26 Jul We’re Breaking Bad News a Lot, and It’s Not Easy — Having the Hard Conversation About Opioids
By: Read Pierce, M.D.
Vice President of Culture Transformation and Strategy, The Institute for Healthcare Excellence
The opioid epidemic in the United States and Canada has drawn much attention from healthcare professional organizations, the media, public health organizations, policy-makers, regulators, governments, and the legal system. While many organizations now offer tools and guidance to clinicians about how to change prescribing habits, increase patient safety through provision of naloxone when prescribing opioids, and start the conversation about alternative pain management approaches, these interventions miss a critical piece of the puzzle: the fact that, for many patients, opioids offer an effective approach to pain control, patients therefore have an incentive to ask about opioids, and clinicians feel a need to say no.
Put another way, in an era when patient experience and customer-driven healthcare are increasingly powerful forces, sitting alongside the patient and clinician in the exam room, our response to the opioid crisis means we are pitting doctors, nurses, and pharmacists directly against the expressed desires of patients.
Almost every time we need to talk about opioids, we are breaking bad news and provoking conflict. This is why we need a multifaceted approach—like the Connect, Understand, and Engage program—to reduce over prescribing as we strive to reduce the opioid crisis, which led to over 200,000 deaths due to opioid overdose since 2016 (sources: CDC, WP).
Asking those who prescribe opioids to simply “say no” seems like a natural and easy solution. Some may argue that such paternalism is necessary to reduce preventable harm. However, in the moment—when a clinician stands face-to-face with a real human being who is suffering from pain and experiencing a host of emotions and needs to resolve this tension in a few moments—many doctors, nurses, and pharmacists would rather avoid the challenging back-and-forth of having this hard conversation.
This challenge is not new: there are numerous examples of conflict between patient preferences and what clinical science tells us is best for people. However, with pain it poses major difficulty for busy clinicians. Unlike other versions of this conundrum—my patient wants antibiotics for a viral infection, even though they won’t help (CDC); my patient is convinced an MRI is necessary for that back pain, even though the majority of acute back pain gets better with time and physical therapy (PainScience)—where the tendency to punt on having the hard conversation, and simply order the requested drug or study, has a mostly hidden risk to the patient and the clinician, the opioid conversation is more black and white. We know opioids treat pain effectively, and yet they are addictive for many people and prescribing them, on average, exacerbates the epidemic of abuse and over-dose deaths.
If we want deaths to drop, we have to stop prescribing and take a different approach to pain management. Clinicians facing this conversation are inevitably forced to break bad news: “I won’t prescribe this medication,” or “you need to talk to someone else, because we’ve decided in this practice to stop refilling your opioids.” That stance is not likely to leave patients with emotions that match their desire for connection and caring. It’s also a source of stress, negativity, and burnout for clinicians.
In addition to guidelines from the CDC, EHR-enabled order sets, advertising campaigns highlighting the risks and alternatives to opioids, and practice-based contracts with patients regarding when opioids will and won’t be prescribed, we need a very practical approach to changing the conversation in the exam room, in real time. We need to put communication skills into the hands of clinicians, which they can access in the moment when that difficult conversation arises, when they are breaking the bad news and trying to walk with patients through the physiological pain and the desperation patients feel in pursuit of an alternative, mutually agreed-upon plan.
Relying solely on paternalism, by telling patients no and punting on the hard conversation, does nothing to maintain the trust and connection between patient and clinician that is the foundation of everything we do in Medicine. It also shifts the burden, back to the primary care physician or the emergency department, where patients go next. And it shifts the burden back onto clinicians, who are more burned out after having 3, 5, 10 or more of these conversations every week.
Fortunately, several groups around the country are taking an alternative approach. One of them is the IHE-IMS “Pain Management Transformation CUE – Connect, Understand, Engage,” a multi-faceted program that teaches skills for having the hard conversation about opioids, recognizing and responding to the ensuing emotions, creating a long-term, sustainable path for pain management that reduces reliance on opioids, and directly addresses the national epidemic. The CUE program also connects patients with pain to long term coaching about using non-opioid strategies for symptom management. The core communication skills in this program also reduce another epidemic—clinician burnout. That kind of impact is good for every person involved in changing the conversation and creating a new approach to care for pain.