the opioid epidemic best pracice prescribing supporting patient

Headache to Heroin

The Opioid Epidemic

“Current Best Practice Prescribingand Supporting the Patient”

Lonny Samuels, [email protected] me on LinkedIn

Solution Focused CEU Programs

mailto:[email protected]

Definition- Webster’s Dictionary

Definition of EPIDEMIC1.: affecting or tending to affect a disproportionately large number of individuals within a population, community, or region at the same time <typhoid was epidemic>

2: characterized by very widespread growth or extent : of, relating to, or constituting an epidemic <the practice had reached epidemic proportions>

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Why this Training? From the January 28th 2016 CMCS (Center for Medicaid and CHIP Services) Bulletin:

I. “According to CDC, opioid medication deaths have quadrupled from 1999 to 2011.”

II. "Of the 43,982 drug overdose deaths in 2013, 37% were associated with prescription opioid analgesics.”

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Why this Training? (continued)

III. “A Primary Driver of the rapid rise in opioid overdose was increased prescriptions for opioid pain medications, especially prescriptions associated high doses, longer course of treatment and in conjunction with benzodiazepine use”.

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IV. “Inappropriate opioid prescribing can also result in costly medical complications such as nonfatal overdoses, falls and fractures, drug-drug interactions and neonatal conditions. These complications result in costly, preventable healthcare expenditures and cause an incalculable amount of emotional suffering.”

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Why this Training? (continued) V. “Research shows the opioid epidemic has a disproportionate impact on Medicaid beneficiaries. Medicaid beneficiaries are prescribed painkillers at twice the rate of non-Medicaid patients and are three-to-six times the risk of prescription opioids. One study from the state of Washington found that 45 percent of people who died from prescription opioid overdoses were Medicaid enrollees.”

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From Center for Disease Control and Prevention 2016:

I. An estimated 20% of patients presenting to physician offices with non-cancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription.”

II. In 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills.

III. 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States.

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IV. The Drug Abuse Warning Network estimated that >420,000 emergency department visits were related to the misuse or abuse of narcotic pain relievers in 2011, the most recent year for which data are available ”

V. In 2013, on the basis of DSM-IV diagnosis criteria, an estimated 1.9 million persons abused or were dependent on prescription opioid pain medication

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Pill Mill Story

From Medscape Medical News January 21, 2016

Physician Who Ran Pill-Mill 'Zoo' Gets 12 Years in Prison

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Dr. Lowe owned and operated a string of clinics in New York City called AstraMed, but only the two clinics where Dr. Terdiman and Dr. Virey worked were involved in the pill-mill conspiracy, according to prosecutors.

Court records describe a brazen criminal enterprise. Drug traffickers known as crew chiefs commanded fake patients, who paid $300 for an office visit lasting only a minute or two. There were no tests or physical examinations. Crew chiefs footed the bill and gave their fake patients nominal sums for their role-in cash.

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The fake patients obtained oxycodone prescriptions, had them filled, and turned over the pills to their crew chiefs, who sold them on the street for $30 apiece in New York City and for more elsewhere. Independent drug dealers and addicts lined up for prescriptions after paying admission fees as high as $1600 apiece in New York City and for more elsewhere.

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Practice management for this kind of clinic sometimes turned violent. Crew chiefs and their bouncers were not above throwing a wayward clinic patron through a window or an uncooperative employee against the wall. Prosecutors alleged that members of the conspiracy murdered at least two individuals who got in their way. Physicians were pressured — and in one instance threatened at gunpoint — to prescribe oxycodone at outrageously high volumes.

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The gangster-style persuasion appeared to work. Between January 2011 and February 2014, AstraMed physicians wrote nearly 35,000 unnecessary prescriptions for oxycodone, totaling some 5.5 million tablets. Their street value topped $165 million. During this period, Dr. Lowe collected more than $7 million in cash for bogus office visits, prosecutors said.

"The defendant's clear greed — and his willingness to use his medical training to turn his clinics into drug dens and his doctors into drug dealers — weighs very strongly in favor of a substantial sentence.”

