Opioid Management and Difficult Patients

ORLANDO — Anthony J. Mariano, PhD, a clinical psychologist in the department of psychiatry and behavioral sciences at the University of Washington and the Veterans Affairs Puget Sound Health Care System, in Seattle, gave a lecture at the annual meeting of the American Academy of Pain Medicine (AAPM) titled “Practical Advice for Real-World Practice: Facilitating Self-Management in Challenging Patients.”¹ Dr Mariano sought to address a common question voiced by pain physicians: should they reinstate opioid treatment in patients successfully taken off these medications?

The answer is: it depends on the patient, on whether he/she has a history of substance misuse, on the patient’s functioning, and whether he/she is actively involved in his or her own pain rehabilitation. “This is the primary directive of opiate prescribing. No matter the answers to those other questions, safety always trumps pain relief,” said Dr Mariano. “So the answer is, if you can’t use opioids safely, if you can’t guarantee appropriate risk mitigation, you shouldn’t do it.”

Why is it so difficult for us to follow through with recommendations? According to Dr Mariano, ”What ends up happening to the average provider in the real world, trying to help people, [is that they] find themselves alone in the room with a patient who is overwhelmed and overwhelming the provider, and the only choice left for the provider seems to be to give up, give in, and get these medications. They are caught between what they think they should do and what they find they really can do.”

To get out of such situations, what should healthcare providers (HCPs) say? Providers need to be aware of their own reactions during this difficult process. Dr Mariano identified 6 common situations and sought to provide advice for each scenario.

1. Negotiations and false hope. When patients are engaging in such promises in order to get HCPs to prescribe opioids, Dr Mariano advises providers to self-monitor in order to determine whether such behaviors by patients were successful in the past. It is important to tell patients that learning self-management strategies is a difficult process. The goal for HCPs is to develop a plan that is safe, make sense medically, and is sustainable. Patients would say: “Of course I want to get off these medicines, I just need a few more for a little while longer.” But increasing doses to take people down later is nonsensical; it only worsens the issue, says Dr Mariano. It is important in these situations that clinicians normalize the situation, recognize that they are asking a lot from patients, and communicate to their patients that they are willing to help them in any way possible, other than continuing the treatment for which the risks outweigh the benefits.
2. Appeals and ethical confusion. A patient may say: “It is your job to help me. Why won’t you give me what I need to find some relief?” or: “I shouldn’t have to suffer like this, nothing else works. What am I supposed to do?” Dr Mariano asks, “What are the provider’s professional and ethical obligations in such situations?” In some instances, the patient will even “absolve” the HCP, saying: “I don’t care about the risks, why should you? I need these pills to survive.” Dr Mariano responds, “These are your responsibilities, not your patients’. Your duty may be to wean this person, as your duty is not to harm.” Avoid taking complete responsibility for urgent and complete pain relief in a patient who is not going to engage in what we know is far more important: being actively engaged in dealing with other life problems. “The bottom line is, there are patients we can’t help,” he added.
3. Blame and guilt. The patient comes and says: “How can you take away the only thing that helps me? You’re ruining my life!” or: “I was doing just fine, now I can’t do anything.” This brings up the “guilt scale.” Here, HCPs need to be careful when assuming that patients are stable.  Providers need to help their patients identify problems other than pain, and try to get them the help they need. Patients may refuse to consult other specialists and insist that all of their problems are caused by pain, but the clinician’s responsibility is to get patients the treatment that they need vs the treatment that they want.
4. Accusations and anger. Sometimes, patients accuse their HCP of being responsible for all their problems: “You’re the reason I’m drinking! The only reason I’m drinking is because you won’t give me enough Percocet.” It is very easy and natural to respond defensively in such situations; however, it is not helpful. “The key is this: don’t argue,” says Dr Mariano. “I don’t think you need to try to convince the patient…What I like to say to patients in that situation is: ‘You’re an adult, you’re making choices, but those choices really limit the options that we have, as safety has to come first.’” If a person has problem with substance abuse, taking them off opioids is not synonymous with refusing to help this person. On the contrary, refusing to prescribe opioids in that situation is refusing to continue harming them. Another group of patients may be misusing, while having poor expectations as to the kind of relief they can get through medications. These patients are not looking for drugs — they are looking for relief. And they may say: “I’ll take what I need, and I need to use more medicines, because you are not giving me enough.” In these situations, it is helpful to explain to people that medications do not work equally well for everybody, to provide them with realistic expectations, and to frame the issue by pointing to the fact that some people do not respond to opiates.
5. Threats and fear. Some patients start threatening their provider: “I’m going to go over your head, I’m going to call your boss, the Senator …  I’m going to file a complaint with the State Medical board…” Although it is easy to feel intimidated in that situation, Dr Mariano recommends HCPs acknowledge the fact that there is coercion and seek advice from pain specialists, “because you know you’re not going to get in trouble if you document your rationale and show that you are seeking advice from your colleagues.” Should a patient threaten suicide, consultation with a mental health professional is imperative.
6. Challenge and doubt. The average practitioner has very little training in pain, and even less in the specifics of prescribing. “If you’re in a situation where you doubt your own expertise, where you doubt whether it is correct to take a certain patient off their medications, you’re going to react very strongly to patients who challenge your competence or whether you care.” Here, the key is seek prompt consultation, as it is important to believe that you are doing the right thing when a patient believes you are doing the wrong thing. Dr Mariano recommends telling patients to consult the Veterans Affairs or Centers for Disease Control websites, so as to get them to realize the HCP is not not making this up.

“The key is not to get frustrated and give up, because these patients need our help more than ever,” Dr Mariano adds. So that saying ‘no’ is more a process of safety and of patient education and support. “It is important to help patients understand that you are not refusing pain treatment. You made a logical decision, you are going to work with them, you are not abandoning them, and you are going to help them with their withdrawal symptoms. You need to help them understand non-opioid options.”

So, when tapering, “be very clear about the rationale — safety is your major concern — and be very specific about the process. Let the patients know about what is going to happen, and then follow through on it. And then, be empathetic but not apologetic, because bad care is not an option,” concluded Dr Mariano.

Reference

1. Mariano AJ. Practical advice for real-world practice: facilitating self-management in challenging patients. Presented at: the American Academy of Pain Medicine 33rd Annual Meeting; March 16-19, 2017; Orlando, Florida.

This article originally appeared on Clinical Pain Advisor