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Chapter 13 

Chapter 13
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date: 02 August 2021

Video 13.1 Discontinuing Opioids

Table 13.2 Motivation Interviewing (MI) Video Demonstration

Patient

Physician

Comment

1.

Hi George, it’s good to see you again. How have you been?

2.

Good to see you doc.

Tell me how it’s been going.

  • It is reasonable to start an appointment with this general greeting or opening of “How have you been?” or “Tell me how it’s been going.” However, with a chronic pain patient returning to the clinic it is unlikely that he is coming in to tell you how great he feels.

  • An alternative might be to be empathic and guess at his experience: “I imagine you are still feeling more pain than you want.” Or “You are probably hoping we can do more to address your pain.”

  • The value of expressing your empathy first and early is that the patient, if he feels understood, may be more likely to engage in behaviors that you guide towards that otherwise he would resist.

3.

Oh, the pain is just still a real problem.

Man I’m sorry to hear that. Still having lots of pain?

The physician expresses some empathy and compassion which is very likely healing. The question however inadvertently helps the patient to focus on pain and not solutions. What might happen if the physician said something like, “The pain is not going away as you would like.” Or “There is more pain at more times than you were thinking there would have to be.”

4.

Yeah it’s just with me all the time.

Tell me a little bit more about that.

  • This is an important decision point for the physician. It is reasonable to follow the patient and express interest in his most pressing experience and perhaps useful to find out more about the pain if the physician has a diagnostic dilemma. However, this question is pulling for the patient to access his pain experiences rather than his pain management experiences.

  • Here are some alternative responses that might express empathy for the patient’s experience and facilitate him accessing pain management motivations:

  • “You wish there were sometimes when you felt less pain.”

  • “It must be difficult to participate in your life if all your experience is captured by your pain all the time.”

  • “You need sometimes when you have less pain.”

  • “The pain is with you all the time but what kinds of things have you been doing that create any variation in the pain?”

5.

Well, I, when I get up it’s like somebody’s been beatin’ on my back with a hammer. It takes me five minutes just to get out of bed. It’s, it’s a little better once I start walkin’, but the pills I’m taking are just not doing what they’re used to do.

So it seems to be getting worse instead of better.

  • The physician does a nice job of demonstrating he is listening by making this reflective listening response or summary. However, the physician is focused on the sustain talk (the don’t change or health risky) side. Coming along side is important but what might happen if the physician adds a focus on the change side: “So it seems to be getting worse instead of better. Tell me more about how it gets better when you start walking.”

  • Or “So it seems to be getting worse instead of better. What else besides the walking seems to make it a little better?”

6.

Yes.

Wow. Well, you know we used this pain scale before. Tell me where your pain, the average pain, uh, level over the past week for you, if 0’s no pain at all and 10’s the worst pain you’ve ever had.

7.

Oh I’d have to say it’s around 8.

Wow. How about if you take the medicine?

8.

Well I just have to say it’s really 9 and then 8 with the medicine.

Yeah.

9.

– so it doesn’t get much better than that. It’s with me all the time and it’s interfering with everything I do.

So severe pain –

This simple short sentence probably lets the patient know that the physician understands and has compassion. It’s a reflective listening statement or a summary of what the patient has said.

10.

Yes.

– all the time. What about your uh, general enjoyment of life. To what level on that 0 to 10 scale is the pain interfering with your general enjoyment of life.

Notice the physician probably knows the answer to this question about enjoyment of life. It would be unusual for someone with an 8 or 9 level of pain to say that they are enjoying their life a lot. If the physician were to offer his guess, “You’re probably not able to enjoy your life very much with that level of pain.” this patient would agree and again experience the physician as empathic and understanding. Another patient could disagree and in such a case notice the patient would be calling his attention to pain management behaviors rather than focusing only on the pain.

11.

Well it’s hard to enjoy life when you’re in pain all the time. I’d have to put it, that up there at around 8 too, it’s just.

Mmm, so life’s not much fun.

Again the physician communicates his understanding. Even without pain relief empathy can be important to patients.

