It is common for the provider/healthcare team to experience challenging conversations with patients as safety guidelines in the area of chronic pain and prescription opioids are implemented. Some topics that may elicit fear in patients and therefore potential discord may include:
- Discussing controlled substance agreements.
- Discussing community, state, and national guidelines for safe-prescribing practices.
- Informing new patients that opioids or other controlled substances will not be prescribed and/or increased.
- Informing patients that opioids will be discontinued and/or tapered.
- Discussing the dangers and side effects of the medication.
It is understandable and predictable for patients to express strong feelings when they are presented with information such as the need to reduce or eliminate opioids. Pain medications can become a patient’s primary coping strategy for dealing with physical, emotional, psychological and post-traumatic pain. Delivering a message about reducing or stopping such medications can be triggering and even terrifying for a patient and the patient’s family. In such situations, patient’s emotions are commonly first expressed in the form of anger directed toward the prescribing provider and healthcare team. When facing a highly emotional patient, it is helpful to consider what may be underlying the strong emotional expression. Often underneath the heightened emotional response such as anger, there is fear, grief, panic, sadness, and/or a belief that living without prescription opioids is impossible. Being curious and understanding about what may be beneath a highly emotional expression does not mean one should not take action in the service of safety; however, treading lightly and following the recommendations below will help make for a more positive outcome.
Prior to engaging in potentially challenging conversations, it is advisable to spend time reflecting on the core values and principles that you are upholding in the difficult conversation. For example, it may be in the service of practicing safe medicine, being in alignment with your colleagues, the medical board and/or community, state, and national safe opioid prescribing guidelines. When you are in alignment with your values and the healthcare team believes that the change is in the patient’s best interest, the difficult conversations are often more manageable and rewarding.
When asking a patient to do something they may be afraid to do or that they do not want to do, they may leave the appointment highly distressed, very angry, and/or inconsolably sad. It is common for providers and the healthcare team to feel that if a patient leaves in such a highly agitated way, this indicates that the outcome of the appointment was a failure. Reconsider this belief. When a provider or healthcare team member asks a patient to make a change that is guided by core principles and values and a belief that it is in the patient’s best interest to make the change, then the state the patient is leaving in can be considered a natural part of the patient’s therapeutic process, and a positive step toward the individual’s overall health and well-being.
Willingness to feel Uncomfortable
Difficult conversations often bring about discomfort for patients, their families, providers, and healthcare team members. When we model our willingness to be uncomfortable to our patients, it helps the process. Consider saying to yourself before engaging in such a conversation, “I am willing to be uncomfortable having this conversation because it is in the service of my value of safety and best-practice medicine.” It can be helpful to notice your own sympathetic nervous system activation (e.g., rapid, shallow breathing; clenching fists or jaw), and then engage in an activity to activate your parasympathetic nervous system (e.g., slowing down your exhale and softening your hands or jaw). Just as these situations can be highly triggering for our patients, they can be highly triggering for providers and the healthcare team, as well. These conversations go much more smoothly when providers or healthcare team members can identify which types of patients and situations trigger them the most and develop an intervention strategy to notice the trigger and proceed calmly and effectively with delivering effective patient care.
Relationship as a Resource
It is important not to underestimate the relationship between the patient and the provider or healthcare team as a resource. Most patients genuinely care for their providers and/or healthcare team and want to work collaboratively with them. Often, genuinely communicating with patients that you will stick by their side through the changes can be one of the most powerful tools. Patients often fear their providers or healthcare team will abandon them, ask them to make changes too quickly, not listen to their fears, and or “fire” them from their practice. Proactively quashing such fears and acknowledging that the fear is real to them will go a long way toward reducing those fears.
Belief and Confidence
Expressing the belief in the patient’s ability to make the change is one of the most valuable tools for creating positive clinical outcomes such as removing or reducing opioids. You may think the patient knows this; however, it is highly advisable to overtly tell the patient, even over multiple appointments, and even if it feels redundant or if you don’t completely believe that your patient will be able to make such changes. Believing the patient can change is critical to the success of the process. Over time, as you see your patient making such changes and actually increasing functioning and quality of life, you will be more confident in your patient’s abilities and it will be easier to relay your belief in them.
Difficult Conversations: Real life examples, Helpful Hints, and Tools – https://www.oregonpainguidance.org/clinical-tools
Motivational Interviewing Resources – http://www.motivationalinterviewing.org
Source: The Art of Difficult Conversations. (n.d.). Oregon Pain Guidance. https://www.oregonpainguidance.org/guideline/the-art-of-difficult-conversations/
Oregon Pain Guidance
The Oregon state resource for healthcare professionals treating pain.