Slide narration: Hello, and welcome to the CDC series Applying CDC's Guideline for Prescribing Opioids. In this module, we will review the CDC recommended strategies for communicating effectively with patients about pain management and opioid use. You will have the opportunity to learn the importance of communicating relevant information to your patients, how to apply motivational interviewing to encourage changes in chronic pain management and use of opioids, and how to properly address conflicts that sometimes arise.At the end of the module, you will be presented multiple choice knowledge check questions to test your mastery of the content.
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CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016
Narration text: You may find it useful to refer to the CDC Guideline during this module. You can access, download, and print a copy of this and other helpful documents by selecting the Resources tab at any time. Some screens include a link icon which, when selected, opens additional online resources. Let's take a closer look at the navigation features of this web-based training. As you've experienced already, the Next and Back buttons enable you to move to a new screen or back to a previous screen. If either the Next or Back button is dimmed, it is disabled, and you will need to complete an action onscreen to continue. Refer to the navigation prompt located at the bottom of the screen to help you determine how to proceed. Selecting the Menu button in the upper right corner opens a list of all the topics available in the module. A selection made from the list advances the training to that topic. Pressing the open Menu tab a second time will collapse it. There is also a set of audio controls located at the bottom of the training window. Here you can pause or play the narration, control the volume, and open the text transcript for the narration if needed. Most slides, however, will not be narrated, and this set of controls will be dimmed and disabled.
The CDC Guideline for Prescribing Opioids for Chronic Pain stresses the importance of collaboration between doctor and patient. Here we emphasize three specific recommendations that highlight the importance of improved collaboration between providers and patients. They provide a basis for discussing with patients the risks and benefits associated with using opioids for chronic pain while working with patients to define realistic goals for function and pain relief to help them improve their quality of life.
In Recommendation 2, CDC recommends clinicians and patients agree on treatment goals together. This includes encouraging a collaborative dialogue with patients to develop specific steps for managing pain while improving activity and function, and recognizing that complete elimination of pain is often not possible with or without use of opioids.
In Recommendation 3, CDC recommends clinicians and patients consider known risks and benefits of initial and continued opioid therapy. Explain benefits as well as common and serious harms of opioid therapy with patients, and then define your collective responsibilities to mitigating risks of opioid therapy. You should also learn about your patient's preferences and values so that you may apply this knowledge to clinical decisions.
In Recommendation 7, CDC recommends clinicians evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dosage escalation. You should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. This includes sharing any knowledge of co-prescriptions or potentially dangerous interactions found in the prescription drug monitoring program (PDMP). If at any point the benefits do not outweigh harms of continued opioid therapy, you should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
Research findings inform how and what we communicate to our patients who are experiencing chronic pain. These findings include:
Effective strategies for working with patients with chronic pain are not learned in a single session. They must be practiced, reviewed, and applied consistently over time. Careful consideration and practice with the following three strategies will lead to improved communication with patients who are experiencing chronic pain.
Establish trust and express empathy regarding the impact of pain on daily activity and function.
Review how current treatment is helping or hindering the patient's quality of life.
Explore options to get to a safer and more effective approach to managing chronic pain long-term.
Trust is established through compassion and empathy, which strengthens the provider-patient relationship. Learn more by selecting a topic from the left menu.
Take time to listen to your patient. Show, both verbally and nonverbally, that you are genuinely interested in helping and collaborating with the patient to find a solution. Check often to ensure your patient understands what is being communicated. Educate your patient to support recommendations or clarify any misunderstandings. Take the time necessary to review and discuss treatment options and fully explain associated risks and benefits. Emphasize your concern for their safety and the desire to find safe approaches that will enhance overall quality of life, not just reduce pain temporarily.
Address your patient by name and be sure to consider your patient's culture, experience, and social influences. Keep in mind that patients may interpret and communicate symptoms, illness, and treatments based on their unique cultural perspective, which may vary greatly from your clinical understanding.
