The Compassionate Refusal of Requested Prescriptions

A Negotiating Workshop

Barry Egener, MD May 4, 2017

1 2 Interviewing Skills with the Chronic Pain Patients

Medford, Oregon May 4, 2017

Agenda

12:00 - 12:15 Introductions, goals, trigger video

12:15 - 1:00 Presentation of a Model

1:00 - 1:15 Demonstration of Model

1:15 - 1:30 Break

1:30 - 3:30 Practice with 4 Actors (4 interviews x 30 min)

3:30 - 4:00 Large Group debrief

Interview Protocol – Four 30 minute cycles:

1) 5 minutes: Identify who will do the interview and focused learning skill to practice

2) 10 minutes: interview

3) 5 minutes: actor and interviewer debrief: first interviewer 1) assesses whether accomplished the skill 2) what he/she did well 3) what feedback he/she wants from actor; then actor gives feedback

4) 5 minutes: group discussion

3 COMPASSIONATE REFUSAL OF REQUESTED PRESCRIPTIONS

Barry Egener, MD

1. Elicit The Patient’s Perspective

2. Present Your Perspective

3. Arrive At Common Goals

4. Set Limits

NEGOTIATION PROCESS

• Deal With Emotions

• Don’t Be Defensive

• Share Control

• Focus On Function, Not Pain

Negotiation Step #1: Elicit the Patient’s Perspective

Help the patient describe:

• The nature of the problem

• How the problem has affected him/her

• Exactly what help the patient wants

4 DON’T ASSUME YOU KNOW!

Negotiation Step #2: Present Your Perspective

▪ Create an Empathic Bridge

▪ Present Your Perspective

▪ Patient Education

Negotiation Step #3: Agree on Common Goals

▪ Concentrate on Areas of Agreement

▪ If unable to identify common goals, revisit patient perspective (step #1)

Negotiation Step #4: Set Limits

▪ Frame limits professionally, not personally

▪ Concentrate on what you are willing to do, rather than on what you refuse to do

5 PROCESSES

Deal With Emotions ▪ Reflection ▪ Validation ▪ Support

REFLECTION

• Informs Patient You’re Aware Of Emotion

• Brings Emotion Into The Open

• Makes Emotions A Legitimate Topic For Discussion

“You seem upset by what I’ve said.”

“You seem pretty angry.”

VALIDATION

• Shows that you understand the reason for the emotion

• Normalizes the patient’s experience

“I can understand that you might be angry with me for not prescribing narcotics when that’s the main reason you came in today.”

YOU DON’T HAVE TO AGREE TO EXPRESS UNDERSTANDING!

6 SUPPORT

• Demonstrates that you’ll be with the patient in her emotion

• Shows that you can help the patient’s distress

“I’m sure it’s been difficult to keep going to the doctor and to repeatedly have these tugs of war about a prescription.”

Or, for example, instead of speaking, hand a crying patient a tissue.

Don’t Be Defensive

▪ Defensiveness Escalates Emotion

▪ Instead, make a statement about the patient’s experience

Share Control

▪ Models Collaboration

▪ Empowers the Patient to Make Changes

Focus on Function, not Pain

▪ Permits progress despite ongoing pain

▪ What can the patient do?

▪ What do the symptoms prevent

7 When Doctor and Patient Can’t Agree ▪ Identify the impasse ▪ Clarify boundaries ▪ Manage your reactions

Identify the Impasse “It seems like we have reached an impasse.”

“You and I have very different views on how best to manage your pain.”

Clarify Boundaries ▪ What you will do: “I’d like to be your doctor and continue to help you with your help, despite our disagreement.”

▪ What you will not do: “Prescribing more of this medicine is something that is not in your best long-term interest. It is something that I feel uncomfortable with and cannot do.”

Manage Your Reactions

▪ When you say, “No” • What do you feel? • What thoughts do you have?

Learn to Soothe Yourself

▪ Breathe! ▪ Self-talk: • I’m being a helpful doctor. • I can get through this.

