Avoid compassion traps “Do you want me to lose my job, do you want me to be on the street?” I want you to have safe and effective pain control and it is my medical opinion that your current medicine won’t give you that. “Do you have pain?” I want to use every minute of our time today to talk about your pain management plan. “I wish you could feel my pain.” I know you’re suffering and I’m sure that we can work together to reduce pain, so you don’t have to suffer.

Avoid “All or Nothing” Traps “So you’re going to do nothing for me then?” “You’re cutting me off and I have to live with my pain?” There are many, many things that people with chronic pain can do other than opiates to manage their pain. Would you like to hear about them? “I’ve tried all of that stuff, none of it works.” I want to hear what you’ve tried so we can find a way for it to be more helpful this time.

Some Explanatory Models of Addiction Impaired model Dry moral model Wet moral model Self medication hypothesis Psychoanalytic model Family interaction model Old and new medical models Bio-psycho-social model

Stay firmly within the medical model “Are you accusing me of being an addict?” I have never accused anyone of diabetes but I’ve diagnosed them with it and that is what I am trying to now, diagnose. “Don’t label me as a druggie” I have no interest in labels at all, I am interested in helping people who are struggling with medical problems. “So you’re basically saying that I’m a junkie.” I’m saying that addiction is a medical problem that responds to treatment not a problem of bad morals or behavior.

Avoid the Policing Role If you become aware of diversion or misuse… Control what you can control Prescribing Report what you are mandated to report Child abuse/neglect Don’t take it personally

Managing Threats “I heard it’s illegal for you to let me go into withdrawal.” Withdrawal is uncomfortable but not life-threatening, I can prescribe you medicines to help with the withdrawal symptoms. “I’ll just go and use heroin.” I certainly hope you don’t because you know that I don’t think any type of opiate will help your pain. “Don’t bother with any other meds, I’ll just kill myself.” I need to ask you some more questions about your thoughts about suicide. “I’m getting a lawyer.” “I’m calling KGW.” You do what you feel is right, of course. That’s what I’m doing for you, too. “You have a family, don’t you doc?” – Call the police

Endgame “There is nothing you can do or say that will cause me to prescribe ________. Now, how do you want to spend the rest of our time?”

The Language of Addiction Listen to what people say, our language betrays what we think and feel Patients take lisinopril but the doctor “has them on” oxycodone Taking other meds vs “eating” opiates Refer to opiates with personal pronoun, “My Vicodin” Use slang names for opiates Use “supposed to”, “try to”, etc when describing how they take opiates as opposed to what they actually do

The Language of Addiction Listen to what people say, our language betrays what we think and feel Patient says med “gives me energy” Use to treat non-targeted symptoms Unsanctioned dosage increases Meds eaten by dog, fell in toilet, left in Seaside, picked up by ex-wife, etc...

Diagnosing Addiction Ask yourself… “Has this patient developed a relationship with this medication beyond what I prescribed it for?” “Does this patient go to lengths to get this medication that most of my patients don’t?”

Discussing Toxicology Speak to what you know to be true, trust your science “I did not use cocaine, are you calling me a liar?” I know it’s very hard to talk about drug use, even with your doctor, but I want you to know that I’m not here to judge you but to help you. I know it’s embarrassing to change your story now… I am concerned that your use of alcohol (or drugs) may be causing some of your symptoms and actually making you feel worse. I know that this can be a difficult subject to discuss, even with your doctor, but it is important to consider this medical condition so that we can work together to help you feel better. A helpful lab test for diagnosing this is a urine test, which I am ordering for you.

General Recommendations Stay in the medical expert roll Emphasize concern and condition Speak to what is behind a patient’s comment, not to the comment itself Speak to what you know to be true, trust your science

Very Brief Intervention Concern Condition Convert Continue - Express clinical concern - Medical issue - Elicit some change talk - Next steps? Next time?

How to “FRAME” What You Say “The results of your questionnaire indicate that your use of alcohol puts you at risk from problems due to drinking. Of course, any decisions regarding a change are yours to make. As your doctor, I would like to share some advice with you on modifying your drinking habits – would that be ok? I want you to know that we have a lot of options to help you, should you decide to make a change.. I know that change can be difficult and at the same time, I am confident that if you decide to change you will be able to do so. Would you like to talk about some options that we have for supporting you in this?” F R A M E S

Recommended length of taper Degree of Shared Decision Making about Situation Recommended length of taper Degree of Shared Decision Making about Opioid Taper Intervention/Setting Substance use disorder No taper, immediate referral None – provider choice alone Intervention: Transition to medication assisted treatment (buprenorphine or methadone) for OUD, Naloxone rescue kit Setting: Inpatient or Outpatient Buprenorphine (OBOT Diversion No taper* Determine need based on actual use of opioids, if any At risk for immediate, large harms Weeks to months Moderate – provider led & patient views sought Intervention: Supportive care Naloxone rescue kit Setting: Outpatient opioid taper Therapeutic failure Months Option: Buprenorphine (OBOT) At risk for future, smaller harms Months to Years

The brain cares more about the percentile decrease than the absolute decrease. On the red curve 10 to 9 and 1 to 0 both represent absolute decreases of one unit but the first is a 10% decrease and the second is a 100% decrease. On the blue curve the first decrease is the same but the second decrease (1 to 0.0875 at time unit 24 to 25) is a 10% decrease. DOSE TIME

DOSE TIME

Opioid taper options Percent decreases per 4 week blocks Weeks 1 to 4 5 to 8 9 to 12 13 to 16 17 to 20 21 to 24 25 to 28 4 weeks 25,33,50,100 8 weeks 30 50 12 weeks 20 25 16 weeks 15 20 weeks 10 24 weeks 28 weeks

Key Concepts for Tapering Opioid Medications Establish a relationship – “They don’t care how much you know until they know how much you care.” Set Expectations Shared decision making Discuss withdrawal symptoms and temporary increase in pain Advise patient to keep a journal, reviewing helps to normalize the process Set goals for points in time Tapers are unidirectional, decide if you want to allow “breaks” or “pauses” Maintain best practices Urine drugs screens, pill counts, PDMP review, etc

Key Concepts for Tapering Opioid Medications Allow patient to choose taper speed, when appropriate Addiction becomes apparent during taper (unable to make dose reduction or even increases dose) Detox or agreement of taper by certain date or detox, but no further Rx Inform patient of happy paradox that their pain will be much more manageable once they are off their pain medication! Most patients say they had made the change a lot earlier, that they can think better, get more done and are more present for family and work.