DOCTOR: So, Lori, how are you?
LORI: 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: 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... (beat, trying to ease into it) My back is probably not helping. Most nights I can't even lie down...
LORI: That's why I called about the refill.
LORI THOUGHT: Why'd you make me come in today? Are you gonna take away my pills?
COACH: Good job. You showed empathy for Lori's job troubles, which helped build rapport. The more she trusts that you understand and care for her, the more likely she is to be honest about her opioid use.
DOCTOR: 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, you helped her feel less defensive, which made her willing to be honest with you that she is sometimes taking more oxycodone than prescribed.
DOCTOR: 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 THOUGHT: Oh, no... Please believe me.
COACH: Even though you used an open-ended question to broach the subject gently, Lori is still worried about telling you the truth about her other prescription. In the rest of the visit, continue to show empathy and understanding to help her trust you.
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... 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...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: 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?" 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: 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 THOUGHT: Yeah, "alone" is a really good word for how I've been feeling.
COACH: 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, you helped her confide that she lost her job because she was high at work.
DOCTOR: Would it be all right if we talked about some common threads I'm hearing in what you're saying?
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: Can you just write me a prescription?... Please?... I won't... I'll take it as it says, I won't ...Okay?
LORI THOUGHT: I can't talk about this. Please don't make me talk about this.
COACH: Asking permission before telling Lori that you think she has OUD shows that you respect 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."
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: 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... You think I have, uh, a "substance use disorder." I guess I can... I mean, that doesn't sound too awful. But... does that mean you're going to take them away? Because I mean, not having them? Sucks. It's unbearable. 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, you're helping Lori move toward being ready to discuss treatment.
DOCTOR: 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.
DOCTOR: What you're experiencing is a medical condition. Here 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 affirming your long history with Lori and all the past successes you've seen her have. You helped her feel comfortable admitting -- even to herself -- that her pain isn't the primary reason she's continuing to use opioids.
DOCTOR: Would it be all right if we talk about some treatment options that are available to you?
LORI: Um, sure. I guess.
DOCTOR: 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 THOUGHT: It can't hurt to hear the options...
COACH: Good job. It's always respectful to ask permission before sharing information with a patient. Now Lori will be more receptive to what you have to say and better prepared to choose between various treatment options.
DOCTOR: What do you know about methadone?
LORI: Uh, seriously?... Isn't that, for... I mean it's for... heroin, right?
DOCTOR: 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.
DOCTOR: 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 THOUGHT: I can't go be with... people like that. That's not me...
COACH: Nice use of Ask-Tell-Ask to share information. By first asking Lori what she already knew about methadone, you were able to adjust your explanation to acknowledge her concerns about its association with heroin, instead of just talking about how the medication works.
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: Uh, yeah, I think that'd be a better fit for me. To just come here, I mean.
DOCTOR: 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. You would have to do an intake exam before we start, and then I'd need to see you more often for a little while 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: Okay... Are those the only options?
LORI THOUGHT: That doesn't sound too bad, I guess…
COACH: 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.
DOCTOR: Another option would be to undergo medically managed withdrawal. You would receive medicines to help with the symptoms of withdrawal and would taper off opioids over the course of several days to a week. After the opioids are out of your system, I could prescribe you a medicine called naltrexone to help control your cravings. It is an injection that lasts for 28 days and it doesn’t allow opioids to work in your body during that time. So even if you took opioids on top of naltrexone, they wouldn’t work.
LORI: What do you mean?
DOCTOR: Think of naltrexone like a shield. When you're using it, your brain can't feel anything when you take opioids, so it can help people stop wanting to use them. But it can make you very sick if you haven’t cleared all the opioids out of your system.
LORI: It's a lot to think about... I mean, I'm... I'm scared.
COACH: Naltrexone is a good option for some patients, but it is generally not recommended for patients like Lori, who may need opioids to manage chronic pain.
DOCTOR: 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.
DOCTOR: 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 THOUGHT: I guess it's worth trying. Some people get off this stuff, right?