12.

No.

Wow. I’m sorry to hear that. What about your activity level. You remember one of the things we want to do with this medicine is try to get you more active doing the things you want to do. On a scale of 0 to 10, how much is the, the pain interfering with your general activity level?

13.

It’s interfered a great deal. I’d say about, I guess maybe a 7 or 8 uh, because uh, it just hurts to do anything.

So you’re still not able to do the things that you really want to do.

  • The physician is calling attention to how the patient would enjoy creating more activities and life for himself without directly telling him to do so. If told directly to physically move more this patient would very likely take an even more adamant stance that he needs more medication for pain relief.

  • Variations on this might include: “Logically enough, you are looking for less pain before you start doing the things you need to do.”

  • Or: “If you could get some pain relief you might be able to see yourself doing some things in your day.”

  • Perhaps if the physician said something like this the patient might either feel understood or not have to say what he says next which reinforces his experience of his pain as being debilitating.

14.

No, I can’t work. I mean, I, even doing anything hurts, and even sittin’ down hurts. If I move suddenly then I get a sharp pain and it’s just with me all the time.

Wow.

15.

It just seems like the medicine’s not working. I think I need something stronger.

Well, we started at the Lortab 10 three times a day and then we went up to four times a day. Tell me how you’re taking your medicine.

  • It might be very reasonable for the physician to describe the medication schedule or perhaps this is just happening in this video demonstration for us viewers. There may be some advantage in going directly to the open question, “Tell me how you’re taking your medicine.” to learn what the patient is doing without anchoring his answer to 4 times a day.

  • Alternately the physician could get out in front of the health risky behavior (taking more medication than is prescribed) by saying something like, “With these levels of pain I imagine you have tried taking more medications than we have arranged. Perhaps you have even out before the prescription was ready for a refill.” If the physician’s guess is correct the patient will feel understood and the consult will more easily focus on the truth. If the physician’s guess is incorrect the patient will describe the health promoting behavior of his reasons for not increasing pain medication.

16.

Well, I try to take it pretty much like the, like it says to take it. And I’ve noticed that, I have taken it, I’ve doubled up on it a little to try to –

Mm hmm.

It is useful to notice and perhaps to follow up on the patient saying, “I try to take it pretty much like it says to take it.” This is change talk. The physician could ask, “How come you try to take it as it says to take it?” thereby soliciting possible other change talk.

17.

– it doesn’t seem to be doing much good.

Even when you double up?

18.

Right.

Tell me what happens.

Now the physician is pulling for change talk, focusing on reasons to not take more medication.

19.

Well, it’s uh, it may increase the pain relief a little but it also makes me feel kinda drowsy and woozy and uh, it’s just not, uh, it’s just not doing what it’s supposed to do.

Yeah, yeah. I noticed that the last time you were here. It seemed like you had uh, you were drowsy or sleepy, almost uh, a little bit drugged, so you have that feeling sometimes.

  • The physician demonstrates his understanding and has a neutral emotional tone with his summary. This is important because if the physician takes via words or emotional tone, the view that taking more medication is a “bad” thing to do, the patient will almost certainly defend the view that it is a reasonable or a “good” thing to do. By being neutral in tone the physician avoids condoning taking more medication and nurtures the patient’s motivation to not take more medication because of disliking the “drowsy and woozy” feelings.

  • If the physician chose at this point to focus on the patient’s motivation to not double up on the medication he might do so by exploring additional aspects of motivation besides the desire dimension (the patient does not enjoy the drowsy and woozy feelings):

  • “So doubling up makes you feel drowsy and woozy. What other reasons to you have for not doubling up?” or

  • “So doubling up makes you feel drowsy and woozy. Why else do you think it is a good idea to not increase your intake of this medication?”

20.

Sometimes.

Tell me what else you’ve uh, tried to decrease your pain. I know last time we talked about uh, trying to increase your exercise, maybe walking more and I wrote you a prescription for some physical therapy.