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Acute Pain

Acute Pain

Acute pain begins suddenly and is usually sharp in quality. It serves as a warning of disease or a threat to the body. Acute pain might be caused by many events or circumstances, including: surgery, broken bones, dental work, burns or cuts labor and childbirth.

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Chronic Pain

Chronic Pain

Chronic pain persists despite the fact that the injury has healed. Pain signals remain active in the nervous system for weeks, months, or years. Physical effects include tense muscles, limited mobility, a lack of energy, and changes in appetite. Emotional effects include depression, anger, anxiety, and fear of re-injury. Such a fear might hinder a person's ability to return to normal work or leisure activities. Common chronic pain complaints include:

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Chronic Pain

Headache, Low Back Pain, Cancer Pain, Arthritis Pain, Neurogenic pain (pain resulting from damage to nerves),Psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside)

Chronic pain might have originated with an initial trauma/injury or infection, or there might be an ongoing cause of pain. However, some people suffer chronic pain in the absence of any past injury or evidence of body damage.

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Non-Medicinal Pain Management

Heat: Heat helps decrease pain and muscle spasms. Apply heat to the area for 20 to 30 minutes every 2 hours for as many days as directed.

Ice: Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack or put crushed ice in a plastic bag. Cover it with a towel and place it on the area for 15 to 20 minutes every hour as directed.

Massage therapy: This may help relax tight muscles and decrease pain.

Physical therapy: This teaches you exercises to help improve movement and strength, and to decrease pain. 17


Transcutaneous electrical nerve stimulation (TENS): This is a portable, pocket-sized, battery-powered device that attaches to your skin. It is usually placed over the area of pain. It uses mild, safe electrical signals to help control pain.

Spinal cord stimulation (SCS): An electrode is implanted near your spinal cord during a simple procedure. The electrode uses mild, safe electrical signals to relax the nerves that cause your pain.

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Aromatherapy: This is a way of using scents to relax, relieve stress, and decrease pain. Aromatherapy uses oils, extracts, or fragrances from flowers, herbs, and trees. They may be inhaled or used during massages, facials, body wraps, and baths.

Guided imagery: This teaches you ways to put pictures in your mind that will make pain less intense. It may help you learn how to change the way your body senses and responds to pain.

Laughter: Laughter may help you let go of stress, anger, fear, depression, and hopelessness.

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Music: This may help increase energy levels and improve your mood. It may help reduce pain by triggering your body to release endorphins. These are natural body chemicals that decrease pain.

Biofeedback: This teaches your body to respond differently to the stress of being in pain. Caregivers may use a biofeedback machine to help you know when your body is relaxed. Biofeedback is a technique you can use to learn to control your body's functions, such as your heart rate. With biofeedback, you're connected to electrical sensors that help you receive information (feedback) about your body (bio).

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Self-hypnosis: This is a way to direct your attention to something other than your pain. For example, you might repeat a positive statement about ignoring the pain or seeing the pain in a positive way.

Acupuncture: This therapy uses very thin needles to balance energy channels in the body. This is thought to help reduce pain and other symptoms.

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NSAIDs (Non-Steroidal Anti-Inflammatory Drugs

Generic Brand NameBromfenac Prolensa, BromdayDiclofenac Cataflam, Voltaren, ZipsorDiflunisal DolobidEtodolac Lodine, Lodine XLFenoprofen NalfonFlurbiprofen Ansaid

IbuprofenAdvil, Cramp End, Dolgesic, Excedrin IB, Genpril, Haltran, Ibren, Ibu, Ibuprin, Ibuprohm, Ibu-Tab, Medipren, Midol IB, Motrin, Nuprin, Pamprin-IB, Q-Profen, Rufen, Trendar

Indomethacin Indocin, Indocin SR, TivorbexKetoprofen Actron, Orudis, OruvailKetorolac Toradol, SprixMeclofenamate MeclomenMefenamic Acid PonstelMeloxicam Mobic, VivlodexNabumetone RelafenNaproxen Aleve, Anaprox,

Anaprox DS, EC-Naprosyn, Naprelan, NaprosynOxaprozin DayproPhenylbutazone CotylbutazonePiroxicam FeldeneSulindac ClinorilTolmetin Tolectin, Tolectin DS

