By: Bryan Hendrickson
As a profession, we are beginning to grasp the severity and reality of the opiate epidemic. Many of us were recently born into this era as new providers, or find ourselves suddenly responsible for helping patients identified under the lens of this new understanding, that opiate medications cause harm. Talking with new patients about opioid medications presents a unique opportunity to exercise compassion, meld patient and physician-oriented objectives, and to lay foundations for relationships that will help foster change.
When a patient walks into the room with a history of opioid medication use, it helps me to remember that their primary concern is their pain. It is important that we hear and acknowledge that pain and help provide a framework that offers support and understanding. It is also important that we acknowledge that, for the most part, patients on these controlled substances had them prescribed by another provider. I try to imagine there was a relationship of trust with my patients and their previous providers, that patients expressed their pain and, at some point, the solution presented was opiate medication. I try to shift away from assigning blame, but acknowledge our own shared responsibility for creating these situations. Pausing to remember that pain is the primary concern and acknowledging our roles as a profession helps me create opportunities to listen and empathize, then move towards addressing concerns and potential change with opiate medication use.
As physicians operating within the time constraints of modern clinical practice, we often emphasize agenda setting and outlining goals for each visit. Sometimes when encountering a situation where chronic opiate medication use is involved, it is easy to jump right to the objective of reducing or eliminating opiate medications. This is likely a beneficial goal for our patients. It is clearly an important and safety oriented objective. However, it may not even be in the consideration set of objectives for a patient coming into the office that day. How we engage patients in their primary concerns and introduce these additional objectives can have a strong impact on patients’ willingness to discuss reductions in opiate medication use and, particularly, on their interest in making changes.
Laying Foundation for Change
I find it helpful to keep the initial focus of a new patient visit for chronic pain on a straightforward history of pain and the events leading up to the current situation. I use this as an opportunity to begin a conversation about the impact of pain on function, but continue to keep the emphasis on collecting the story. I follow this with a detailed exam at the location of the pain. Then, having listened to the story and personally evaluated the pain, I move to discussing an overall plan.
I discuss the multiple modalities available for managing pain and begin a conversation that shifts towards functional goals and realistic expectations for reducing pain. I confirm my understanding of current opiate medication use and then introduce potential risks among the known benefits of opioid medication. I consider how best to move towards reducing discussing eliminating these potentially harmful medications. There are times where the end result of this process is dissatisfaction or disagreement; however, most often this approach leads to an opportunity to provide information and begin a conversation about change.
Moving towards a Legacy
I believe we best serve our patients by taking personal responsibility for addressing opiate medication use. We have opportunities to exercise compassion, facilitate shared decision making, and build foundations for change, that can help reduce harm from opioid medications. As we learn from the opioid epidemic and how to address it as a profession, perhaps our legacy will be the relationships we build in these shared efforts.
Bryan Hendrickson, MD, is currently a third-year resident in the Division of Family Medicine. His medical interests include community medicine, clinical informatics, medical education, and LGBTQ health.