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: I imagine it's been a little stressful figuring out the next move.
Lori: Yeah, definitely that. So I'm having trouble sleeping, too, which, my back is probably not helping. Most nights I can't even lie down. That’s why I called about the refill.
Lori’s thought: Why did you make me come in today? Are you going to take away my pills?
Coach: The provider did a good job showing empathy for Lori’s job troubles, which helped build rapport. The more she trusts that he understands and cares for her, the more likely she is to be honest about her opioid use.
Dr. Pasko: I understand you're having a lot of pain and stress right now. Losing a job and all that worry, it's definitely something that can affect your pain levels.
Lori: Yeah. I mean, it's been, with the not sleeping, sometimes, the only way I can shut my mind down and go to bed is to take a little extra oxycodone, you know? Just right now, from the stress. So, I guess I went through it too fast this month.
Coach: Nice job! By validating the pain and stress that Lori is feeling, the provider helped her feel less defensive, which made her willing to be honest with him that she is sometimes taking more oxycodone than prescribed.
Dr. Pasko: Our prescription policy changed recently. We now check an online database before refilling any opioid prescription, like the oxycodone you’re taking, so we have a more complete picture of our patients' medication histories and prescription fills. And I saw that you recently had another prescription for oxycodone written by a Dr. Leonard Einhorn. Can you tell me a little about that?
Lori: 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: Oh no, please believe me.
Coach: Even though the provider used an open-ended question to broach the subject gently, Lori is still worried about telling him the truth about her other prescription. In the rest of the visit, the provider should continue to show empathy and understanding to help her trust him.
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: The provider 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 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: The provider 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: It sounds like you've been carrying this alone for a long time.
Lori: When I said I lost my job? I'd been upset and maybe, I guess maybe I took too many pills, and I was there but not there really and I, I screwed up. Big time. With a client. It was not my finest hour.
Lori's thought: Yeah, "alone" is a really good word for how I've been feeling.
Coach: The provider did a good job. Even if you disapprove of a patient's choices, there may still be elements of their story you can relate to and empathize with, such as the difficulty of carrying a burden alone. By validating Lori's feelings without judgment, the provider helped her confide that she lost her job because she was high at work.
Dr. Pasko: Would it be all right if we talked about some common threads I'm hearing in what you're saying?
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?
Coach: Asking permission before telling Lori that he thinks she has OUD shows that the provider respects her and won't push her into any treatment she isn't ready for. Affirming a patient's autonomy to say "no," actually makes them more likely to say "yes."
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. (sighs) 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, the provider is building her confidence and motivation to change.
Dr. Pasko: A substance use disorder isn't a moral failing. I see how much you're beating yourself up about this, but it happens to a lot of people. And what doctors have found is that certain people are more likely to have trouble with opioids and it's not because they did anything wrong. It's got more to do with their genetic make-up and what's going on in their lives.
Lori: So, (processing) You think I have, uh, a "substance use disorder." I guess I can, I mean that doesn’t sound too awful. (nervously) But does that mean you're going to take them away? Because I mean, not having them sucks! It's unbearable. (collecting herself) I'm sorry.
Coach: People with substance use disorders often have internalized cultural messages about their disease being their own fault. By normalizing that SUDs are influenced by many factors other than just willpower, the provider is helping Lori move toward being ready to discuss treatment.
Dr. Pasko: I’ve been seeing you for a long time, Lori. Through law school, getting your job, tackling your high blood pressure, your commitment to your physical therapy after the accident, I want to help you get all the support you need to recover from this, too.
Lori: I wish it was that easy, I can’t even get through a day without these pills.
Dr. Pasko: What you’re experiencing is a medical condition. (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 purpose of discussing treatment options with Lori, you 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: The provider did a good job affirming his long history with Lori and all the past successes he’s seen her have. He helped her feel comfortable admitting, even to herself, that her pain isn’t the primary reason she’s continuing to use opioids.
Dr. Pasko: Would it be all right if we talk about some treatment options that are available to you?
Lori: (nervously) Um, sure. I guess.
Dr. Pasko: (reassuring) I know you're worried about the withdrawal symptoms. But there are a lot of things we can do to help with that discomfort.
Lori: Okay.
Lori's thought: It can't hurt to hear the options.