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. 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 effective provider-patient communication, motivational interviewing techniques, and showing empathy, care, and compassion. These key elements can pave the road to positive clinical outcomes.1-3

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

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Flip the Script Campaigns

Multiple states have adopted a “Flip the Script” campaign that encourages patients to begin the conversation with their prescribers about their opioid use.6,7 These programs provide resources on understanding and managing pain, opioid addiction, and how to have difficult conversations with patients about switching opioid prescriptions. Flip the Script programs aim to reduce opioid misuse by encouraging patients to talk openly about their pain, use non-opioid alternatives to manage pain, and provide guidance on how to safely use prescription opioids.


Examples of Flip the Script conversations

https://www.opioidlibrary.org/wp-content/uploads/2019/12/MN_DHS_Difficult-conversations.pdf


Additional resources from Flip the Script campaigns

https://mn.gov/dhs/opip/

https://flipthescriptonpain.org/


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.3,5,8 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.

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Training Resources for Motivational Interviewing

Centers for Disease Control and Prevention

Motivational Interviewing Training. 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.

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


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.


  1. Difficult conversations. Oregon Pain Guidance. 2021. Accessed March 15, 2021. https://www.oregonpainguidance.org/clinics/difficult-conversations/
  2. 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
  3. 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 March 9, 2021. https://store.samhsa.gov/sites/default/files/d7/priv/tip35_final_508_compliant_-_02252020_0.pdf
  4. Opioid prescribing guidelines. Oregon Pain Guidance of Southern Oregon. August 2014. Accessed March 15, 2021. https://www.careoregon.org/docs/default-source/providers/manuals-and-formulary/opioid-prescribers-guidelines.pdf
  5. Lembke A, Shames J, Heesacker L, Halperin R, Stephens M. BRAVO! a collaborative approach to opioid tapering. Oregon Pain Guidance. March 2020. Accessed March 9, 2020. http://oregonpainguidance.org/wp-content/uploads/2020/04/BRAVO-FINAL-3.13.20.pdf
  6. What happens when you flip the script? Minnesota Department of Human Services. Updated 2019. Accessed March 15, 2021. https://www.opioidlibrary.org/video/what-happens-when-you-flip-the-script/
  7. Empowering you to speak up about pain. Flip the Script. Accessed July 13, 2021. https://flipthescriptonpain.org/
  8. 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

Prepared by:

Liana Osis, PharmD
Clinical Pharmacist, Academic Detailer
University of Illinois Chicago College of Pharmacy

Nerissa Caballes, PharmD, MS, CRC
Supervisor, Academic Detailer
University of Illinois Chicago College of Pharmacy

The information presented is current as of October 2021. This information is intended as an educational piece and should not be used as the sole source for clinical decision making.