Listen intently to your patient's concerns, trying to empathize with his or her perspective. Maintain eye contact and use appropriate nonverbal cues. Relay the information back to the patient in his or her own words to confirm understanding. Allow adequate time to correct misunderstandings and answer questions.
Use empathic statements, such as:
Consider your nonverbal communication, such as:
Change happens from within. Collaborate with each of your patients to evaluate how current therapy is impacting quality of life and to assess readiness for change.
Motivational interviewing can help encourage patients to make personal changes they already deem important for reaching a particular goal, such as regular exercise or eating a balanced diet.
Many patients using opioids long-term for chronic pain would like to reduce their dosage or stop using opioids altogether. They may already be well aware of the risks of long-term opioid use and in tune with the side effects that they are experiencing.
Simultaneously, they may be fearful that making any changes in their pain management will increase their pain. Willingness to try out a new approach on an "experimental" basis requires trust.
Through motivational interviewing techniques, providers and patients together consider:
This collaborative effort may be sufficient to motivate moving forward on changes such as tapering medication and/or beginning nonpharmacologic treatments such as physical therapy and exercise.
Motivational interviewing techniques can be applied before, during, or after opioid therapy. Motivational interviewing helps patients consider options for a step toward improved pain and function.
Here is an example of a motivational interview between provider and patient.
The first step is to express empathy through reflective listening. Here the provider asks open-ended questions, listens carefully, repeats the information in the patient's own words, and corrects any misunderstandings.
The provider says, "John, I know you have been dealing with chronic pain for quite a while now. Tell me what has changed or progressed since our last visit."
The patient says, "Well, I don't think the medicine is working anymore, doctor. My back pain causes me to miss too much work and most days the only thing I can do is sit in my recliner."
Note how the clinician repeats his patient's words and empathizes with his situation, "I would be just as frustrated. You said you think the medicine isn't working anymore, and your back pain causes you to miss too much work. Most days the only thing you can do is sit in your recliner. Tell me more about your experience with your current prescription."
The patient responds, "My current prescription is doing nothing for me other than make me feel like a zombie. I am afraid I am going to lose my job, and my family just doesn't get it."
The provider summarizes by saying, "Let's make sure I understand. Your medication doesn't control the pain and makes you feel like a zombie. It also sounds like your employer and family are having trouble understanding what you are going through. There is a possibility of losing your job, which I can understand would put an enormous burden on you and your family. We are going to work on this together."
Next, the clinician highlights discrepancy between patient's goals or values and their current behavior. Note how he reflects the patient's ambivalence back, showing how his actions are contrary to his goals and values.
"So John, what kind of change would help you feel more like yourself?"
The patient states, "If I could just increase my dosage, I am sure I could get back to work, making me feel a bit more normal I guess."
"You said that up to this point your prescription is doing nothing for you and makes you feel like a zombie. What makes you want to continue treating the pain in the same way?"
The patient questions the provider by asking, "What options do I have? I have been taking the same thing for years now."
Observe that the clinician avoids arguments and direct confrontation. Note how here the doctor changes direction and finds common ground, allowing the patient to comment on benefits.
"Many people in your situation find that if their dosage is very gradually lowered, they begin to feel better and do better, and think more clearly. Sometimes their pain is reduced, but it is uncommon for the pain to get worse. Patients tell me that they begin to feel more like their old selves again."
The patient responds, "Hold on a second. Are you trying to tell me that the pain is in my imagination? How can you possibly believe pain medication makes pain worse?"
"Your pain is real. I realize it sounds counterintuitive, but high dosages of opioids can cause dependence and tolerance. This can sometimes make a bad situation worse. Opioids do help with severe pain in the short term. You've been on these meds for a while now, so short-term benefits are behind us. I, however, don't think you are ready to taper your dosage yet. If we try something new, we can do it gradually, and make adjustments based on how it goes."
