October 2019, Volume XXXIII, No 7

Behavioral Health

“Flip the script” on opioids and pain management

Starting difficult patient conversations

t’s time to change the narrative around opioid therapy and pain management in Minnesota to better support patients dealing with pain. The Minnesota Department of Human Services (DHS)’s “Flip the Script” education campaign is intended to do just that. The campaign is designed to support health care professionals treating patients in pain, share tools and resources to help patients understand the role of opioids for pain management, and ensure that the benefits of opioid therapy outweigh the risks. The goal is to support Minnesota prescribers with resources on how to manage patient pain while making sure they stay safe, particularly for those who may feel overwhelmed after years on the front lines of the opioid epidemic.

Discussing opioid therapy with patients can be difficult—opioid therapy and pain management are emotional topics for patients and health care providers. The conversations can feel uncomfortable and may take repetition. However, having these conversations is the right thing to do to ensure patient safety, improve their ability to self-manage pain, and increase their quality of life. See below for tips to start these difficult conversations.

The need for action

The opioid crisis has taken a significant toll on our local communities, state, and nation. In 2017 alone, 422 Minnesotans died of a drug overdose—187 of which involved a prescription opioid, according to a 2017 DHS report. Although many of these tragedies involved heroin and fentanyl, the majority of the deaths began with pills prescribed by providers. We can do better.

The medical community has made significant progress in understanding the appropriate role of opioid therapy in acute and chronic pain management. Opioid analgesia remains an important option for managing pain following severe, acute events and for managing cancer-related pain and pain at the end of life. However, we also know that a significant amount of opioids prescribed after acute events goes unused; the risk of long-term opioid use begins after only a few days on opioid therapy; long-term opioid use is associated with significant adverse outcomes; and variation in health care professionals’ opioid prescribing cannot be fully explained by differences in patient diagnoses, demographics, or health care specialty.

Discussing opioid therapy with patients can be difficult.

The medical community has also learned more about the pathophysiology of chronic pain and the appropriateness of treating it with long-term opioid therapy. Opioids are not proven to be effective for chronic pain and may even make pain worse.

It’s the law

The 2015 Minnesota Legislature authorized the Opioid Prescribing Improvement Program to address dependence and misuse related to prescription opioids. The program requires the state to develop: opioid prescribing guidelines for acute, post-acute, and chronic pain; annual prescribing reports for providers who prescribe opioids to Minnesota Medicaid and MinnesotaCare members; an opioid prescribing quality improvement program for providers who care for Minnesota Medicaid and MinnesotaCare members; and a provider campaign directed at speaking with patients about opioid therapy and pain management.

To develop its campaign, DHS collaborated with the medical community, including metro area and Greater Minnesota providers from both large health systems and small clinics recognized for their expertise in opioid therapy. Other project partners include the Minnesota Medical Association, Minnesota Hospital Association, and University of Minnesota.

Case study

The Flip the Script campaign features a video testimonial from a Greater Minnesota doctor who altered his opioid prescribing practices, improved his relationship with patients, and changed how he thinks about his work. Dr. Paul Kietzmann, a primary care physician with Alomere Health in Alexandria, transformed his approach to prescribing opioid therapy after reviewing his personal opioid prescribing data and patterns made him question why his prescribing differed from his peers. Coupled with increased knowledge about pain management and patient safety and the support of his clinical practice, he began to reframe conversations with his patients about pain and opioid therapy around safety, function, and achieving goals.

Dr. Kietzmann made changes to his prescribing with his patients in a way that maintained their trust, provided them control over the process, and took their unique needs into account.

Help doing the tough stuff

Conversations about opioid therapy and pain management take practice, require patience, often require repetition, and do not always end on a positive note.

Experts in the medical community stressed the importance of developing an education campaign with a framework that works for providers, informed by key messages, conversation starters, and strategies that you can return to when needed. These resources, along with a free podcast on Minnesota’s opioid prescribing guidelines that provides continuing education credit, can be found at mn.gov/dhs/flip-the-script.

Among the resources are specific “conversation starters” for multiple stages of patient care:

Acute pain. Health care providers should exercise caution in prescribing opioids during the one–four days after a severe injury or a severe medical condition and up to seven days following a major surgical procedure or trauma. During this acute phase, consider telling your patients:

“Pain is a normal part of the healing process after an injury or surgery. We cannot eliminate all pain, but we can help you manage the most severe parts.”

“In many cases, using opioids to manage severe pain during the healing process is appropriate and the standard of care. I will prescribe you an amount that will be enough to get you through the first few days of the most severe pain, and then transition you to non-opioid pain relievers.”

“It is important that you discard any leftover pills in a safe way. Medication disposal resources are available on the Minnesota Pollution Control website.”

Post-acute pain. This period, extending up to 45 days after the onset of pain, represents a critical period for secondary prevention of chronic opioid use and substance use disorder. It is imperative that a prescriber work with the patient to limit the days of opioids prescribed following an acute event. In speaking with patients who request opioids during this period, consider these conversation starters:

“As we learn more about opioids, we now know that dependency and other risks of long-term use begin much earlier than we previously thought. There may also be things going on in your life other than your injury that affect the pain.”