8 ACTOR SCENARIOS

▪ Ralph Meyer (played by Andrew Huff)

▪ Ralph Meyer is a regular patient of yours.

▪ He has come to the office as a walk-in, as your last patient on Friday afternoon.

▪ You last saw him Monday (4 days ago) and gave him prescriptions for:

o OxyContin 80mg bid x 14 tabs

o Percocet 100 tabs

▪ Ralph is a successful real estate salesman who recently had successful RIGHT hip replacement surgery. He is now four months post-op and went back to work one month ago.

▪ He had originally had painful avascular necrosis for one year prior to his hip replacement surgery. For the 1 year pre-op, he was taking high doses of Oxycodone to keep his pain under control so that he could continue to work.

▪ Pre-operatively, he was taking OxyContin 80mg bid and 10 Percocet per day for breakthrough pain.

9 ▪ Since surgery, he has not been able to reduce the dose of the analgesic medication. The orthopaedic surgeon’s recent letter says that there is no problem with the new hip.

• The avascular necrosis was a late consequence of a previous injury (three years ago): he had a hip fracture caused by a fall when the deck on his house collapsed - had ORIF (pins + plate) for the original injury.

▪ He has no other medical problems, but he had a significant alcohol problem in the past. He has been an active member of A.A. for 10 years and he still goes to weekly meetings.

▪ His wife is healthy and also works as a real estate agent. They are a busy couple and have no children.

Respond to the patient’s presenting complaint.

Formulate a diagnostic hypothesis.

Discuss an appropriate management plan with the patient.

DO NOT DO A PHYSICAL EXAMINATION.

 Bill the Bricklayer (played by Peter Rothsfeld)

Bill is a 52-year-old bricklayer. He was injured three times between 2002 and 2007. Each injury resulted in a workers’ compensation claim for low back pain; each of those claims resulted in a surgery to decompress and/or fuse the L4-5 and L5-S1 region of his lumbar spine. Those claims are now all closed. Per the patient’s report, each surgery “helped”. In 2016 he had an additional injury, again involving his low back. He has recently been told that there is no surgical treatment that is likely to be helpful. Bill’s medications have

10 steadily increased in number and amount over the same years. Presently, he is on:

Acetaminophen-Oxycodone 325/7.5, ½ to 2, six times a day

Daytrana 30mg/9hr film, ¼ qd (for ADD)

Diazepam 10 mg 1 qid (for anxiety)

Methadone 10mg, 2 four or five times a day

Topical: ketamine 10%, Baclofen 2%, Cyclobenzaprine 2%, Diclofenac 3%, Gabapentin 6%, Tetracaine 2%, apply 4 times a day over low back

These medications were prescribed by Bill’s family practitioner, who was recently told by his state licensing authority that should he choose not to refer Bill to a pain specialist for all further pain treatment, action would be taken against his license. For that reason, only, a referral to a pain specialist was made. Both Bill and his treating doctor feel that the referral is completely unnecessary.

Bill’s chief complaint is pain that radiates into his left leg, to his foot. The pain is 10 on a scale of 10. It is a constant, burning pain. “Doing anything” makes it worse; “my pills and patches” help make it better. Without his medications, “I could not do anything”, Bill says. His daily activity level is sub-sedentary. “I couldn’t survive without the medicine”, he says. Bill reports that his wife, Susan, is angry about how “the system” is treating him, “She says if the claims manager had to live with me like she does, he’d appreciate how much I suffer.”

Bill has worked as a bricklayer all of his life. He dropped out of high school in the 11th grade, and went to work for a construction company. He was a good worker, he says – he was always on the job site, even when others did not show up. That meant that he worked harder than most of the others, which really “tore up” his back. He has built about everything that can be built from bricks. He takes pride as they drive around town in showing his children some of the buildings he has helped build.

11 Bill says that he is likely to lose his house, because his timeloss payments aren’t enough to pay the mortgage and provide money for food and other necessities. “Just when I think that I am getting ahead, I get slapped down,” Bill states.

