providers each have an average of
425
currently active opiate prescriptions (written in the past two years) outstanding.
The bottom 7 each have an average of
57
such prescriptions.
These are all fulltime providers although average patients seen is not taken into account.
These are crude measurements, but how can we account for an
8-FOLD
difference?
Slide3Why Do We Do This Job?
To help people.
To alleviate suffering.
To fix stuff.
To prevent future illness.
Slide4Why Do We Do This Job?
To be in charge.
People pay us for our advice. This is very egosyntonic!
To be in the upper 5% - 15% of individual income in the US.
People we have never met before will take off their clothes and submit to painful things just because we tell them to.
Consequently, this job places us in a power position.
Slide5Why Do We Do This Job?
Alleviating suffering and being in charge can come into conflict.
“My back still really hurts”
“My pain is keeping me from taking care of my kids.”
“I ran out of Percocet early. I need a refill.”
“The surgeon told me he couldn’t give me any more Dilaudid, that I would have to see my family doctor.”
“I can’t live like this.”
“Can’t you get rid of my pain, doctor?”
“My provider didn’t help my pain. I gave her 1 star only because you can’t give no stars.”
Slide6The 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?
Slide7The 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?’
Slide8Sensory discriminative componentNerve impulses reach specific brain areas.Motor componentTrapezius spasm for example.Autonomic componentPain leads to reactions of the autonomic nervous system such as hypotension.Emotional componentPain is associated to a greater or lesser degree with emotions, such as anxiety, sadness, anger, aversion or helplessness. Cognitive componentPain is classified by the brain and evaluated on the basis of previous experience.
How Pain Is Perceived
Slide9Autonomic Component
“Fainting” from sudden painful event.
Sweating with pain.
Etc.
These are transient.
Slide10For example, muscle spasm after trapezius injury.Muscle tension headache following migraine.Motor component may be synergistic with original painful event and may supersede it in intensity.
Motor Component
Slide11Emotional and Cognitive Components
These occur
in the CNS.
These may become the only lasting components of a painful event.
Not under very much
conscious control.
Slide12The Dopaminergic Mesolimbic System
PFC= Prefrontal Cortex NA=Nucleus Accumbens VTA= Ventral Tegmental Area
A = Amygdala C = Caudate Nucleus
Slide13Limbic Survival
The
Four F’s
of survival are mediated via these pathways.
Fight
Flight
Food
Procreation
Slide14Limbic 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.”
Slide15Limbic System Connections
Amygdala
Assesses whether or not the experience is pleasurable or bad.
Facilitates additional connections between VTA and Nucleus Accumbens.
Hippocampus
Records memories of pleasure state and where and when experience occurred.
“When I took those pills, I felt so much better.”
Slide16Chronic Pain
Changes the way that the Sensory Discriminative Component is processed.
Pain carrying nerves become more sensitive allowing less and less powerful stimuli to produce the same amount of pain, lowering the pain threshold.
This may affect the motor component.
“My neck is always stiff and painful even though the surgeon told me that my surgery was a success.”
Slide17Chronic Pain
Affects the
Cognitive
Component
Longstanding
pain becomes
defined as
suffering
.
Dopamine flow is diminished.
Serotonin flow is diminished,
Opiates replenish these
in the short run.
Slide18Acetaminophen and NSAID’s alter prostaglandin synthesis (and thus inflammation) at the site of pain production.Alter sensory discriminative component.Opiates have little activity outside the central nervous system.Opiates work mainly on the emotional and cognitive components of pain perception.
Some Pharmacology
Slide19Chronic opiate use
Causes additional
mu
-receptors to be made.
Enhances opiate metabolism in the liver.
Enhances opiate deposition in adipose and other tissues.
Pain carrying nerves become more sensitive allowing less and less powerful stimuli to produce the same amount of pain, lowering the pain threshold.
TOLERANCE thus develops requiring ever larger doses to produce the same effect.
This requires greater dose to produce the same effects in the limbic system and the merry go round spins faster and faster.
Slide20Chronic Pain and Long-term Opiate use
Our
patients are
SUFFERING EVERY DAY.
They have sleep problems, constipation, headaches, and
reduced libido
.
Side effects of opiates.
For many patients, their pain becomes their main leisure time activity.
It dominates their lives no less than those of opiate addicts.
They are often made to feel like weak people who need to argue with us just to get
some
relief!
“Why aren’t you helping me?”
Slide21Chronic Pain and Long Term Opiate Use
March 6, 2018
Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain
The SPACE Randomized Clinical Trial
JAMA.
2018;319(9):872-882. doi:10.1001/jama.2018.0899
At one year, patients treated with NSAID’s or Acetaminophen reported the same degree of pain relief as those treated with titrated opiates.
Slide22Chronic Pain and Long Term Opiate Use
We helpers feel inadequate and useless.
Our power position is threatened.
“I’m suffering, and you don’t want to help me.”
It’s easy to become frustrated and then angry and then depressed.
Writing the damn prescription is just
so
easy!
Slide23We are in the lifestyle change business.
No wonder we often fail.
People have arrived at a certain approach to life that works even if it is destructive to their health.
Effecting change in diet, exercise, smoking, checking blood sugars, etc. is very hard to do.
Telling someone suffering with pain that he or she should get off opiates is harder still.
Slide24MOTIVATIONAL 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.
Slide25https://store.samhsa.gov/shin/content//SMA13-4212/SMA13-4212.pdf