“Let’s talk about some of the other factors that may contribute to your pain after the healing process has begun. We do this with all of our patients recovering from an injury or surgery, and it helps us to provide the most effective treatment.”

The longer you take opioid pain medications, the greater  your risk for addiction.

Chronic pain. The risks increase for patients experiencing chronic pain. You might start your conversations with:

“The medical community’s understanding of pain—especially chronic pain—has changed. We understand that acute pain and chronic pain are different, and that chronic pain is often very complex. What maintains your chronic pain isn’t typically the same as what initially caused your pain when you first became injured or ill. It is important that we manage all kinds of pain, but we need to manage them differently.”

“There is now evidence that long-term opioid therapy is no more effective than other types of pain management options, yet it has significant risk of harm. It is my responsibility as a health care professional to provide you with the most effective care that I can, while keeping you safe.”

“I am concerned about your safety if we continue to rely on opioids to manage your pain. I know that your pain is real, and it is difficult. However, the longer you take opioid pain medications, the greater your risk for addiction or accidental death.”

In addition to these conversation starters, develop a personal strategy to care for patients experiencing chronic pain. Specific tips:

Be your patient’s partner in this journey. Validating pain is an important first step. Listen and reflect what you have heard the patient say about his or her pain experience.

Educate patients about pain management and opioid therapy. Ask what they understand or have heard in the news about opioids.

Motivate the patient to make a change. Use motivational interviewing skills to help elicit behavior change. Reassure the patient and express confidence that he or she will be successful.

Activate the treatment plan.

Non-opioid pain management conversation starters

Flipping the script also involves educating patients about non-opioid options. Suggested conversation starters:

“Your care needs to be comprehensive. Chronic pain is complex, and we need to treat different aspects of the pain with different types of therapy.”

“Unlike opioids, these other treatments will help you be more active, stay functional, and do things you enjoy. Some of the therapies I am suggesting do not provide an immediate sense of relief. However, over time, they produce long-term and safe improvement.”

Talking about tapering

A significant challenge faced by health care providers is the ongoing care of patients who have been exposed to opioid therapy for many years—some of whom receive daily doses that far exceed the recommended daily dosage. For many of these patients, a thorough risk benefit analysis, coupled with ongoing discussion of their goals and concerns, may reveal an opportunity to taper their daily dosage.

However, there are patients for whom tapering will destabilize and expose them to additional risk of harm. In April 2019, the U.S. Food and Drug Administration (FDA) released a safety warning about tapering opioid therapy for physically dependent patients.

Tapering patients off opioid therapy should never be forced. Tapers must be tailored to the individual patient’s clinical and personal situation, and the taper plan should follow evidence-based recommendations to minimize risks and avoid severe side effects.

Tapering conversation starters:

“I am concerned about your safety if we continue your opioids at the current dose.”

“The medical community has learned in the past few years that your risk of harm increases with the amount of opioids you take and with the length of time you take them. I want to reduce the risk associated with your opioid dose while we focus on a long-term plan to manage your pain and improve your function.”

 “It is healthy and good to once in a while test how much you need this dose. You may be surprised that you do as well or better on a smaller dose.”

“I will support you in your effort to taper. We can work on this slowly and gradually reduce the amount you take over time.”

Continuing education

DHS partnered with the University of Minnesota Medical School’s Office of Continuing Professional Development to develop a podcast of the Minnesota Opioid Prescribing Guidelines. The free podcast educates listeners on prescribing recommendations and offers continuing education credits to physicians, dentists, nurses, and pharmacists.

DHS also partnered with the Minnesota Medical Association to develop a series of webinars that provide a deeper dive into the guidelines, the sentinel measures, and the opioid prescribing report program. These webinars are available on the Opioid Prescribing Improvement Program provider education website at mn.gov/dhs/flip-the-script and through the Minnesota Medical Association.

It’s time to flip the script

The conversation you have with your patient about pain management and opioid use can represent a dramatic turning point. There are ways to reframe the conversation about pain management and opioids with your patients, avoid pitfalls, catch trouble signs, and keep your patients on the right path. Flip the Script provides the tools, education, and resources you need to give your patients the chance to write a far more positive life story for themselves, while helping you get back to the work you do best—helping your patients get and stay healthy.

Jeff Schiff, MD, MBA, is an emergency medicine physician at Children’s Hospitals and Clinics in St. Paul and a clinical assistant professor in the Department of Pediatrics at the University of Minnesota. Until recently, he served as medical director at the Minnesota Department of Human Services.

Sarah Rinn, MPH, is the Opioid Prescribing Improvement Program Coordinator at the Minnesota Department of Human Services. She holds a Master’s in Public Health in health policy from the George Washington University in Washington, DC.

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Sarah Rinn, MPH, is the Opioid Prescribing Improvement Program Coordinator at the Minnesota Department of Human Services. She holds a Master’s in Public Health in health policy from the George Washington University in Washington, DC.