Bill and Susan have been married for 13 years. Each had a prior marriage that ended in divorce. They have two teenage children: a boy, 17, by Bill’s prior marriage, and a girl, 15, by Susan’s. “The girl is no problem,” Bill explains, “but the boy has been getting into trouble, and is not doing well in school.” Bill answers a question regarding how he would describe his family by saying “All this pain makes me pretty short-tempered, so I guess things are pretty rough right now.”

Bill smokes about one pack per day. He drinks “1 or 2 six-packs” a week, depending on what sports are on television.

When asked about his goals, Bill states, “I just want to get fixed, and then I’ll go back to work.”

Bill doubts that he can return to bricklaying. He has not yet thought about what it is that he might do in the future. “I have to get fixed first,” he explains, “before I can know what I can do.” Bill notes dismissively “all the insurance company wants is to close my claim so they can save money. Well, I would go back to work if I could, but I can’t.”

Bill does not understand why he has to see a new doctor. “What’s wrong with my doctor?” he asks. “He is giving me what I need so I don’t suffer. No offence, but I don’t understand why I have to see you.”

Bill’s hobbies are hunting and fishing, but, because of back pain, he has not done either “for as long as I can remember.”

12 Bill is Insistent that he needs to be on the same medications as were previously prescribed. He does not want to “suffer”, and is highly resistant to decreasing his medications. Bill becomes argumentative if a physician speaks to him in an authoritarian manner. (“I’m not going to get pushed around,” he says.)

PRIOR MEDICAL HISTORY

Appendectomy at age 23

Laminectomy left L5-S1: age 40

Laminectomy right L5-S1: age 44

Fusion, L5-S1: Age 45

Laminectomy right L4-5: age 47

The goal of the encounter for the physician is to get Bill’s buy-in to a tapering of his medications, and to treatment in a multi-disciplinary pain program. The specifics of the tapering program need not be developed for this exercise, but Bill’s commitment to, and willingness to trust in the taper and the pain clinic treatment are paramount.

13  Anne (played by Sara Smith)

58 year old female LPN, employed in a large Long Term Care Facility for seniors, in your city. They are chronically short-staffed, and you have had a number of their employees see you in your office for what appears to be minor MSK injuries (most of which take a very lengthy time to resolve), as well as “stress leave” requests.

Anne has been in your practice for 12 years. She smokes ½ package cigarettes per day and admits to drinking “socially”. She is divorced with 2 daughters. The oldest, 26, lives with her boyfriend and works in a retail store. The youngest, 23, is unemployed and lives with Anne. This daughter socializes very little, has worked intermittently at various jobs, smokes pot “frequently”, and watches a lot of television.

Anne has a history of depression, usually related to life events. Her divorce 8 years ago caused a major depression for which she was hospitalized for 2 months. She was off work for 6 months, but gradually returned to the nursing home and stopped her antidepressants. She admits to social drinking, but has also reported binges in the past when she was having trouble coping with the stresses in her life.

Anne injured her dominant right shoulder about 1 year ago, while doing a patient transfer. You initially diagnosed a shoulder strain injury and prescribed an anti- inflammatory medical and referred her for physiotherapy. She returned to see you 2 weeks later with complaints of increased pain, stiffness in the shoulder and that the physio was “making it worse”. You prescribed acetaminophen/codeine and discussed continuing with physio.

Over the course of the next 8 months, her pain has either remained the same or increased, despite your (reluctantly) switching from acetaminophen/codeine to acetaminophen/hydrocodone. You also prescribed lorazepam 1 mg as her anxiety level increased. She complained of not sleeping and was appearing to be increased “stressed and depressed”. X-rays had shown little abnormality in the shoulder and AC joint. An MRI of the shoulder labarum showed mild degenerative changes only. An orthopaedic consult deemed her to be non- surgical, with the recommendation for an occupational rehab program.

She entered an Occ Rehab program but discontinued this after 2 weeks as this exacerbated her shoulder symptoms, and she now complained of neck pain, stiffness, and radicular symptoms going down her right arm to her hand and fingers. Imaging studies (x-ray, MRI of cervical spine and thoracic outlet) were essentially normal.