COACH: Nice job. By validating Lori’s concerns, you helped her open up further and admit how much she hates what OUD has done to her.
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.
DOCTOR: 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.
DOCTOR: 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.
DOCTOR: 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.
DOCTOR: 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... All right.
DOCTOR: 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: Um, Okay.
COACH: Good work. 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 office visit with a patient who has OUD.
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.
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: 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.
DOCTOR: I think that’s a great idea. Having another supportive person involved can only help. I'll make that appointment now.
LORI: Thanks.
Overall, the doctor did a great job engaging Lori in discussing her opioid use and motivating her to seek treatment. The doctor was respectful and empathetic while evaluating Lori for opioid use disorder. He took his time and expressed concern for Lori’s feelings, instead of rushing to complete the visit. Because he listened to her experiences and didn’t judge her, Lori felt comfortable telling him the truth about her increasingly problematic opioid use.
Empathy built Lori’s motivation for treatment! This is a crucial step, since patients who don’t feel motivated during treatment are less likely to stick with it and more likely to relapse. When it comes to deciding on a treatment plan, patient’s like Lori need accurate information about all the different pharmacology options, like this doctor displayed. He additionally did a great job planning the next steps for Lori. The doctor recommended she seek counseling and described the process for her upcoming intake visit to start buprenorphine. Most importantly, he remembered to discuss life-saving risk-reduction steps, like prescribing naloxone and warning Lori about the danger of mixing medications.
In real life, some patients might not be as ready to change. Don't get frustrated if it takes several visits before a patient is ready to discuss treatment, or even believe that you want to help them. The most important thing is to continue seeing them and focus on their well-being and safety. Even with the aid of pharmacology, many people recovering from opioid use disorder experience relapses. It's a difficult but common part of the recovery process.
Taking certain harm reduction steps can greatly increase your patients' chances of survival during a relapse or before beginning treatment. Most importantly, always prescribe naloxone to patients with OUD. Naloxone can be administered by a patient's family and friends, or first responders, to rapidly reverse the effects of opioids. This prevents respiratory distress in case of accidental overdose.
Warn patients about mixing drugs. 65% of deaths from heroin overdose and 77% of deaths from pain reliever overdose also involve alcohol or another medication, often benzodiazapines. Let your patients know these risks, and that -- while you don't recommend it -- if they do mix drugs, they should use a smaller amount of each one.
Discuss with your patients how they administer opioids. Patients who inject opioids may be at risk for vein damage, bacterial infections, or viruses like HIV and hepatitis C. Encourage patients who inject drugs to use resources for new syringes and equipment.
Encourage patients not to use opioids alone. To reduce the risk of death during an overdose, patients should make sure that a friend or family member is nearby who can administer naloxone.
And lastly, stay involved. Patients may feel ashamed to tell you if they start using again. Help them see they can trust you even during setbacks. Remember that continued opioid use can be a sign that their treatment dose is too low, or that they need more counseling, behavioral health, or case management support. Some patients may benefit from the additional structure and daily monitoring in an Opioid Treatment Program, but a return to opioid use does not in itself indicate this need. Many patients with OUD experience better recovery outcomes when they receive community and psychosocial support. Yet, there are often far fewer counselors and support services than patients, especially in rural areas. And it can be difficult to cover the costs of these services.
This is why it's so important to be able to offer patients pharmacology for OUD. Medications keep patients stable while they do the hard work of changing their behavior and rebuilding their lives. And the support they get from you can make a difference! Research found that patients who received standard medical management during medication monitoring visits had similar outcomes to patients who also saw a substance abuse or mental health counselor. So, as a primary care provider, the best thing you can do is to have multiple options available to treat patients with OUD. One of the most important is buprenorphine. To get a DATA-2000 waiver to prescribe buprenorphine, you must complete training -- 8 hours for physicians, 24 hours for Nurse Practitioners and PAs -- and then apply online. Waiver applications are reviewed by the DEA and SAMHSA within 45 days of receipt.
This concludes the simulation. Please click the link below to request a certificate of completion.