Talk with Patients about Opiod Misuse

Overview

Welcome to the screen reader for the simulation De-Escalation in Care Settings. This course provides a review of foundational concepts in pharmacotherapy and opioid use disorder, as well as techniques for discussing opioid misuse with patients and de-escalating patient agitation. You will watch providers have conversations with virtual patients to practice discussing opioid use and motivating the patient to pursue pharmacotherapy or reduce their dosage.

Opioid Use Disorder

Pic 0: The title card appears on screen before fading to a screen with a woman named Dr. Melanie Owens in front of a blue background.

Dr. Owens: I'm sure you're aware there's an opioid crisis in America right now.

Pic 1: Two portions of text appear next to her. The top one reads “Overdoses (2016): 64,070 deaths.” The bottom one reads “AIDS (1995): 50,877 deaths.”

According to state-by-state cause-of-death data, more people are dying of drug overdoses than died of AIDS at the height of the AIDS epidemic.

So why aren't we all reaching out to treat our patients who are struggling with these drugs?

Pic 2: Dr. Owens is replaced by a title screen which reads “Stigma and Misperceptions.”

Unfortunately, too many people still see substance use as a moral failing, and wrongly dismiss it as a bad choice that "gives people what they deserve." Such stigma and misperceptions can make it hard for patients to seek help.

Pic 3: The title remains on screen while below it three example sentences are displayed. After a short pause, each of them is crossed out with red scribbles.

“Addicts die. It’s natural selection.”

“It’s their own fault.”

“Why save criminals?”

Pic 4: A line of white figures appears. They fill with blue to represent a range of 24 to 36 percent of the figures. The text “24 percent to 36 percent” appears above the figures.

And when patients don't get help, it can be devastating for them and for those around them. It has been estimated that between 24% and 36% of opioid-dependent adults cycle in and out of incarceration facilities each year.

Pic 5: The screen returns to a close-up of Dr. Owens. Text appears next to her which reads “OUD: Opioid Use Disorder.”

I'm Dr. Melanie Owens, and I've worked in family medicine and addiction services for more than a decade. In that time, I've treated hundreds of patients with Opioid Use Disorder, also known as OUD, most of them right here in my office.

Pic 6: The text disappears and is replaced by text that reads “75 percent of heroin users start with pain relievers.”

And while many people may think of heroin when they hear about opioids, 75 percent of heroin users actually start with prescription pain relievers.

Pic 7: The screen changes to a blank one where the words “Opioid Use Disorder” appear.

But most patients use pain relievers as prescribed. So how do we recognize if a patient has developed an Opioid Use Disorder?

Pic 8: The words get pushed to one side and new text appears on the right which reads “a problematic pattern of opioid use leading to clinically significant impairment or distress.” (American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric pub.)

The DSM-V defines OUD as "a problematic pattern of opioid use leading to clinically significant impairment or distress." The following symptoms are strong indicators for a potential OUD. 

Pic 9: The screen changes to one titled “Signs of Opioid Use Disorder” with the following examples.

See resources section for complete DSM-5 criteria.

Pic 10: The screen returns to a close-up of Dr. Owens. The text “Look for changes in behavior” appears next to her.

Anyone who uses opioids regularly, including people who use them as prescribed over longer periods of time, will develop tolerance. But any change in behavior due to opioid cravings is an important sign that a patient is developing OUD.

Pic 11: The screen changes to a title card which reads “Withdrawal Symptoms.” After a moment, the title remains but a series of 7 emoticons appear underneath. After a second the screen zooms in on the first four, then the last three, which includes

  1. A green face with a squiggle for a mouth, one eye is bigger than the other, and there are little green bubbles above the head. The text next to it reads “couldn’t stop vomiting.”
  2. A brown face with an open mouth and eyes clenched shut. There are brown squiggles over the top of its head. The text next to it reads “drool, snot, diarrhea, I was just exploding out of every orifice.”
  3. A blue face with its tongue sticking out from its mouth. There are three sweat droplets over the left side of its head. The text next to it reads “sweated through six shirts in an hour.”
  4. A red face with clenched teeth, one eye bigger than the other. There are two red lightning symbols above its head. The text next to it reads “muscle cramps, spasming, every joint hurts.”
  5. A purple face with under-eye circles and a flat mouth. There is a purple curlicue above its head. The text next to it reads “couldn’t sleep for days.”
  6. A yellow face with a frown and clenched-shut eyes. There is a thought bubble above their head with an image of a pill in it. The text next to it reads “would give anything for another pill, another shot.”
  7. An orange face with a shocked expression and open mouth with emphasis lines above its head. The text next to it reads “I was panicking, no way to get away.”

And when a person's brain adjusts to expect an increased amount of opioids in their system, that can lead to agonizing withdrawal if they stop using.

Pic 12: A title appears which reads “Medically-managed opioid withdrawal.” Underneath are two bullet points which read “Detox” and “Rehab.” Underneath the bullet points, text reads “does not equal OUD treatment.”

Opioid withdrawal symptoms can be managed medically, also called "detox" or "rehab." But just going through withdrawal doesn't treat the underlying OUD.

Pic 13: The screen changes to a graph with a yellow and blue line. The yellow represents craving, and the blue represents tolerance. At first they increase at the same pace, but when they reach a portion of the graph titled “Detox,” yellow goes up a little bit and plateaus while the blue gradually decreases. After the Detox portion, there’s a new highlighted portion titled “Resumed Use.”

In fact, after a period of abstaining from opioids, people lose their physical tolerance, but continue to have the same cravings, triggers, and emotional distress they had before, sometimes for years. This often drives them to return to opioid use.

Pic 14: A vertical dotted line appears between the lower tolerance point and the higher cravings point labeled “Overdose.”

But if someone who lost their tolerance takes the same amount of opioid they used to take, they can easily overdose. This can make the cycle of detoxification and relapse deadly for patients.

Pic 15: The screen returns to a close-up of Dr. Owens. After a moment, the text “Pharmacotherapy for OUD” appears next to her.

Fortunately, there are effective therapies that can reduce the risk of overdose and support recovery. Along with behavioral counseling, we can use medications specifically tailored to opioid receptors to help patients manage opioid use disorder with far less danger of relapse and overdose.

These types of combined therapies are known as Pharmacotherapy for OUD.