The physician’s neutral tone also allows him to now explore what else the patient might be doing to manage his pain. If the physician had expressed in word or tone disapproval of doubling up on the medication, this question about what else would likely be perceived by the patient as a test or punishment.

21.

Right.

Have you done any PT?

In the previous line the physician is using an open question that encourages the patient to tell his story. This closed question stops that a little and perhaps now puts pressure on the physician to come up with the next question and perhaps the patient feels more passive, waiting for the next question.

22.

Well I tried the walkin’, and uh –

Mm hmm.

23.

– I uh, checked out the PT but to me it was like, you know, I can’t do this stuff and workin’ out and things like that, I can’t do that with the pain I’m in, and the walkin’ doesn’t seem to help much either.

Mm hmm. Mm hmm.

24.

Uh, sometimes a little bit of movement will help. I can stretch.

Yeah.

There might be an opportunity for the physician to nurture the patient’s pain management with stretching by saying something like, “Tell me more about how you stretch to help.” Or maybe, “Walking doesn’t help all the time and certain other exercises would be too painful but tell me about the stretches you do and why you think they help.”

25.

But uh, as far as uh, any significant walkin’, it just is too painful.

Yeah, so activity of any kind seems to make things worse.

This might be intentional or not but the physician has exaggerated what the patient has said. The patient has said, working out and walking doesn’t help. He has also said that a little bit of movement or stretching can help. Mostly the patient is saying that nothing but the medication helps. The physician wisely overstates the sustain talk (motivation to not do the health promoting behavior) by saying “activity of any kind seems to make things worse.” On a lucky day, perhaps the patient would disagree with this and say, “No, stretching sometimes helps.” which would come from the patient accessing his motivation or experiences to engage in the health promoting behavior (change talk). Here he just agrees (line 26) so the physician is likely perceived as understanding and the physician has also learned how unlikely the patient is to engage in any activity.

26.

Yeah, yeah.

Mmm. Well, I had something I needed to ask you about George. I got a letter from your uh, insurance company, and they um, they said that you been getting Lortab from uh, two other doctors besides me, which is uh, something we agreed on your original visit uh, that you wouldn’t do. What can you tell me about that?

  • The physician’s tone here is again neutral and not punishing or scolding. It is as if he is talking about the weather. This increases the likelihood that the patient will engage in a genuine exploration of how he is managing his pain.

  • Notice that if the physician had earlier proposed needing more medication as a logical outcome of doubling up it would make the transition to exploring obtaining medication from other doctors a bit smoother. At issue is not so much whether the patient is getting medications from other doctors (since the physician is very likely to trust the insurance report and the prescription monitoring program) but how the patient might find his motivation to not get multiple prescriptions.

  • These might be some ways to pull for those experiences: “So doubling up on the medication means you need more of it and I can imagine it just makes sense to you to try and get it from any doctor. But what might be the downside of seeing multiple doctors for this pain or this pain medication?” or “So doubling up on the medication means you need more of it and I can imagine it just makes sense to you to try and get it from any doctor. But what might you regret by getting and using more medication?”

27.

That’s gotta be a mistake. Somebody just make a clerical error or something ‘cause that, that didn’t happen.

Well, I checked the uh, prescription monitoring program as well and uh, they also show that George Danten with uh, a birthdate of 4/17/51 has gotten Lortab from ____.

28.

Well, somebody just got my information then ‘cause that’s gotta be what happened because that’s, I didn’t do that.

You didn’t go to any other doctors.

The physician again is neutral in his tone which is invaluable. If the physician pushes strongly for not obtaining multiple prescriptions the patient will very likely not return but still obtain multiple prescriptions, or become better at covering his tracks, or become more of a believer in his need for more medication. By remaining neutral the physician could solicit and nurture the patient’s motivation to change (albeit very little motivation): “I suppose it’s possible that the insurance company and the prescription monitoring program got it wrong. Perhaps more importantly it sounds like you want me to believe that you are only getting medications from me. Why is that important to you?”

29.

No. Somebody just got my information from some place.

