Overall, the provider struggled to engage Lori in discussing her opioid use, and he failed to sufficiently motivate her to seek treatment. Let’s take a look at what went wrong.
Conversation Goals
Goal 1: Evaluate for OUD
Dr. Pasko struggled to find the right tone while evaluating Lori for opioid use. He frequently slipped into a controlling approach, but did try to show Lori respect and empathy, which eventually helped her feel comfortable talking about her opioid use.
Goal 2: Build Motivation to Reduce Use
Dr. Pasko tried to push Lori into starting treatment too quickly and struggled to build her motivation first. It’s important to help patients find their own reasons to make a big change like entering treatment for OUD. If they’re not motivated, they are less likely to stick with treatments and more likely to relapse and possibly overdose.
Goal 3: Decide on Treatment Plan
When the provider was helping Lori decide on a treatment plan, he made errors in his description of the pharmacology drugs, and chose not to correct himself. For details on the errors he made, see Areas for Improvement, below.
Goal 4: Plan Immediate Next Steps
The provider described the process for her upcoming intake visit for buprenorphine, but did not recommend that she try counseling. Worse, he skipped discussing any risk-prevention steps to help her avoid overdose, including prescribing naloxone, and warning her about mixing medications.
Successful Moments
Here are some things to remember when dealing with this kind of incident:
Asking Open-Ended Questions
“Out of the different options we’ve talked about, do any feel like they would be the right fit for you?”
Phrasing a recommendation as an open-ended question is a good way to avoid seeming controlling. It gives the patients an easy way to agree, but leaves open the ability to say why if they’re not comfortable with a suggestion and explain why.
Expressing Empathy
“If you felt more than your usual pain when you stopped taking the pills, that’s not uncommon.”
Normalizing the experience of OUD is a great way to address the stigma many patients feel and help them be comfortable talking about treating their condition. Affirming their strengths and validating their feelings are also good techniques.
Respectfully Sharing Information
The provider chose not to use Ask-Tell-Ask. Asking for permission before sharing new information is an effective way to engage patients and also show them respect.
Areas for Improvement
Here are some common mistakes that Dr. Pasko made.
Factual Errors
“One thing I can do right now is prescribe naltrexone to block your cravings.”
Naltrexone can precipitate painful withdrawal symptoms in patients who take it without first undergoing 7 to 14 days of medically supervised withdrawal. Make sure that your recommendations for medication follow the correct prescribing information. You can review the Pharmacology for OUD movie in your menu.
Rushed the Patient
“There are a lot of good treatments we could offer to help with your opioid use.”
There is nothing wrong with what Dr. Pasko said here, but he pushed Lori too soon, before she was ready to discuss treatment. Make sure you build your patients’ motivation before you bring up treatment, they’ll have a better chance of success if they’re really committed to making a change.
Lack of Empathy
“You need to do detox. I can’t treat you until you get clean.”
Bluntly telling Lori that he can’t help her, even if well-intentioned, comes across as judgmental and unempathetic. Dr. Pasko should try using validation, normalization, or affirmations instead.
Recommendations
In future conversation with patients who have opioid use disorder, remember that the following techniques can help you build and maintain the relationship you need to help them seek recovery.
Open-Ended Questions:
Ask questions without a yes/no or one-word answer.
Showing Empathy:
Affirmation: Acknowledge your patients’ autonomy, strengths and past successes to build their confidence.
Validation: Acknowledge that your patients’ struggles are real and important.
Normalizing: Acknowledge other people have had and overcome the same challenges.
Respectful Sharing of Information:
Ask Permission before sharing new information.
Use Ask-Tell-Ask to learn what patients already know before sharing new information, then follow up to be sure they understood.