Appendix VI: Difficult Discussions With Patients

As this manual has been addressing explicitly and implicitly throughout – the challenge with prescribing opioids for CNCP is that we want to support our patients and minimize their suffering. Most of the time, the patient’s goals and our goals are compatible. In the case of addiction and misuse however, the patient may want us to do things that are harmful (keep prescribing a medication that is destroying their life, increase dose and/or quantity, decrease monitoring frequency, switch to different formulation, etc). This discordance naturally brings up challenging conversations. This chapter is meant to be a practical guide on how to handle some of the challenging conversations.

It sounds easy, but the most important thing is to support the patient! This can be very difficult if the patient is upset.

When presented with the scenario of an aberrant UDT or other aberrant behaviours, an appropriate first step would be to consider a differential diagnosis including lab error, miscommunication of provider expectations, inadequate pain control, opioid misuse, addiction or diversion.¹ In the instance where opioid addiction or diversion is highly suspected, the physician will face a difficult discussion with the patient.

Often even the nonjudgmental physician can find themselves with thoughts of whether they can trust their patient, whether their pain is real or to the extent they report it, or whether the patient is drug-seeking or diverting their medication.¹ Being aware of these thoughts is important in avoiding an approach that is punitive and jeopardizes trust along with the patient-physician relationship¹.

A study by Matthias et al.² looked at patient and provider views on tapering conversations and identified a key theme as explaining reasons for tapering the medication. Very important to this was providing an individualized explanation to the patient and shifting the conversation away from the current opioid crisis.² Highlighting the patient’s medical history or unique risks allows for the patient to see applicability to himself/herself.² Some patients may fail to see common ground and think the physician does not believe their pain is real or severe. In these instances the physician should empathize with the patient, reinforcing their understanding of the patient’s pain and its effect on their function and life.¹ Physicians can further empathize by demonstrating their frustration with a lack of effective medications for the treatment of pain. This can in-turn lead to the discussion of alternative options for treating pain and reinforces the physician’s commitment to treating pain.¹ Reassurance that patients would not be abandoned during tapering was another key theme that emerged from Matthias et al.²

One approach to the conversation may be to frame the conversation around the benefits and risks of opioid therapy. By informing the patient that the observations are alarming for signs of harm, which now outweigh the benefits of opioid therapy, it avoids the connotation of blaming the patient. Further, by reinforcing the notion that addiction is a possible side effect of opioid use just as others such as constipation or sedation, it allows the physician to blame the medication or treatment rather than inferring fault or stigma on the patient. By expressing concern for the patient’s well-being, it can even strengthen the patient-physician relationship.¹

Some physicians may find themselves using a bargaining technique with their patients, where they negotiate future steps, however some literature¹ suggests this strategy involves the patient and provider being adversary and having opposite goals versus working towards a common goal with shared decision making. An alternative approach involves providing patients with options. Matthias et al.² found that patients and primary care providers had a desire for patients to be given options regarding tapering plans. When the physician provided options for the patient, such as options whether to change dose versus frequency, the patient had some control over the process and it resulted in a process of collaboration.²

Another strategy may include use of the HARMS Program and guidelines as “pushback”. The idea that “it’s not me, it’s the program and expectations” is a helpful way to both maintain rapport with the patient (anger can be directed towards the “faceless” program or guideline), and to make sure that the point of contention (concerns about safety) are being addressed effectively. One reason that we built the HARMS program to be applied to everyone at our clinic prescribed opioids for CNCP is so that UDT wouldn’t be a matter of physician mistrust. We wanted to make it as objective as possible. It’s not that my physician doesn’t trust me or is a “bad guy”, but rather the program is universal and everyone prescribed opioids for CNCP is subjected to it. Reinforcing the idea that the HARMS Program UDT is a universal tool to identify harms of the medication, rather than a sign of mistrust, allows the provider to maintain the physician patient relationship.¹

A few lines that we found helpful during discussions with the patient, include:

• “I’m not going to do something that looks like it is harmful to you”
• (if you have BPIs showing that pain and function are not improving despite dose escalations) “I see that you are asking for a higher dose, but you have showed me that increasing your dose is not helping, in fact it is making things worse. This is not uncommon with opioids, they’ve even coined a name for it (opioid-induced hyperalgesia) and further dose escalations will only make things worse…”