Mmm. Well, I’m, I’m concerned and I, I, I hear that you’re dealing with a lot of pain. Uh, I’m concerned that the numbers that we’ve had when we started about your pain and your activity, we haven’t really budged those at all, um, and then some other things. You called uh, in the middle of the month this time that your prescription had been stolen. We really don’t like to, to refill after that.

  • The physician of course needs to provide ethical and responsible care which includes not refilling medications inappropriately or not providing too much medication. It might be easier for the patient to hear this as well as agree with it, if the physician were to expand his affirmation (“I hear that you’re dealing with a lot of pain”).

  • This might include calling attention to something the patient is doing well prior to focusing on something the patient will find unlikeable. This might sound like, “I hear that you’re dealing with a lot of pain and you have had to become creative and resourceful to find the pain medication. You are understandably focused on the pain medication because you are very motivated by the pain levels you experience. My guess is that you have reached the limit of what this or any other opiate pain reliever is going to do for you.” Or providing an affirmation to the patient in some area other than pain management then going to the difficult to hear news: “I know from getting to know you that you have persisted through some tough situations, like in {Vietnam, loss of your job, divorce}. My guess is that you have reached the limit of what this or any other opiate pain reliever is going to do for you.”

30.

Well, I couldn’t have gotten by.

So you got extra pills this month.

31.

I just think I need something stronger. This stuff’s just not workin’ like it used to.

So you’re feeling is maybe more medicine would help.

  • The physician’s response demonstrates valuable empathy and understanding. Alterative responses that might pull for more patient motivation might be:

  • “You want the medication to work like it used to.” (This might be part of the lead in toward a discussion of how the medication can be used so as to minimize the development of tolerance.)

  • “The medication is not enough. You need something to provide additional or adjunctive pain relief.” (This might facilitate the patient finding his motivation to try activities or physical therapy again or for the first time really).

32.

Yeah, yeah, I think so.

Well, I, I guess I have to say uh, I feel like maybe the opposite is true, that maybe we’re doing more harm than good with the medicine. When we first talked uh, we talked about the fact that, you know, these are dangerous medicines, so, sometimes you, you get more pain you take more medicine and then suddenly you go to sleep and you don’t wake up. And I really don’t want that to happen with you.

  • Health care providers typically use a variety of helping styles, sometimes educating, advising or telling which might be called a directing helping style. Other times listening and empathizing which might be called a following helping style.

  • In this example, the physician is now providing some education using a directing helping style. An alternative would be to use a motivational interviewing style where the physician attempts to solicit from the patient the advice or information he would otherwise be giving: “What concerns do you have about using more of this medication or what you refer to as a stronger medication?” or “It’s understandable that you want less pain but what might happen if you use too much of this medication?”

33.

Well, isn’t there some other kind of medicine that’s not quite like that? Something that’ll work. I mean, I’m kind of at the end of my rope here.

Yeah. Well, there are some other options and I want, I want to talk through ‘em with you today. I guess one of my first concerns is whether the pills have become a part of the problem. Sometimes people, you know, they get pain, they take a pill, they take another pill and then suddenly that takes on a life of its own and their life begins to revolve around the pills and it gets chaotic and they’re getting’ side effects and scary things happen, uh, they wonder if maybe the pills have become the main problem. I’m wondering, you know, have you ever thought about that? Do we need to be talkin’ about detox today?

  • It seems accurate and intentionally helpful to describe how detox might be worth considering. However, since the patient is not thinking of himself as using too much medication and certainly not thinking of himself as addicted (which might be his association with “detox”) he very likely will resist this idea. What if the physician said what he says in line 35 which is another explanation for reducing the medication? Might the patient go along easier with that?

  • The principle here is to come along side the patient and look at his situation with him rather than face the patient and in the most extreme version confront him. How does the patient understand or explain that the medication is no longer working? He has already experienced the trade off of more medication results in some temporary increase in relief but with the loss of alertness. So for example, the physician might say this, “Your experience is pretty common with all pain medications. If taken regularly or too often they don’t work as well like you are noticing and then more medication provides only a little more relief with the loss of alertness again like you have noticed. It’s unfortunate and a dilemma.” This kind of statement is fishing for the patient to identify the medication as the problem rather than the physician being the one to say it is the problem.