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Other Medications

Generic Brand NameAcetaminophen Tylenol

Generic Brand NameCelecoxib Celebrex

Generic Brand NameTramadol UltramTramadol and Acetaminophen Ultracet

COX-2 Inhibitors

Central Analgesics

Non-Narcotic Analgesics

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OpioidsGeneric Brand Name

Buprenorphine Buprenex, Butrans transdermal patchButorphanol StadolCodeine Hydrocodone Hydromorphone Dilaudid, Dilaudid-5, Dilaudid-HP, Hydrostat IR,

Exalgo ERLevorphanol Levo-DromoranMeperidine DemerolMethadone Dolophine, Methadose

MorphineAstramorph PF, AVINZA, Duramorph, Kadian, M S Contin, MSIR, Oramorph SR, Rescudose, Roxanol

Nalbuphine NubainOxycodone OxyContin, Roxicodone, OxectaOxymorphone NumorphanPentazocine TalwinPropoxyphene Cotanal-65, DarvonTapentadol Nucynta

Narcotic Pain Medications (Painkillers)

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Opioid CombinationsGeneric Brand Name

Butalbital, Acetaminophen, and Caffeine Femcet, Fioricet, Esgic, Esgic-Plus

Butalbital, Aspirin, and Caffeine FiorinalButalbital, acetaminophen, caffeine, and codeine Fioricet with Codeine

Hydrocodone and Ibuprofen Hydrostal IR, VicoprofenMorphine/Naltrexone EmbedaPentazocine/Naloxone Talwin NXNarcotic Analgesics and Acetaminophen

Acetaminophen and Codeine Capital with Codeine, Margesic #3, Phenaphen with Codeine, Tylenol with Codeine

Dihydrocodeine, Acetaminophen, and Caffeine DHCplus

Hydrocodone and Acetaminophen

Allay, Anexsia 5/500, Anexsia 7.5/650, Dolacet, Dolagesic, Duocet, Hycomed, Hydrocet, Hydrogesic, HY-PHEN, Lorcet 10/650, Lorcet-HD, Lortab, Panacet 5/500, Panlor, Stagesic, T-Gesic, Ugesic, Vicodin, Zydone

Oxycodone and Acetaminophen Endocet, Percocet, Roxicet, Roxilox, Tylox; Xartemis XR

Pentazocine and Acetaminophen Talacen

Propoxyphene and Acetaminophen Darvocet-N 50, Darvocet-N 100, E-Lor, Propacet 100

Combinations

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Opioids and Aspirin

Narcotic Analgesics and AspirinAspirin, Caffeine, and Dihydrocodeine Synalgos-DCAspirin and Codeine Empirin with CodeineHydrocodone and Aspirin

Damason-P, Lortab ASA, Panasal 5/500

Oxycodone and Aspirin

Endodan, Percodan, Percodan-Demi, Roxiprin

Pentazocine and Aspirin Talwin Compound

Propoxyphene, Aspirin, and Caffeine

Darvon Compound-65, PC-Cap, Propoxyphene Compound-65

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Topicals

Generic Brand Name

CapsaicinArthriCare, ARTH-RX, Axsain, Capsagel, Dura-Patch, Methacin, Qutenza, Zotrix, Zotrix-HP

Generic Brand NameBenzocaine Americaine, Endocaine, LagolBenzocaine / Menthol Benzocol, Butyl Aminobenzoate,

DermoplastDibucaine Cinchocaine, Nupercainal Cream,

Nupercainal OintmentLidocaine LidaMantle, Lidoderm, Lignocainem,

XylocaineLidocaine/ Prilocaine EMLA

Topical Analgesics

Topical Anesthetics

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Tricyclic Antidepressants

• Tricyclic antidepressants are the most common type of antidepressant used for pain. They include:

• Amitriptyline• Imipramine (Tofranil)• Clomipramine (Anafranil)• Doxepin• Nortriptyline (Pamelor)• Desipramine (Norpramin)

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Anticonvulsants

Generic Name Brand Namecarbamazepine Epitol, Tegretolgabapentin Gralise, Neurontinoxcarbazepine Trileptalpregabalin Lyricatopiramate Topamax

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Cannabis as Painkiller

Cannabinoids have shown significant promise in basic experiments on pain. Peripheral nerves that detect pain sensations contain abundant receptors for cannabinoids, and cannabinoids appear to block peripheral nerve pain in experimental animals. Even more encouraging, basic studies suggest that opiates and cannabinoids suppress pain through different mechanisms. If that is the case, marijuana-based medicines could perhaps be combined with opiates to boost their pain-relieving power while limiting their side effects…….

