Pic 0: The screen opens to a medical examination room, where a man sits across from a middle-aged woman.
Dr. Pasko: So, Lori, how are you?
Lori: (uncomfortable) Eh. Fine.
Dr. Pasko: What’s new since you were here last?
Lori: Well, I, uh, I was let go from work last month after this huge case fell through. Which is fine? I guess? It’s not like I’ll miss spending 14 hours a day in a windowless room highlighting depositions, but.
Dr. Pasko: So, I know you're here today because you called to get your oxycodone refilled. And I wanted to see you first because I have some concerns.
Lori: (defensive) What sort of concerns?
Lori's thought: Why won't you give me my pills?
Coach: Immediately bringing up Lori's opioid use made her feel defensive and worried. Dr. Pasko should make sure he builds rapport with her instead of putting her on the spot. She won't be comfortable talking about her opioid use if she feels he’s judging her.
Dr. Pasko: I can't refill your prescription today.
Lori: (worried) What? I, I'm almost out. When will you be?
Dr. Pasko: I know you're getting medicine from other doctors. I checked a database and it shows that you've gotten prescriptions from a, a Dr. Leonard Einhorn.
Lori: I can explain. It’s stupid. Alex, my husband, and I were on a trip with some friends from college and I left my medicine at the hotel when we checked out. I don’t know why, but I felt dumb about it and my friend said it would look weird if I came in and asked for an early refill, so she suggested I go to her doctor that one time and that just made sense to me. I still ended up having to go a few days without it, but it was dumb. I should’ve just called you.
Lori’s thought: You don’t believe me. I need to get my pills somewhere else.
Coach: By confronting Lori with the results of the PDMP without asking her what happened, Dr. Pasko made her feel defensive and scared. In the rest of the visit, he should try to show empathy and understanding to build trust.
Dr. Pasko: I'm worried you're developing an addiction.
Lori: (nervous) No. You're wrong. I have pain. I'm not an addict.
Coach: Patients may have strong feelings about a word like "addiction." They probably have a sense of the prejudice against "addicts" and "addiction" in our culture. Try to avoid these terms when you can.
Dr. Pasko: You went behind my back to get pills from another doctor so that you could take more than I prescribed.
Lori: It wasn't like that!
Dr. Pasko: If I can't trust you, I won't be able to keep treating you.
Lori: (crying)
Coach: It's not productive to use a "tough love" approach or take a patient's behavior personally. Patients with OUD need to know you understand and accept them. Without that, they're unlikely to persist with treatment. Let's go back and see a different choice Dr. Pasko could have made.
Dr. Pasko: Your urine test also came back positive for codeine and morphine. Our system doesn't show you receiving any prescription for those.
Lori: Uh, right. That was, you know, it's been bad this month, with the stress and everything, so I had some really bad nights, and I, uh, ran out of my pills really quickly, and then the pain got awful. But I didn't want to come in too soon because I didn’t want you to think I was weak, so I just borrowed some. You know, some old cough syrup from Alex and, whatever helped me keep going.
Lori's thought: I need a better story. I sound too desperate.
Coach: Lori knows that Dr. Pasko understands that she's lying, but she's not ready to tell him the truth yet. Showing her that he respects and empathizes with her can help her trust him. She needs to know that he won't turn against her if she tells him the truth.
Dr. Pasko: I'm going to ask you a few questions about your opioid use.
Lori: (wary) Uh, okay.
Dr. Pasko: When you don’t take your pills on time, do you start to feel anxious, nauseous, or start sweating?
Lori: (getting panicky) It’s not like that. I’ve just been under a lot of stress.
Dr. Pasko: And have you ever missed work, or a social evet because you had taken too many pills, or because you wanted to take pills instead?
Lori: No. No, I’m fine.
Coach: Lori is getting upset. Asking a lot of closed questions in a row can feel like an interrogation. Instead, Dr. Pasko should make sure to build a rapport and use open-ended questions to draw out Lori’s experiences.
Dr. Pasko: You said you went a few days without your medication. How did it feel when that happened?
Lori: Not great.
Dr. Pasko: Can you tell me more?
Lori: It's kinda brutal. My whole body hurts. Everything. The pain gets so bad I can literally start puking. But I don't think. Again, I should've just come to you when that happened. Sorry about that.
Coach: Dr. Pasko did a good job. By asking an open-ended question, he encouraged Lori to share the details of how she feels without her medication. This confirmed that she's experiencing withdrawal symptoms, without him having to confront her by specifically asking about withdrawal.
Dr. Pasko: If you felt more than your usual pain when you stopped taking the pills, that's not uncommon. When anyone takes opioid pain relievers for a while, their bodies get used to them. And it can be pretty terrible to stop if you're not prepared.