34.

Detox? No, I don’t think so, I don’t think so. I think I just need something stronger.

You don’t think the pills have become a problem for you, that they’re just creating more and more craving for more and more pills.

Unintentionally, the physician has perhaps created this disagreement. When the physician argues for the health promoting behavior (reducing pain medication) the patient takes the other side and argues for the health risky behavior (more pain medication). If the physician had earlier guessed at how the patient found it reasonable to see more medication it might be possible to side step this tension and disagreement.

35.

Not really. All I know is I just, I have to have them, but now they’re not workin’ so, I gotta have something.

Yeah. Well, let me talk to you about another option. You remember we talked in the first visit about some, sometimes the, the opioid pills actually increase the pain level. We don’t really understand why that happens but the pain actually gets worse, uh, and that creates a cycle ‘cause you take the pill and the pain’s worse so you wanna take another pill and then we increase the dose.

36.

Well maybe that’s what’s happening to me, because it just seems like it’s not working and it could be that it’s getting’ even worse.

Yeah.

  • The patient is describing some motivation, albeit small, to engage in the health promoting behavior. He is giving a reason to not take more medication: “because it just seems like it’s not working and it could be that it’s getting’ even worse.” This would be a good time to reinforce or solicit additional experiences consistent with this:

  • “You don’t want it to get worse.” (Pulls for desire to reduce medication).

  • “You are able to recognize that the increase in medication is not really working like you hoped it would.” (Pulls for ability to reduce medication).

  • “You need something beyond just the medication.” (Pulls for need to reduce medication).

37.

It just seems like it’s not workin’ at all. That’s why I think I need something stronger.

Yeah. Well if the pill is actually the problem then the answer for that is actually to detox you off, to, to taper them down, come completely off the medication and see if the pain gets better. And I think with your chronic back problems that you have, it’s, it’s unlikely that the pain will go completely away, but it may come down to a 6 or a 5 or a 4 if we get rid of the medicines. So what we do in that case is we taper you off the medicines over about a month’s period of time and uh, what I like to do is engage people with a support group ‘cause it’s, it’s a challenge comin’ off the medicine after being on them a long time.

The physician has a good sense of direction in that he is focused on some helpful behaviors but perhaps he is trying to go there too quickly and ahead of the patient. If he were to say some of the things suggested in line 36 now he might be able to ask, “So more or a stronger medication is not going to work. How have you solved problems like this in your life before where something you thought could or should work did not work?” This pulls for the patient to access his resources and ideas for solutions instead of the physician being the one to suggest them and the patient reject them.

38.

That’s pretty scary. Doesn’t make any sense to me to come off the medicine. I mean, how can, how can comin’ off the medicine make the pain better?

Well, if the medicine’s actually increased your pain then the pain does get better. We’ve seen it numerous times. And so that would be an option.

  • So notice how here the physician is accurately describing the advantages of the medication reduction and the patient is resisting. Ideally the patient should be the one in the lead for the health promoting alternative because by doing so the patient increases his motivation and likelihood for actually doing the behavior.

  • The physician has inadvertently created a dance with where he provides a useful suggestion and the patient rejects it. This is sometimes referred to has, “Yes, but.” The physician usually experiences this as frustrating because he is providing useful solutions and the patient is objecting to them. The alternative is to not take the change side and leave it open for the patient. Something like what is described in line 37 might work or after the patient says what he says here in line 38 perhaps, “It doesn’t make sense to you to give up the medication which is the only thing that you are using to create a small reduction from 9 to 8 of pain relief. What does make sense to you to do?”

39.

I can see how that could be happening because I took, take it and then eventually it reaches a point where it seems like it’s not only not working but maybe even being worse.

Yeah.