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Cannabis as Painkiller

…But because of the ethical and logistical difficulties of conducting pain experiments on human volunteers, marijuana's potential to relieve pain has yet to be conclusively confirmed in the clinic. Only a few such studies have been conducted. Most tested the ability of cannabinoids to relieve chronic pain in people with cancer or acute pain following surgery or injury. Unfortunately, few of these studies are directly comparable because the methods used to conduct them varied greatly and in some cases appear to have been less than scientifically sound.

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Cannabis-Diversion of Opioids

A major reason doctors do not prescribe opiates if a patient tests positive for cannabis…

What do you pay your drug dealer with to get your marijuana if you have no money, but you have pain medicine?

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Opiates Dangerous Combinations

Benzodiazepines, such as alprazolam (Xanax®), diazepam (Valium®), clonazepam (Klonopin®), and lorazepam (Ativan®), depress central nervous system (CNS) activity and are used to relieve symptoms of anxiety, panic attacks, and seizures. However, when combined with other drugs that depress CNS activity, such as alcohol or opioid pain relievers benzodiazepines may present serious or even life-threatening problems.

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Opiates Dangerous Combinations

Being Prescribed Opiates while also being in an opiate replacement drug treatment with Buprenorphine (Suboxone) or Methadone.

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Evaluating Morphine Equivalent Dosing (MED)

The standardized measurement for the amount of opiate medication is calculated via a conversion of any opiate medication to its equivalent in morphine. This is Morphine Equivalent Dosing (MED)

The following are excerpts from best practice guidelines from leaders in the field of opiate treatment of chronic pain. MED is an essential component in these guidelines:• The American Pain Society

• Washington State Agency Medical Directors’ Group (AMDG)

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Best Practice American Pain Society

2009 Clinical Guidelines from the American Pain Society “The guideline defines high dose opioid therapy as >200 mg daily of oral morphine (or equivalent). These doses are outside the ranges evaluated in randomized trials and prescribed in only a small minority of patients in observational studies. When opioid doses reach this threshold, more frequent and intense monitoring is recommended. Clinicians should consider weaning or discontinuation of chronic opioid therapy if assessments indicate reduced analgesia, function, or quality of life; aberrant drug‑related behaviors; or the presence of intolerable adverse effects.”

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Best Practice Washington State

Washington State Agency Medical Directors’ Group “While there is evidence that opioids can provide significant pain relief in the short term, there is little evidence for sustained improvement in function and pain relief over longer periods of time. Chronic Opioid Analgesic Therapy (COAT) is associated with the development of tolerance, a decrease in analgesic effect with the same dose over time. Providers must pay attention to the development of tolerance and avoid ongoing dose escalation to overcome this effect.

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Best Practice Washington State (continued)

The 2010 edition recommended a 120 mg/day MED threshold to seek consultation with a pain specialist as a strategy to prevent serious adverse outcomes, including fatal overdoses. Group Health Cooperative (GHC), which implemented the best practices from the 2010 edition, has demonstrated a reduction in opioid doses for their COAT patients. For the last quarter of 2014, less than one-quarter of COAT patients seen by GHC providers received 50 mg/day MED or greater and only 7.3% exceeded 120 mg/day MED.

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Overdose risk approximately doubles at doses between 20 and 49 mg/day MED, and increases nine-fold at doses of 100 mg/day MED or more (Figure C). Although the 2015 guideline maintains the 120 mg/day MED threshold for consultation and some guidelines have lower dose thresholds ranging from 50 to 90 mg/day MED, there is no completely safe opioid dose.

There is a correlation between the amount of opioids prescribed for patients and their potential availability for diversion, with associated risks for individuals in the community.”

