Prescribing Opioids Safely: How to Engage Patients in Tough Conversations
Prescribing Opioids Safely: How to Engage Patients in Tough Conversations
Hi. My name is Hennie Garza. I'm a pharmacist with TMF Health Quality Institute. This video is a primer for developing tools to successfully navigate one of the most difficult discussions to have in practice, a discussion about prescription opioids.
Discussions about opioids can be difficult for a variety of reasons. They can involve a significant amount of emotion, the potential for physical harm to a patient if the root of the problem is not addressed, the potential legal liability for a pharmacist if a controlled substance prescription results in harm, and the potential for physical violence that surrounds opioid diversion in the United States.
Several reasons can trigger the need for this discussion, including high or potentially incorrect dosing. Concurrent prescriptions of other medications that might lead to a suspicion of a risk of substance abuse disorder. Adverse drug reaction, such as frequent prescription fills of controlled substances noted on a Prescription Drug Monitoring Program, or PDMP. Or concomitant use of benzodiazepines, which can place the patient at risk for accidental overdose.
Techniques that can be employed to guide the conversation, keep it professional, and lead to a positive outcome include staying patient centered, emphasizing your concern for the patient, the patient's condition, and a desire to reduce risk or harm. Keep the tone nonaccusatory, avoiding a tone that would imply an opioid addiction. Address the etiology of the problem. And try to steer clear of responding to defensive comments.
These comments can lead to verbal reaction traps, which make a positive outcome very difficult to achieve. Examples of these traps include a compassion trap, where a patient might accuse a pharmacist of not caring about their pain. An all-or-nothing trap, an example being a patient asking, so are you just going to cut me off, and I'll just have to live with my pain?
An addiction-labeling trap, where a patient accuses the pharmacist of labeling them as an addict. A desperation or threatening trap-- for example, a patient who threatens legal action over a concern about opioid dosing. Or an end-game trap, where the patient attempts to withdraw from the conversation altogether.
In our example, we will see how our pharmacist handles a difficult discussion about several concerns that arise when she checks the PDMP while filling a patient's prescription.
Hi. I'd like this prescription from my doctor filled, please.
OK. Sure. Can you verify your full name for me?
All right, Mr. Jones. And can you verify your date of birth for me?
April 1, 1948.
Excellent. I'm going to give this over to my pharmacist and have her take a look at it. Do you want to take a seat in our waiting area? It should just be a couple moments.
OK. Thank you.
Is the patient Mr. Jones who dropped off the script waiting in the waiting area?
Yeah. I think he's still out there.
So after checking with the PDMP, I've noticed that he is taking oxycodone with acetaminophen in combination with the diazepam from another doctor. And I'm concerned about this. And I would like to discuss this with him.
The combined daily morphine milligram dose looks to be a little too high as well. And he is also prescribed an antidepressant, which could mean that he has some behavioral health conditions, which might put him at risk for bad outcomes. Could you please ask him to come to the consultation area?
Sure. I'll go get him.
Hi, Mr. Jones. My name is Dr. McBride. I wanted to speak to you about a few of your medications.
So are you still taking the sertraline and the diazepam and the oxycodone with acetaminophen?
Yes. Dr. Patel, my psychiatrist, has prescribed the sertraline and the diazepam for my depression and anxiety. And Dr. Smith, my PCP, has prescribed the oxycodone with acetaminophen for my knee pain. However, today I went to see Dr. Patel and explained that I have continuing knee pain. And so she prescribed the morphine for me until I get to see Dr. Smith again a month from now. So why do you ask?
Well, there are a couple of things that are concerning me about your medications. The first one is that taking the sedative medication like diazepam daily with the oxycodone and acetaminophen and the long-acting morphine can all have a cumulative effect, resulting in more sedation or drowsiness that is greater than what is intended.
Also, taking two opioid medications daily with diazepam is really concerning, first for the physical dependence on the medications and the increased risk of accidental and unintentional overdose, not to mention the increased likelihood of side effects. And the total daily morphine equivalence dose, in combining that with the oxycodone and the acetaminophen with the long-acting morphine, exceeds the recommended target that is set by the Centers for Disease Control, or the CDC.
So what are you suggesting? That I'm some kind of junkie?
No. Not at all, Mr. Jones. I'm just worried about the possible side effects on your body by taking all of these medications daily. I don't want to see you place at increased risk for harm for taking all of these medications. That's all.
Well, Dr. Patel and Dr. Smith are highly educated physicians. I doubt that they would prescribe something that's dangerous for me. So I'd like to suggest you just fill my prescription, please.
Yes, Mr. Jones. I'm in no way questioning Dr. Patel or Dr. Smith's professional judgment. It's just that sometimes the doctors don't have the patient's medication list when they prescribe certain medications. And I just want to make sure that they are aware.
So now you're suggesting I lied to my doctors?
No, not at all, just saying that sometimes the doctors don't have all of the information that is needed to make a decision at the time.
So now what? Are you going to fill my prescription or not? Or am I going to have to be in pain for a month?
No, Mr. Jones. So before I fill your prescription, I would like to give Dr. Smith a call and discuss my concerns with her. That's all. So if she is already aware of these concerns and still insists on filling the prescription, then I will gladly fill it for you.
So now I have to wait.
If you could just wait a couple of moments while I give Dr. Smith a call, then I can call you back up when your prescription is ready.
You know, this is really cruel. You all are cruel to your patients. I'm inclined to call state regulators and report this incident.
And you have every right to be concerned. I just want to prevent any further harm. And that's why I'm trying to give the doctor a call first before I fill the medication.
So when can I get my medication?
So we will call you up as soon as I can contact Dr. Smith. So do you mind waiting a few minutes while I give her a call?
I have no choice. I'll wait.
OK. Thank you.
All right, Mr. Jones. I was able to speak to your primary care physician. And she said some very nice things about you. And she also said that you have been taking the diazepam for a while. And you haven't experienced any side effects from that medication.
OK. So what else?
She also agreed with me about the long-acting morphine. With your oxycodone and acetaminophen together, this might be too much medication and might result in excess sedation for you. However, we both agree that your pain should be controlled.
So now what?
So Dr. Smith contacted Dr. Patel. And they have agreed on a new temporary plan for your pain management. So Dr. Patel would like to give you a 10-day supply of a long-acting oxycodone. This would allow you to take the medication two times a day, so one every 12 hours.
And in addition, she's also going to give you a lower dose of the oxycodone with acetaminophen. So with that medication, you're going to take one tablet once a day as needed for your pain. And in addition to her changing the dosing, she would like to see you in a week at her clinic so that you all can go over how the medications are working to alleviate your pain.
OK. But what about my prescription for low-dose morphine?
So you won't need it. I've already filled the new prescription authorized from Dr. Smith. So next week, once you go to see her, you can discuss how those are working for you.
OK. Well, I wasn't too happy with you questioning my prescription, Dr. McBride. But I guess everything worked out OK. Thank you.
No problem, Mr. Jones. Have a great day.
We saw how the pharmacist was concerned about an issue with an opioid prescription that she was cued into from the patient's medication list and PDMP check. She approached the situation calmly, didn't lose her composure or allowed herself to be led into a trap, and was able to bring about a positive result that both the pharmacist and the patient had lived with.
Thanks for watching. And please visit our website, tmfqin.org, for more resources in helping to reduce the effects of the opioid epidemic.
For more than 45 years, TMF has helped the health care providers and practitioners in a variety of care settings improve the care for their patients. Let us help your facility strengthen its quality improvement initiatives.
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