DOCTOR: So, Lori, how are you?
LORI: (uncomfortable) Enh. Fine.
DR. DOCTOR: 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…
DOCTOR: So, I know you're here today because you called to get your oxycodone refilled. (Lori nods) And I wanted to see you first because... I have some concerns.
LORI: (defensive) What sort of concerns?
LORI THOUGHT: Why won't you give me my pills?
COACH: Immediately bringing up Lori's opioid use made her feel defensive and worried. Make sure you build rapport with her instead of putting her on the spot. She won’t be comfortable talking about her opioid use if she feels you’ve judged her.
DOCTOR: I can't refill your prescription today.
LORI: (worried) What? (beat) I-I'm almost out. When will you be...?
DOCTOR: I know you're getting medicine from other doctors. (Lori shakes her head in shock)
I checked a database and it shows that you've gotten prescriptions from a... Dr. Leonard Einhorn.
LORI: I can explain… (coming up with lies on the spot; she wasn't expecting this) 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 THOUGHT: You don't believe me. I need to get my pills somewhere else…
DOCTOR: Your urine test also came back positive for codeine and morphine. Our system doesn't show you receiving any prescription for those.
LORI: Uh... (coming up with an excuse on the fly) 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 THOUGHT: I need a better story. I sound too desperate...
COACH: Lori knows that you understand that she's lying, but she's not ready to tell you the truth yet. Showing her that you respect and empathize with her to help her trust you. She needs to know that you won't turn against her if she tells you the truth.
DOCTOR: I'm going to ask you a few questions about your opioid use.
LORI: (wary, coming up with all her excuses) Uh, okay…
DOCTOR: 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.
DOCTOR: And have you ever missed work, or a social event because you had taken too many pills, or because you wanted to take pills instead?
LORI: No. No, I'm fine.
DOCTOR: You said you went a few days without your medication... How did it feel when that happened?
LORI: Not... great.
DOCTOR: 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... (she stops herself, concerned that she's about to risk not getting pills) Again, I should've just come to you when that happened. Sorry about that.
COACH: Good job. By asking an open-ended question, you 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.
DOCTOR: 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 having them. It can feel pretty terrible to stop if you're not prepared.
LORI: Yeah. The times I've gone without... (not yet wanting to admit to other pills) ...the medicine, it's been- (beat) 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: Good job normalizing Lori's withdrawal experience. By explaining that withdrawal symptoms are natural for anyone using opioids for an extended period, you helped her feel less worried about what you think of her.
DOCTOR: 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?" (Pause.) And I think he knew it was because... So he went and I stayed. And that Monday, when I went to work, everything just... Never mind, it's... never mind.
LORI THOUGHT: I was so blitzed that day... I couldn't even remember the client's name.
COACH: Great job. By using an open-ended question, you 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.
DOCTOR: I'm hearing that the opioids you're taking are causing some real problems for you.
LORI: I think I know what you're going to say...
DOCTOR: 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: (fighting back tears) Can you just write me a prescription?... Please?... I won't... I'll take it as it says, I won't...Okay?
DOCTOR: 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... "First batch is free," like...as a joke.
LORI 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, you're building her confidence and motivation to change.
DOCTOR: 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.
DOCTOR: There are treatments we can talk about.
LORI: 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.
LORI THOUGHT: I've been lying to everyone for so long. It feels good to just admit it.
COACH: Good job 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.
DOCTOR: 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: Maybe. I don't know. Is it really gonna help my pain?
DOCTOR: I often find that once we can stabilize people on buprenorphine their pain starts to improve, and we can also 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 you wouldn't have to go to a new clinic or start with a new doctor.
LORI: I don't know...
LORI THOUGHT: That doesn't sound too bad, I guess…
DOCTOR: One thing I can do for you right now is prescribe naltrexone to block your cravings.
LORI: What does that do?
DOCTOR: It's a medication that blocks your brain's opioid receptors, so opioids won't affect you anymore. And since it's not a controlled substance, I can prescribe it today, if you want.
COACH: 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. Try correcting your mistake so Lori can make an informed decision.
DOCTOR: 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 (winces) withdrawal. What if my back gets bad again?
DOCTOR: 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.
DOCTOR: 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-
DOCTOR: Buprenorphine.
LORI: Yeah. That.
COACH: Lori was a little confused by your struggles to keep the facts straight about her medication options, but now she's made a good choice. And because the doctor has a DATA-2000 waiver, he is able to offer the treatment she wants right in his office.
DOCTOR: 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.
DOCTOR: 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.
DOCTOR: 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 THOUGHT: Oooh, this stuff better work…
COACH: Good job. By asking permission before sharing what could be disturbing information -- that Lori will have to feel some withdrawal symptoms before starting -- you helped her feel respected and supported enough to make an intake appointment.
DOCTOR: 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'll think about it. Okay? I'm just not... I didn't come in here expecting to... (takes a breath) I just don't think I'm ready.
DOCTOR: I'm going to put that appointment on the calendar for next week anyway, if that's okay? And, if you're not ready, we can just use the time to talk a little more... see if there are any concerns I can help you address...
LORI: Yeah, okay.
DOCTOR: I can't give you the refill you came in for, but please do come back when you're out of pills. The medications used during treatment are a lot safer than trying to get opioids on your own.
LORI: Look, I'll think about it, okay? That's all I can say.
Overall the doctor struggled to engage Lori in discussing her opioid use, and the doctor failed to sufficiently motivate her to seek treatment. This doctor occasionally slipped into a controlling approach, but did try to show Lori respect and empathy, which eventually helped her feel comfortable talking about he opioid use. This doctor pushed her to start treatment. It’s important to show more empathy for Lori and help her find her own reasons to start treatment. Empathy will build her motivation to change and she will be more likely to stick to her treatment plan in the long run.
When the doctor was helping Lori decide on a treatment plan, they made errors in their description of the pharmacology drugs, and did not always choose to correct those errors. Although the doctor described the process for her upcoming intake visit for buprenorphine, but didn’t recommend that she try counseling. Worse, the doctor skipped discussing any risk-prevention steps to help her avoid overdose, including prescribing naloxone, and warning her about mixing medications.