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Provider Education-CDC Guideline for prescribing Opioids for Chronic Pain-United States 2016

An 50 page book from the CDC that has detailed information in best practice in prescribing opiates for chronic pain and research to back it up.

12 points of emphasis

“Hot off the press”-March 18th 2016. Newest Best Practice Guidelinehttp://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

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Provider Educational MaterialBest Practice CDC 12 points

1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.

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Best Practice CDC 12 points (continued)

2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

Written Pain Treatment Agreement preferred in other agency best practice documents.

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3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.

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4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.

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5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.

Consultation/referral to pain management preferred in other agency best practice documents when high MED.

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6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

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7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.

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8. Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.

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9. Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

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10. When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.

Pill Counting also part of other best practice documents.

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11. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.

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12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

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CDC Provider Educational Materials

7 provider educational materials based on-CDC Guideline for prescribing Opioids for Chronic Pain-United States 2016http://www.cdc.gov/drugoverdose/prescribing/resources.html

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Additional Provider Educational Materials

Helping to insure adherence to Medication Treatment Plan.

• The Prescription Drug Monitoring Program (cornerstone 1)

• Sample Patient-Doctor Pain Treatment Agreement(cornerstone 2)

• Pill Counting Procedure (cornerstone 3)

• Urine Drug Testing (cornerstone 4)

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Prescription Drug Monitoring Program (PDMP)

The first cornerstone of best practice is registering and using the PDMP to know exactly the controlled medications a patient has filled.

The PDMP is a database that houses the controlled medication prescription information for the State of Maryland. Information and registration is available at:https://crisphealth.org/CRISP-HIE-SERVICES/Prescription-Drug-Monitoring-Program-PDMP

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Sample Patient-Doctor Pain Treatment Agreement

The second cornerstone of best practice is creation, use, and enforcement of a patient-doctor pain treatment agreement.

A two page example of a pain treatment agreement developed by American Academy of Pain Medicinehttp://www.painmed.org/files/agreement-on-controlled-substances-therapy.pdf

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Pill Count Procedure

The third cornerstone is the use of pill counting.

A two page pill count procedure developed by The State of Maine Quality Counts Divisionhttps://www.mainequalitycounts.org/image_upload/Pill_Count_Procedure_PCHC.pdf

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Urine Testing Guide (Saliva also now used)

The fourth cornerstone is the use urine drug testing.

A ten page document regarding urine drug testing published on OpioidRisk website (http://www.opioidrisk.com)

A negative test means something too!

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When High Dose Opioids are Part of Life

• Pain has become not having the medicine. The body and

mind seem to work together to combine a craving sensation with the pain relief.

• Opioid-induced hyperalgesia (OIH) is defined as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli. The type of pain experienced might be the same as the underlying pain or might be different from the original underlying pain. OIH appears to be a distinct, definable, and characteristic phenomenon that could explain loss of opioid efficacy in some patients.

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When New Best Practice Meets the Patient

Doctor decides to follow best practice (Training, DEA worries, Other Professionals, and/or Insurance Company Pressures)• The patient was diverting the medicine (should be found out if

drug tests were being performed as best practice would dictate). Withdrawal should not be an issue (obviously).

• The patient doctor shops. Hopefully, other doctors will follow best practice and refer patient back to the previous doctor.

• The prescribing doctor refers patient to pain management office who should be following best practice.

• The patient now must taper if doctor or pain management practice feels this is the best practice for the patient’s treatment.

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Tapering or discontinuing opioids

From Washington State:

Not all patients benefit from opioids, and a prescriber frequently faces the challenge of reducing the opioid dose or discontinuing the opioid altogether. From a medical standpoint, weaning from opioids can be done safely by slowly tapering the opioid dose and taking into account the following issues:

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Tapering or discontinuing opioids (continued)

• A decrease by 10% of the original dose per week is usually well tolerated with minimal physiological adverse effects. Some patients can be tapered more rapidly without problems (over 6 to 8 weeks). �

• If opioid abstinence syndrome is encountered, it is rarely medically serious although symptoms may be unpleasant.

