Physicians often lack training in communications skills that would enable them to navigate challenging patient encounters effectively. “Difficult” patients have specific obstructive behaviors that make it hard to establish a successful doctor-patient partnership and can result in strong negative emotions in the physician.
Rather than label the patient as “difficult,” it is more useful to consider the encounter difficult and employ diagnostic and intervention techniques similar to solving any other clinical problem. One of those difficult encounters is dealing with a patient who complains of severe pain and requests an opioid prescription. As the misuse of prescription medications has increased dramatically in the past few years, particularly for opiates, it has become increasingly important to identify drug-seeking behavior. This article provides tips and strategies that orthopaedic surgeons can use.
One of the first steps that must be taken in dealing with a patient who is seeking pain medications is to try to understand the underlying motivations and needs for these drugs. Although physicians may often assume that the desire for these medications is based primarily on addictive tendencies or lack of coping mechanisms to deal with pain, the situation may be more complex. For example, the patient may misunderstand the normal course of recovery, be unaware of treatment alternatives, or have failed to adhere to a treatment program such as physical therapy, oral NSAIDs, or activity modification.
- A helpful way to categorize patients who seek drugs is to separate their psychological and physical needs from their clinical circumstances.
- In one group are patients with real physical and medical pathology who want pain medication for the following reasons:
- They have an undetermined diagnosis, and all treatment modalities have failed to address their pain, leaving pain medication as their only effective choice.
- They have a known diagnosis and refuse any invasive techniques such as surgery. If all noninvasive therapies have failed, pain medications may be the only relief.
- They have postoperative pain as a result of a poor response to the surgical intervention or have sustained a surgical complication.
- They have a known diagnosis but were inappropriately treated with pain medication as the first line of management and now have a psychological or physical dependency.
Other groups consist of patients with no physical pathology who are physically or psychologically addicted and dependent on pain medications and those who simply want to obtain narcotics for nonmedical purposes such as sale or distribution (also known as diversion).
Understanding the patient’s underlying motivation is important in tailoring the discussion regarding medication use. Treatment goals will differ, based on the patient’s needs. The physician’s decision to continue to treat the patient will depend on whether the physician has the necessary skill and resources to deal with the patient’s physical condition and the time and patience to address the patient’s drug-seeking behavior.
A difficult discussion
The actual discussion regarding drug use is a difficult one for physicians for a variety of reasons. For example, the physician may want to give the patient the “benefit of the doubt.” Or the physician may be embarrassed to ask or confront the patient about medication habits.
Surgeons want patients to have a successful outcome and may let them use pain medications as a bridge until the surgery finally heals. Physicians are often conflict avoiders and may agree to patients’ requests for medication prescriptions to prevent confrontations and negative criticism.
Finally, practical constraints such as lack of time in a busy clinic and lack of formal training in this area may inhibit the physician’s ability to address the patient’s psychological, social, and medical issues surrounding the use of pain medication.
The following strategies may be helpful in discussing drug use with a patient:
- Be empathetic and acknowledge the patient’s suffering and conflicting emotions about pain medication use.
- Do not be paternalistic; be willing to admit to personal inadequacies in managing a drug problem. This opens the door for referral to pain management or to a tertiary facility to confirm and support the diagnoses.
- Be firm and confident in the presentation of information and encourage honest responses by using simple, open-ended questions.
- Maintain privacy and strict confidentiality to make patients comfortable and open to sharing their concerns.
- Most importantly, document everything and assess the patient’s understanding of any agreements.
To prevent inappropriate requests for pain medication, physicians should have a policy that covers their use, including the timing and frequency of refills, and should make patients aware of this policy at the first visit. If possible, prescribing controlled substances at the first visit should be avoided.
Surgeons should partner with the patient’s other physicians and healthcare providers to limit the patient’s sources of pain medications. Additionally, these issues as well as the frequency and timing of drug refills can be documented in a mutually agreed upon pain management contract. Giving patients a clear understanding of time frames for recovery from injury or surgery at the outset of treatment is essential.
Whenever possible, orthopaedic surgeons should request and review old medical records and speak with the patient’s primary physician about past medication problems. Currently, 37 states have Prescription Drug Monitoring Programs designed to assist law enforcement in the identification of doctor shoppers; these data are also accessible to physicians. More aggressive deterrents include the use of urine drug screens and in-office DNA testing for cytochrome P450 activity.
For additional resources, see the online and ePub versions of this article available at www.aaos.org
Michael R. Marks, MD, MBA; Donna Phillips, MD; David Halsey, MD; and Andrew Wong, MD, are faculty for the Instructional Course Lecture 126, “Difficult Conversations in Orthopaedics,” which will be held on Tuesday, March 11, 10:30 a.m.–12:30 p.m., in the Morial Convention Center. The complete course will appear in ICL 64, which will be released in February 2015.
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