Coach: Dr. Pasko should be careful. While he was trying to empathize with the shame Lori is feeling, he ended up reinforcing the stigma that OUD is something she should be ashamed of. He should make sure she understands that many treatment options for OUD are outpatient and can fit into her life.
Dr. Pasko: I'm not comfortable prescribing you any more opioids now that I know you meet the criteria for opioid use disorder. We can talk about other pain management.
Lori: But I’m in pain. I keep telling you that! I can’t just stop taking my pills.
Lori’s thought: I just need another doctor who’ll give me my prescription.
Coach: Instead of talking about what he can't do for Lori, Dr. Pasko should make sure she knows and understands the treatment options that are available to her.
Dr. Pasko: One of your options would be going to a methadone clinic, but I don't recommend that for you. Methadone's really better for heroin users than someone who's just using pills.
Lori: I mean I'm not, like, shooting up!
Coach: Dr. Pasko should be careful not to accidentally reinforce stigma against a treatment that may work for Lori! Methadone is popularly associated with heroin, but it is an effective treatment for all opioid use disorders, including prescription opioids, and offers more structure than an office-based treatment program.
Dr. Pasko: I'll do what I can, but you'll need an addiction counselor or psychologist to oversee your treatment. I'm really not a specialist in this area.
Lori: (backing away) Uh, sure, right. You're definitely right.
Dr. Pasko: I can make a referral to my colleague upstairs. He's an excellent therapist.
Lori: Yeah, sure. Whatever you think is best.
Coach: Simply recommending that a patient struggling with OUD get counseling or addiction support is unlikely to work. Vulnerable patients may feel abandoned or be intimidated at the thought of starting over with someone new. Let's go back and find a better solution.
Dr. Pasko: Actually, I shouldn't have said that. There’s really not a lot of difference in how heroin and oxycodone affect the brain. Methadone is an opioid too, so it fills the same receptors in the brain and can help with both. The difference is that methadone is very long acting, so you feel stable all day. You won’t feel withdrawal symptoms, and should have very few cravings. And it may also help with your pain. It’s administered daily on-site at a clinic, in a structured environment.
Lori: Ouch.
Dr. Pasko (acknowledging) It’s a commitment. During the induction period, they will adjust the dose until you are stable. After that your visits could potentially start spacing out. But patients do continue to go in regularly for counseling and medication. What are your thoughts on maybe taking this approach?
Lori: I can’t. I mean, I do need to get hired again at some point. I can’t have people thinking I. I can’t.
Lori’s thought: I can’t go be with people like that. That’s not me.
Coach: By validating Lori’s concerns about methadone and asking her permission to share more information, Dr. Pasko re-engaged her in decision making. But he should make sure he respects her choice that methadone isn’t the right solution for her.
Dr. Pasko: If you don't want to use methadone, another option is a medicine called buprenorphine.
Lori: Burping morphine?
Dr. Pasko: Buprenorphine. It's another long-acting opioid, like methadone, but I can prescribe it here. It works exactly the same as methadone and will treat your pain.
Lori: Okay.
Coach: Dr. Pasko should be careful only to give accurate information! As a partial agonist, buprenorphine may help alleviate some pain, but its ceiling effect means it is not always sufficient to manage chronic moderate to severe pain. He’s going to try correcting his mistake so that Lori can make an informed decision.
Dr. Pasko: Actually, buprenorphine works slightly differently than methadone, and it can sometimes be less effective for severe pain. But many people report that it does address their pain. We can see how it works for you.
Lori: Yeah, I, uh, really don't want to go to a clinic, you know?
Dr. Pasko: I often find that once we can stabilize people on buprenorphine their pain starts to improve, and then we can try some other approaches, like physical therapy and non-opioid pain medications. The buprenorphine will stop you from having the withdrawal symptoms and cravings that have made this so difficult. And I can prescribe it here, so that you wouldn’t have to go to a new clinic or start with a new doctor.
Lori: (dubious) I don’t know.
Lori’s thought: (dubious) That doesn’t sound too bad, I guess.
Dr. Pasko: One thing I can do for you right now is prescribe naltrexone to block your cravings.
Lori: What does that do?
Dr. Pasko: It's a medication that blocks your brain's opioid receptors, so opioids won't affect you any more. And since it's not a controlled substance, I can prescribe it today, if you want.
Coach: Dr. Pasko should be careful! A patient needs to be opioid abstinent for 7-14 days before starting naltrexone. Taking it without first going through medically managed detoxification can trigger acute withdrawal. Dr. Pasko is going to correct his mistake so Lori can make an informed decision.
Dr. Pasko: Actually, to use naltrexone, you must complete medically managed withdrawal first. Naltrexone doesn't treat withdrawal symptoms and it can precipitate withdrawal if you take it too soon.
Lori: Ooh, one of those others sounds better, then. I really don't want to, you know.
Dr. Pasko: Out of the different options we've talked about, the methadone, the buprenorphine, and medically managed withdrawal, are there any that feel like they would be the right fit for you?
Lori: Maybe the Bupo, Buper.
Dr. Pasko: Buprenorphine.
Lori: (hopeful) Yeah. That.
Coach: Lori was a little confused by Dr. Pasko’s struggles to keep the facts straight about her medication options, but now she’s made a good choice. And because Dr. Pasko has a DATA-2000 waiver, Lori can get that treatment without changing providers or going to a different practice.
Dr. Pasko: I think buprenorphine could be a good fit for you. Do you mind if we talk about what our next steps would be to get started?
Lori: Of course.
Dr. Pasko: Before we can start you on it, we need you to be feeling some withdrawal symptoms, usually about 12 hours after taking your last dose of opioids. Around how many days of medication do you have left right now?
Lori: Uh, maybe a week? Five days.
Dr. Pasko: Hmm, well why don't we make an intake appointment for next Friday, and we can try to start treatment that same day? Once we have you on the right dose, I'll be able to write you a prescription you can fill in a pharmacy and take at home.
Lori: (uncertain) I, I don’t know. I guess.
Lori’s thought: I don’t want some crappy replacement. I want my pills!
Coach: Dr. Pasko did a good job. By asking permission before sharing what could be disturbing information, that Lori will have to feel some withdrawal symptoms before starting, he helped her feel respected and supported enough to make an intake appointment.
Dr. Pasko: I know you can get through this, Lori. We're all on your team, everyone in this office wants to help you. We've all known you a long time and we're going to help you get through this.
Lori: I, I just don’t think I can do this. I just wanted my prescription, that’s all!
Dr. Pasko: And you know I can’t give you that, Lori.
Lori: Because you think I’m an addict! But I’m not! I’m just, in pain! That’s all that is. Pain!
Dr. Pasko: You need this treatment, Lori.
Lori: (angrily) I know what I need! And I’m not getting it here.