• Symptoms of an abstinence syndrome, such as nausea, diarrhea, muscle pain and myoclonus can be managed with clonidine 0.1 – 0.2 mg orally every 6 hours or clonidine transdermal patch 0.1mg/24hrs (Catapres TTS-1™) weekly during the taper while monitoring often. In some patients it may be necessary to slow the taper timeline to monthly, rather than weekly dosage adjustments.

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Tapering or discontinuing opioids (continued)

• Symptoms of mild opioid withdrawal may persist for six months after opioids have been discontinued. Rapid reoccurrence of tolerance can occur for months to years after prior chronic use. �

• Consider using adjuvant agents, such as antidepressants to manage irritability, sleep disturbance or antiepileptics for neuropathic pain. �

• Do not treat withdrawal symptoms with opioids or benzodiazepines after discontinuing opioids. Referral for �counseling or other support during this period is recommended if there are significant behavioral issues. �

• Referral to a pain specialist or chemical dependency center should be made for complicated withdrawal symptoms.

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Supporting the Tapering Patient

The tapering patient now enters your life and is your client:

Social Worker, Therapist, Psychologist, Nurse, Nurse Practitioner, Physician’s Assistant, Physician, Certified Addiction Counsellor, Case Manager, Others in the Helping Professions.

How to Support the Client in this difficult Situation:

My four pronged fused approach: 1)Humanism, 2)Education, 3)Solution Focused Therapy and 4)Motivational Interviewing

Every therapist and client relationship is different. It’s not science but more of the art in fusing these four techniques to help the client achieve the goal of a proper medical treatment plan with healthy coping and internal locus of control.

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Humanism

• Humans have free will; not all behavior is determined.

• All individuals are unique and have an innate (inborn) drive to achieve their maximum potential.

• A proper understanding of human behavior can only be achieved by studying humans - not animals.

• One should study the individual case rather than the average performance of groups.

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Humanism (continued)

EMPATHY• Remember, there is good chance the person before you put their

faith in a doctor to treat them for their pain. There is good chance the doctor prescribed high dose of medicine because this was their best practice at the time.

• Can’t you see yourself in the same position as the person before you?

• This is humanism. Rogers (key figure in the Humanistic Movement) found that the client/therapist relationship accounted for 80% of the client’s progress and, 20% was accounted for by the therapists choice of therapy and expertise.

• Be genuine, transparent, and caring. You client will feel joined in the pursuit of mental well being during their shift of medical treatment.

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Education

• Talk about the things we have been discussing in the previous slides.

• Especially that society and government is forcing doctor’s to prescribe less and lower doses of opioids.

• Present the information at the understanding level of the client.

• Be very matter of fact.

• Always move forward and do not get caught in discussing the past.

• Eventually get to the point where the client realizes that the opioid dose is going to come down, so let’s work on it together.

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Solution Focused Therapy

• Change is constant and inevitable

• Clients are the experts and define goals

• Clients have resources and strengths to solve problems

• Future orientation - history is not essential

• Emphasis is on what is possible and changeable

• Short term

• Clients want change

• Throw away the “AH HA” goal of therapy69

Solution Focused Therapy (continued)

The Miracle questionDe Shazer's (1988) miracle question: "Suppose that one night, while you are asleep, there is a miracle and the problem that brought you here is solved. However, because you are asleep you don't know that the miracle has already happened. When you wake up in the morning, what will be different that will tell you that the miracle has taken place? What else?"

Erickson's original version of the question involved asking his client to look into the future and see themselves as they wanted to be, problems solved, and then to explain what had happened to cause this change to come about. He might also ask clients to think of a date in the future, then worked backwards, asking them what had happened at various points on the way.

O'Hanlon suggests other variations of the question:•a time machine•crystal ball•rainbow bridge•a letter from a future self

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Building on the miracle question:

• What difference would you (& others) notice?

• What are the first things you notice?

• Has any of this ever happened before?

• Would it help to recreate any of these miracles?

• What would need to happen to do this?

• What else?

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Solution Focused Therapy (continued)Exception Questions

• Has anything been better since the last appointment? What's changed? What's better?

• Can you think of a time in the past (month/year/ever) that you did not have this problem?

• What would have to happen for that to occur more often?

