Coach: The provider did a good job. It's always respectful to ask permission before sharing information with a patient. Now Lori will be more receptive to what he has to say and better prepared to choose between various treatment options.
Dr. Pasko: What do you know about methadone?
Lori: Uh, seriously? Isn't that, for, I mean it's for heroin, right?
Dr. Pasko: Methadone is known for treating heroin use, but heroin, methadone and the medications you've been taking are all opioids, so they affect the brain in similar ways. 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: This was a nice use of Ask-Tell-Ask to share information. By first asking Lori what she already knew about methadone, the provider was able to adjust his explanation to acknowledge her concerns about its association with heroin, instead of just talking about how the medication works.
Dr. Pasko: Another option would be a medication called buprenorphine. This is something I would be able to prescribe here in the office. Is that something you’d like to hear more about?
Lori: Uh, yeah, I think that’d be a better fit for me. To just come here, I mean.
Dr. Pasko: Buprenorphine also activates the parts of your brain that opioids affect, but only partially, so it’s harder to misuse or overdose. And like methadone, it can help with cravings and withdrawal symptoms and let you feel stable throughout the day. Now, you would have to take an intake exam before we start, and then I’d need to see you more often for a little while, just to make sure that you feel like it’s helping you and that we have you on the right dose. I’d also want you working with a counselor to find more ways to deal with stress.
Lori: (intrigued) Okay, are those the only options?
Lori’s thought: (hopeful) That doesn’t sound too bad I guess.
Coach: The provider did a good job respectfully sharing information. When there's no reason to expect a patient to have existing knowledge about a topic (like buprenorphine), you can begin Ask-Tell-Ask by asking if they'd like to hear the information, and then following up with a question to make sure they understood.
Dr. Pasko: If you're not comfortable with methadone or buprenorphine, you could consider going to a medically managed detoxification program. They would use medications to help you feel comfortable during withdrawal, but when you're done, you wouldn't continue with medication. You would engage in education, counseling, peer and support groups to help you develop new ways to respond to stress that don't involve oxycodone. What would you think of that?
Lori: So, like a rehab, then? But what if, I mean, what if it's not just withdrawal. What if my back gets bad again?
Dr. Pasko: If your back is still bothering you, then that might not be the best approach. Stress and pain are big reasons people relapse, and I want you to have the best chance to make a full recovery.
Lori: It’s a lot to think about. I mean, I’m, I’m scared.
Coach: Patients who rely on counseling and/or detox alone are much more likely to relapse and potentially overdose. While you don't want to push a patient into a treatment they're not comfortable with, it's important to help them make an informed decision.
Dr. Pasko: The concerns you're having are completely normal. A big change like this isn't easy.
Lori: I just, I hate what it's done to me. I mean, I lost my job. I hated my job, but I should have been able to do it, right? I never thought I would be this person. I, I hate it.
Dr. Pasko: I hear how much you want to make this change. So, let's figure out what's going to work best for you.
Lori: Okay.
Lori's thought: I guess it's worth trying. Some people get off this stuff, right?
Coach: The provider did a nice job. By validating Lori's concerns, he helped her open up further and admit how much she hates what OUD has done to her.
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: The provider did a nice job collaborating with Lori to make a treatment plan that's right for her! He helped her make an informed decision. 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: And now let's make sure we talk a little about how to stay safe from overdosing until we start treatment. A lot of times when people experience an overdose, it's actually from mixing opioids with other medications, like anxiety medicines, sleep medicines, or alcohol. Those can work together with the opioids to make you stop breathing.
Lori: I won't, I never. (stops) All right.
Dr. Pasko: And I'm going to write you a prescription for naloxone. It's a sort of antidote. If you accidentally take too many opioids and stop breathing, your husband or a friend should have it on hand to revive you.
Lori: (winces) Um. Okay.
Coach: This was good. Talking to patients about mixing medications and providing naloxone in case of an overdose are crucial harm-reduction steps that should happen before the end of any visit with a patient who has OUD.
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: Yeah, let’s try that.
Lori’s thought: Oh, this stuff better work.
Coach: This was good. By asking permission before sharing what could be disturbing information, that Lori will have to feel some withdrawal symptoms before starting, the provider helped her feel respected and supported enough to make an intake appointment.
Dr. Pasko: So the medication definitely helps with the physical symptoms you've experienced, but there are often emotional triggers, as well, and it can be helpful to talk about those and learn new ways of responding to them. I'm wondering what you think of starting counseling?
Lori: I guess it would be, I've been pretty alone, you know, after I lost my job. And Alex is, well, it's been hard for him to, to know what to say to me.
Dr. Pasko: It can really help to have someone neutral to talk to, who won't be affected by your decisions.
Lori: Yeah. My, my friend, the one with the horse pills, I think he’s seeing someone now, too. Maybe I’ll, you know, check in and see if they’re helping.
Dr. Pasko: And I can give you resources for a few other places that offer counseling services.
Lori: Yeah, it, it might be good to talk to someone.
Coach: This was a nice job of using an open-ended question to broach the idea of counseling. Lori seems open to the idea, but be aware that some patients may be more hesitant, due to misconceptions about counseling, time constraints, or cost or lack of insurance.
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: Maybe, maybe I’ll see if Alex can come with me? For that first appointment? I think maybe he would be glad. He, he knows what the pills have been doing to me.
Dr. Pasko: I think that’s a great idea. Having another supportive person involved can only help. I’ll make that appointment now.
Lori: (warmly) Thanks.