  • Again notice that the patient is providing change talk. It’s the same reason as he gave in line 36 and again perhaps it would be the springboard for other experiences that would go in the change direction:

  • “You would enjoy more pain relief without the drowsy and woozy.” (Pulls for desire to use the medication more moderately.)

  • “You are able to notice when the medication is not giving you much more relief.” (Pulls for his ability to modulate his medication use.)

  • “You need something else to step in when the medication is not working anymore.” (Pulls for his recognition that although not easy or pleasant he may have to do something other than take medication.)

  • “What have you done before when you have been what seems like the end of your rope?” (Pulls for him to access his resources rather than depend on the physician to “fix him.”)

40.

So, why don’t I just use some, isn’t there something different I can take?

Well, I just don’t feel like the opioids are, are safe for you. The one, the one other option that we have is a med, medication called uh, Buprenorphine or Suboxone, and it replaces the Lortab that you’re on. It gives a moderate uh, amount of pain relief, probably not as strong as the Lortab but it stops the craving, uh, and it sort of gets you out of that cycle of, of chasin’ medicines and, and, and looking for uh, medicine all the time, and allows you to go on and, and focus on um, other ways to relieve your pain. We could uh, get you into physical therapy, actually try that, or if you’d rather, we can, sometimes meditation helps people, so um, that would be the third option is we can switch you over to the Suboxone, uh, increase some of these non-opioid um, pain management techniques, uh, and see if you don’t get better.

  • All that has been suggested above might result in no different outcome than the patient remaining attached to more medication or what he imagines is stronger medication. Perhaps using more of a motivational interviewing approach could have avoided this. Motivational interviewing did start and has demonstrated its effectiveness first with substance use.

  • The physician is accurate perhaps in using the word, “craving” just like he was when using the word “detox.” The patient however unlikely experiences his desire for medication as “craving” but rather just a logical extension of seeking pain relief. Using the patient’s perspective increases the chances that the patient will engage in the health promoting behavior: “It gives a moderate amount of pain relief, probably not as strong as the Lortab but it does not go down this path of more medication producing little pain relief or worse, more pain.”

41.

Well, I can see some logic in doing that, but I just think that right now, I just need a stronger, something to get this pain away first before I look at anything else.

Mm hmm.

Notice again that the patient is “Yes, butting” which perhaps indicates that the physician is taking the change side too strongly and the patient then defends the don’t change side.

42.

If I can do that and get rid of the pain then maybe I can, you know, talk about some of those other things after that.

Yeah. Well, George, I’m, I’m just at the point where I don’t feel like the opioids are safe for you anymore, so I’m, I’m, I’m not gonna write ya anymore opioids. I’d be willing to go with the tapering we talked about or with the Suboxone or uh, uh, I’ll send to the detox ___

The physician describes his choice with a gentle and neutral tone without scolding or punishing the patient. He might enhance this even further if he were to add something like, “I can’t imagine you will not like that because you are believing the only way to proceed now is more medication but I am dedicated to the same goal you are which is creating some pain reduction and I don’t think opioid medications are going to do that.”

43.

Well I know what kind of pain I’m in and if you’re not willing to give me what I need then I’m gonna have to go somewhere else and try to get it.

Well, I’m, I’m sorry that you feel that way, um, but sometimes we just sort of have to agree to disagree. Uh, I think some of these other options might be safer for ya. I’m happy to care for your other problems. We’ll continue to treat your hypertension and your other medical needs, uh, but I’m just not comfortable writing the opioids anymore so uh, if you feel like you need to find someone else to do that, uh, you go ahead. If you think about it and these other options sound good to you, the door’s open, you can call me at any time.

44.

Well, I think that’s what I’m gonna have to do. I appreciate what you say, and I’m not closing the door on them, but I know what I gotta do for myself right now.

Okay.

From the Screening, Brief Intervention and Referral for Treatment (SBIRT) online project from the American Society of Addiction Medicine. This video demonstrates MI with a commentary script of techniques provided by Robert Rhode PhD.

Other SBIRT training videos available at http://sbirtonline.org/videos