Opioids: Navigating Difficult Conversations

Discussing opioid management for chronic pain with patients can be challenging.¹ Conversations can feel uncomfortable for both patients and prescribers.^1-3 They can generate negative feelings of guilt, tension, or frustration, especially if there is a need for behavior changes and eliminating opioids from the treatment regimen. Employing appropriate strategies and educational materials to discuss therapy changes can drive positive conversations about limiting opioid use. Approaches to navigate change include showing empathy, care, and compassion, engaging in effective provider-patient communication, and utilizing motivational interviewing techniques. These key elements can pave the road to positive clinical outcomes.

Effective Provider-Patient Communication

Open, caring communication is important when having difficult conversations.^4,5 Start by showing empathy through actively listening to your patients, recognizing their fears, and responding to their emotional and medical needs.

Empathy is key: https://www.bmc.org/addiction/leaders/when-talking-to-patients-about-opioid-misuse-empathy-key

How to show empathy to patients – even when you are stressed: https://www.wolterskluwer.com/en/expert-insights/how-to-show-empathy-to-patients-even-when-youre-stressed

Communicate Effectively With Patients

Several tools and strategies can be employed to help facilitate positive discussions about adjustments to opioid prescriptions and patient perspectives on pain treatment.¹ One approach focuses on five principles – Belief and Confidence, Values, Realistic Expectations, Relationship as a Resource, and Willingness to Feel Uncomfortable. Another method also follows five-steps, with an emphasis on emotions, both patient and provider perspectives, common goals, and limit setting. An additional guide recommends to SOAR (Shared Decision Making, Outcomes, Assurance, and Risk/Redirect) through challenging conversations and include patients in the process.

Additional Resources on communication Strategies

Handouts, videos, and helpful tips: https://www.opioidlibrary.org/wp-content/uploads/2019/12/MN_DHS_Difficult-conversations.pdf

Flip the Script campaign: https://mn.gov/dhs/opip/

Behavior Change By Using Motivational Interviewing (MI)

Motivational interviewing is a patient-centered counseling approach to help patients explore and resolve ambiguity about behavior change.^3,5,6 Insightful listening is an essential part of the four MI techniques (ie, engaging, focusing, evoking, and planning). More than 200 randomized controlled trials demonstrated that motivational interviewing can be used to effectively decrease or eliminate patient substance use disorders along with other risky health behaviors.

Additional Resources for Motivational Interviewing

Centers for Disease Control and Prevention

https://www.cdc.gov/drugoverdose/training/motivational-interviewing/index.html

The goal of this training is to identify the main elements of MI, introduce the medical team to MI techniques and various tools, and apply MI to patients in medical settings.

Motivational Interviewing Network of Trainers (MINT)

MINT is an international organization devoted to encouraging the use of best quality MI.

https://motivationalinterviewing.org/

Summary

The opioid epidemic continues to have a major impact on thousands of Americans. Prompting discussions about limiting opioid use and practicing motivational interviewing techniques can improve patient care and quality of life.

References

Difficult conversations. Oregon Pain Guidance. 2021. Accessed August 9, 2022. https://www.oregonpainguidance.org/clinics/difficult-conversations/
Wyse JJ, Ganzini, L, Dobscha SK et al. Setting expectations, following orders, safety, and standardization: clinicians’ strategies to guide difficult conversations about opioid prescribing. J Gen Intern Med. 2019; 34(7):1200-1206. doi:10.1007/s11606-019-04983-y
Substance Abuse and Mental Health Services Administration. Enhancing motivation for change in substance use disorder treatment. Publication No. PEP 19-02-01-003. Treatment Improvement Protocol (TIP) Series 35. Updated 2019. Accessed August 9, 2022. https://store.samhsa.gov/sites/default/files/d7/priv/tip35_final_508_compliant_-_02252020_0.pdf
Opioid prescribing guidelines. Oregon Pain Guidance of Southern Oregon. August 2014. Accessed August 9, 2022. https://www.careoregon.org/docs/default-source/providers/manuals-and-formulary/opioid-prescribers-guidelines.pdf
Lembke A, Shames J, Heesacker L, Halperin R, Stephens M. BRAVO! a collaborative approach to opioid tapering. Oregon Pain Guidance. February 2022. Accessed August 9, 2022. https://www.oregonpainguidance.org/guideline/tapering/
Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review. Patient Educ Couns. 2004;53(2):147-155. doi: 10.1016/S0738-3991(03)00141-1