• When doesn't the problem happen?

• What's different about those times?

• What are you doing or thinking differently during those better times?

• When have you been able to stop doing....?

• Are there times when you expect to...but you remember something that helps you calm down?

• What else?72

Solution Focused Therapy (continued)Coping Questions

• How do you cope with these difficulties?

• What keeps you going?

• Who is your greatest support?

• What do they do that is helpful?

• What do you do that stops the problem getting worse?

• When you've had this problem before, what helped you get through then?

• How did you manage to solve the problem?

• What advice would you give to someone else who has this problem?

• What else?73

Solution Focused Therapy (continued)Scaling questions

• On a scale of 1 to 10 where 1 is the worst it's ever been and 10 is after the miracle has happened, where are you now?

• Where do you need to be?

• What will help you move up one point?

• How can you keep yourself at that point?

• What would be the first sign that you had moved on one point further?

• Who would be the first person to notice you've moved one point up? What would they notice?

• What else?74


• De Shazer's Skeleton Keys

•Between now and next time....observe what works - notice what is going well in your situation that you would like to continue (keep doing what works)•Do something different •Pay attention to when.....(an exception happens)•Write, read, and burn thoughts•Write about what is bothering you for 15 minutes each night, at the same time. •When you've fully expressed everything you think needs to be expressed, read it over each night until you really think it's complete…….

and you've got it all out, then burn the paper you've written on

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Motivational InterviewingMotivational interviewing is practiced by licensed therapists and substance-abuse counselors. Initially defined in 1983 by William Miller, motivational interviewing is used as a form of therapy to help treat people dealing with addictions, including drug and alcohol. During the treatment, interpersonal processes patients use to continue or change certain addictive behaviors are examined. It is the five principles of motivational interviewing, principles that focus on empowering patients, that make the treatment different from more traditional therapies..

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Motivational Interviewing (continued)1. Express and Show Empathy Toward Clients

Counselors or psychologists express and demonstrate empathy when discussing behaviors, thoughts and life events that clients regularly engage in. By expressing empathy, counselors can start to build rapport and trust which, in turn, may help clients to become more open, sharing more of their personal history, struggles and concerns. This principle also accepts that clients might be ambivalent during counseling sessions, especially at the start of counseling. Skillful and active listening that reflects what the client shares is another component of this principle counselors practice.

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Motivational Interviewing (continued)2. Support and Develop Discrepancy

During motivational interviewing, clients give reasons for changing their behavior -- instead of viewing counselors as authority figures with the right answers. For example, clients might decide to stop taking so much pain medicine to build healthy relationships with their children. If clients are exhibiting behaviors and making choices that take them away from their goals, counselors gradually point out this gap between behaviors and goals to clients.

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Motivational Interviewing (continued)3. Deal with Resistance

When clients resist changing their behavior, counselors do not confront the client’s resistance. Instead, counselors avoid struggling to get client’s to see their point of view. As discussions continue, counselors work with clients to get them to see and examine different viewpoints, allowing clients to choose which points of view they want to stick with. Furthermore, resistance, when it occurs, is a sign for counselors to alter their approach to the talk therapy.

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Motivational Interviewing (continued)4. Support Self-Efficacy

Clients are made to feel that they are capable of achieving the change they want. This principal involves counselors discussing and pointing out previous behavioral and life successes clients have experienced. For example, counselors might remind clients recovering from drug addiction that they have kept a job for two years and have been drug-free for six months. Current or previous strengths and skills clients possess are also discussed, thereby increasing the clients’ belief that they can change.

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Motivational Interviewing (continued)5. Autonomy

Counselors demonstrate to clients that the authentic power for them to change comes from within, not from the counselor. This emphasizes the thought that there is no one way to achieve the change that clients want. It is also expressed to clients that they are ultimately responsible for changing their behavior. Additionally, counselors listen as clients develop a list of action steps they can take to change their behavior.

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Resources

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www.scopeofpain.comwww.anthem.com/painmanagementwww.americanhumanist.orgwww.solutionfocused.netwww.motivationalinterviewing.org/www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Thanks

Lonny Samuels, [email protected](410)804-5097

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