"I guess I am able to sleep a bit better, but I still have unbearable pain later in the day. Can you imagine how I would feel if I wasn't taking it?"
The clinician adjusts to patient resistance rather than opposing it directly. Note how here the conversation is redirected toward a positive. "It sounds like you do realize that opioids carry more risks than benefits, but you are in too much pain to consider anything else."
"Doctor, do you think I am going to magically feel better if I stop taking these pills? You have no idea what it is like!"
"You are getting ahead of me. I didn't suggest you stop. Let's step back and talk about the benefits of your current medications."
"Well, it used to be that my medicine relieved most of my pain, but as time passes I feel like nothing is helping me."
"Can you think of anything other than medicine that made you feel better?" the provider asks.
Finally, the clinician supports self-efficacy and optimism. Note how in this step the clinician opens the door to a fresh, positive perspective and then supports the patient's positive action.
"When my pain was under control, which seems like a different lifetime, I could get out more and be more active. That helped. Some of the exercises that my physical therapist recommended were helpful, but when my pain gets worse, I can't do them. They did seem to help me feel better longer, but the pain gets in the way."
"Okay. What do you think might be doable on your good days? And, what can you manage on your bad days so you don't just lie around, which can make your pain worse?"
"On my good days I could manage some of the exercises, and I could get out more than I do. On my bad days, it is really tough. The best I can do on my bad days is just getting off the couch. I know I should get up and go out, but the pain is unbearable. I suppose I could go for a walk. My wife would be happy to see me getting out of the house instead of sitting around all day."
"I think it's great that you want to get a little more active. I think your ideas about pacing what you do make sense. Would you like to hear about other ideas to manage your pain?"
The next principle for effective communication is to explore with patients all feasible options to manage chronic pain. The most appropriate medical treatments, including tapering an opioid, may not be expected or in line with your patient's expectations or beliefs.
This can create conflicts and challenges with patients, which should be addressed directly, with both the provider and patient exploring all options for improving quality of life.
For the provider, this means empathizing with the patient while presenting the benefits of the recommendation, as well as the evidence behind the recommendation.
Next, we will review one proven method for addressing conflicts with patients experiencing chronic pain.
You would be right to say, "We know more about the risks of opioids now than we used to, and we now know that a high dosage of opioid medication poses significant risk, especially for the long term. Let's work together to find a safer pain management plan for you that involves less opioids." However, this is where conflict often begins.
Melissa pleads, "Please, please refill my opioid medications; if I didn't have them I surely couldn't manage my job and my family!"
Confronting Melissa directly by refusing to continue her current opioid prescription will only heighten the conflict. Instead, acknowledge the patient's concerns and work to understand her perspective. Ask open-ended questions if you need clarification. Then, reiterate what you heard to ensure understanding.
"How is the medication helping you? Do you have any side effects?" "I agree that stopping your prescription abruptly would not be a good idea. Given that, what do we need to do going forward?"
"Well, it does make me drowsy, and I am constantly constipated. Sometimes I completely forget things I am supposed to be doing." "But, it is helping me deal with the pain, and that's why I can't imagine not having it." "You're not just going to take away my pain pills, are you?"
Next, you want to validate her concerns and emotions while sharing how her situation isn't unique or troubling. Be empathetic and help to normalize her situation.
"It makes sense that the medication is helping you with your pain, but you could do without the side effects." "I have helped many people in your situation. We'll get you through this too."
"It makes no sense that you can help me, or anyone else, by taking away their pain medicine."
After sharing that others in her situation have been helped, continue in a positive direction by verbalizing reassuring elements of the history and exam. Then, explain how others in similar situations have found relief.
"Let's talk about the good news. You're overall pretty healthy, and while back pain can linger for a while after an injury, we have many other options besides opioids we can use to manage your pain, options that it sounds like you haven't yet tried. That's good news, because it means we have many other strategies to try out." "Many of these methods have worked well for many of my patients."