Lori: Yeah. The times I've gone without the medicine, it's been. Awful. Sweating, disoriented, super anxious. I was crawling out of my skin. There's, um, even been some times when I've started to feel that way and taken more than usual in order to feel, normal? I guess?
Coach: Dr. Pasko did a good job normalizing Lori's withdrawal experience. By explaining that withdrawal symptoms are natural for anyone using opioids for an extended period, he helped her feel less worried about what he thinks of her.
Dr. Pasko: How do those feelings and symptoms you describe impact your work and personal life?
Lori: I, um, I don't. I remember we had plans with friends one weekend, a cabin getaway thing, and I just, couldn’t face anyone, you know? I just wanted to stay home and not feel anything. And Alex got very, "What's wrong with you?" And I think he knew it was because. So he went and I stayed. And that Monday, when I went to work, everything just. (uncomfortably) Never mind, it's. Never mind.
Lori's thought: I was so blitzed that day, I couldn't even remember the client's name.
Coach: By using an open-ended question, Dr. Pasko encouraged Lori to describe and really consider the impact her opioid use is having on her life, instead of reflexively denying that she has a problem.
Dr. Pasko: I'm hearing that the opioids you're taking are causing some real problems for you.
Lori: (worried) I think I know what you’re going to say.
Dr. Pasko: You’ve described some pretty intense withdrawal symptoms. You mentioned sometimes needing a larger amount of oxycodone than prescribed in order to feel normal. And it sounds like both your personal life and your job have been negatively affected by your medication use.
Lori: (struggling) Can, can you just write me a prescription? Please? I won’t, I’ll take it as it says, I won’t. Okay?
Lori’s thought: I can’t talk about this. Please don’t make me talk about this.
Dr. Pasko: Based on what you're telling me, you meet the criteria for an opioid use disorder, Lori. You need to go to rehab.
Lori: No! I, I can't.
Dr. Pasko: I can’t treat you until you get clean.
Lori: I have to go home. I shouldn’t have come here!
Coach: It can be tempting to refer patients with OUD to specialty care, instead of talking with them about such an uncomfortable subject. But few people will complete a referral for treatment unless they trust you and feel supported. Let's back up and see another choice Dr. Pasko could make.
Dr. Pasko: There are a lot of good treatments we could offer to help with your opioid use.
Lori: (nervously) Uh, I don't need, I mean, no, I can't. I should go home.
Coach: Lori isn't ready to discuss treatment yet. Dr. Pasko should keep showing her empathy and normalizing her experiences to build her motivation to change. Then he can try to broach the subject of treatment a little later. Let’s look at a more empathetic choice.
Dr. Pasko: I know this isn't easy to talk about.
Lori: It's just. I'm not. I didn't mean for things to get like this. It's weird. I remember exactly when it- I couldn't find my prescription bottle and we had some friends over and I made a joke about my back and Alex's friend was like, "I've got some horse pills I don't need at home. You want 'em?" And I asked how much and he said (wistful laugh) "First batch is free," like as a joke.
Lori's thought: This isn't who I want to be.
Coach: No one can make a change like committing to OUD treatment without a certain level of confidence in their ability to succeed. By continuing to show empathy to Lori even at her lowest point, Dr. Pasko is building her confidence and motivation to change.
Dr. Pasko: How would you feel about trying to manage your withdrawal, so that going without the pills isn't so unbearable?
Lori: I don't, I just don't even know what that would look like. (fighting tears) It's just gotten so bad. I don't even know if I remember what being me feels like. I see pictures of me and Alex from a few years ago and we're smiling and I'm just. "Who is that?" So you talk about "managing withdrawal," and I don't know if I can even begin to think about what that is.
Dr. Pasko: (gently) There are treatments we can talk about.
Lori: (takes a breath) Okay. I guess we should. I mean I can’t even really tell anymore, what’s the pain from the accident and what’s from, you know, not getting the pills.
Coach: For the purposes of discussing treatment options with Lori, we can assume that Dr. Pasko has a DATA-2000 waiver and is able to prescribe buprenorphine.
Lori’s thought: I’ve been lying to everyone for so long. It feels good to just admit it.
Coach: Dr. Pasko did a good job in using open-ended questions to encourage Lori to share her feelings. This may be the first time she’s admitted, even to herself, that her pain isn’t the primary reason she’s continuing to use opioids.
Dr. Pasko: I know this has been a shock today. And you don't want your friends or colleagues to see you like this. If we treat this right away, they never have to know what's been going on.
Lori: Yeah.
Lori's thought: Oh, no. If people start talking, I'll never get a job again.