14 While you were away on a 3 week vacation, a locum saw Anne, and given her ongoing and significant pain complaints and obvious distress, she prescribed extended release morphine sulfate 20 mg bid, Vicodin for break-through pain, Ativan 1 mg every 8 hours, citalopram for her depression and zolpidem to help her sleep.

She is now back in your office, requesting refills of the above medications, but wanting a stronger pain medication as the new medication helped more than the others, but still wasn’t adequate.

She cries at times, saying that since she injured her shoulder “I can’t do anything”. She states she can’t do household chores as she continues to have so much pain in her shoulder, neck and right arm/hand, and has no motivation “to do anything”. She feels she certainly cannot even contemplate a return to work. She is quite tearful and feels overwhelmed by life. Her daughter who lives at home “is not helping at all”. Her bills are piling up (as is the laundry!) and the power company is threatening to cut her off.

She is asking, apart from the medications, for a referral to another specialist “who will find out what’s wrong with me and fix me”.

At today’s visit Anne is clearly distressed.

You have listened to her, acknowledged her request for refills of her medications and increased potency of the analgesics. In addition, she is waiting to see another specialist for an accurate diagnosis and care.

You begin to approach her gently, saying that the pain medications haven’t really helped her. In fact, you point out, that despite steadily increasing the type and strength of the analgesics, her pain appears to be increasing and her functional abilities are decreasing. You also point out that she has had numerous imaging studies, has seen an orthopaedic surgeon, and no significant pathology was identified.

Anne is sobbing and becomes angry. She accuses you of thinking her pain “is all in my head” and “you don’t believe me”. She admits her life is a mess, but she needs her pain to be cured so she can go back to work.

You must listen, show empathy, but be firm. You need to reinforce that you know her pain is real, but now is the time to go down a different pathway to help her move forward.

: Taper the medication : Substitute anti-inflammatory medication

15 : Enter an activation program – which gradually increases physical functioning - acknowledgement of the pain, but primary focus is on slow, steady reactivation : You will also refer her to a counsellor that you know that will help her “re- frame” her pain and her functional ability : You will see her weekly and monitor, support her progress.

You tell her that you have had a number of patients with similar chronic pain complaints. What works the best is getting off the pain medication and slowly increasing their activity. You speak very positively how well they have done; they still have some pain, but the severity is much less, but they are much, much happier and more satisfied with their lives because they have learned to cope with their pain. Their pain is less important in their lives as they have resumed household work, walking their dogs, recreational activities, and some include a return to work.

Goals: 1. Maintain a conversation that has therapeutic value, despite Anne’s anger and tearfulness. 2. Get Anne’s buy-in to a treatment plan

16  Lester with Low Back Pan (played by Lee Glass)

This is a first visit to your primary care clinic for Lester, who presents with a chief complaint of low back pain. His previous physician moved out of state, which is why he is in your office. From the form that Lester completed in the waiting room, you learn the following:

Lester: Age: 48 Married, divorced, re-married 2 adult children, both married, living elsewhere Education: High school through 11th grade Employment: Lifelong construction worker Injury: Two years ago, bent over to pick up a load of laundry left by his wife for him to wash, felt a pop, and had the immediate onset of low back pain. Usual pain level: 9 on a scale of 0 to 10. Habits: 1 ppd X 30 years, a beer or two a day PMH: Measles age 9; Mumps age 7; Right radial head dislocation at age 3; distal ulna fracture at age 12 Surgeries: None

Recent physician visits: Two weeks ago he was told by a surgeon that he needed a spinal fusion; hewants to avoid that. Reason for visit: “I’ve got to get something for my pain.”

Your physical examination is normal, except for BP = 161/88.

Imaging studies: L5-S1 degenerative disc disease. Central bulging disk at that level not compressing the thecal sac. L5-S1 neural foramen and lateral recesses appear normal with no evidence of nerve root compression. No other evidence of spine pathology.

Your goal: using shared decision-making, develop a treatment plan