"You're talking about taking away pain meds that I have been relying on for months. I don't feel like that is going to work."
At this point the patient is naturally wondering how this is going to work, given the contradictory nature of removing a medicine for pain in order to relieve it. The next step is to explain your recommendation and compare risks and benefits to her expectations.
"It may sound hard to believe, but other patients in your situation have often experienced improvements in pain once they are off opioid pain medication. Opioids tend to be less effective over time, and the risk of physical dependence, tolerance, and overdose increase. Physical dependence can cause you to feel worse, and pain to increase, as the medicine begins to wear off. Patients feel like the pain will get worse without the medications."
"You said it wasn't a good idea to take them away, so what are you planning on doing? This talk is making me very nervous."
After providing an explanation, a patient may still react negatively, or at least emotionally. Take the time to validate emotions and concerns as they arise before negotiating an alternative plan to reach goals of improved function and less pain.
"We have some options that will help you become more active, which can help decrease your pain. First, we can lower your opioid dosage slowly enough that you won't have increased pain, and you are likely to feel better as we get your dosage down. Second, we can add in simple exercises and stretching. Some patients have had great success with yoga and acupuncture for back pain. Third, there are other nonopioid medications that we can try, such as ibuprofen." "I suggest we start with lowering your hydrocodone dosage by 10% per week. We will see how that goes and make adjustments based on how you are doing. I would like to see you back one week after you have lowered your dosage."
"I didn't realize it would be that gradual. I am willing to try it. I suppose I can try yoga too, if you feel it might help."
Before ending the appointment, the provider should explore for any residual concerns, make sure all questions are answered, and ensure the patient knows the path forward.
"I want to make sure we are clear about our plan to reach your goals. Do you have any unanswered questions or concerns?"
"What happens if my pain increases when you lower my pain medicine?"
Melissa should be reassured that the dosage will be held at the current level until she feels ready to begin the taper again. Be sure to prepare patients that there may be good days and bad days with their pain as the taper progresses. The dosage shouldn't, however, be increased. Let's now take a moment to review the process again.
Recent research and expert opinion support which of the following statements? Select all that apply.
The correct answers are A, C, and D. The medical community is still learning about the effectiveness and safety of long-term opioid use. Opioids will not relieve pain completely, and their use always carries the risk of serious, lifelong addiction. Doctors should use urine drug testing and check the PDMP to identify inappropriate use of prescription medicines.
Which of the following statements describe motivational interviewing? Select all that apply.
The correct answers are B, C, and D. The provider should express empathy through reflective listening while seeking to enhance intrinsic motivation. Patients should also be encouraged to make personal changes they already deem important. Conflict should be avoided by redirecting to a more constructive topic.
Which of the following are strategies for addressing conflict? Select all that apply.
The correct answers are A and B. The first step in addressing conflict is to understand the patient's concerns and expectations by asking open-ended questions. Reviewing reassuring features of the history and exam keeps the conversation positive.
Narration Text: Before starting opioid therapy for chronic pain, develop treatment goals with all patients; Consider known risks and benefits of opioid therapy eliciting patient views; Evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of dose escalation; Optimize other therapies and work with patients to taper opioids if benefits do not outweigh harms
Before starting opioid therapy for chronic pain, clinicians should develop treatment goals with all patients.
Consider known risks and benefits of opioid therapy, eliciting patient views.
Evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of dosage escalation.
Optimize other therapies and work with patients to taper opioids if benefits do not outweigh harms.
Supporting research can be found in the CDC Guideline for Prescribing Opioids for Chronic Pain.
You may now continue to the Training and Continuing Education Online System (TCEOnline) to receive continuing education credit for this training module. Please register on TCEOnline, search for the course (WB2858), select the appropriate credit type, and complete the course evaluation and posttest in the Participant Services section. Directions for completing this process are available in the Resources tab.
Select the Resources tab for links to clinical tools designed to help you apply these recommendations in your practice.