Conversa)onsAsMedicineCompassion-BasedDifficultConversa)ons

LauraHeesacker,LCSWBehavioralHealth

Innova)onSpecialistHeesackerl@careoregon.org

IHAVENOTHINGTODECLAREINREGARDS

CONFLICTSOFINTEREST

IWORKWITHJCCANDHOLDA

CONTRACTW/THESTATEOFOREGON-PDO-CDCGRANT

Iwanttothankthepar)cipantsforaFendingandCentralOregonforInvi)ngme

GeneralObjec)ves

1) Suggest4trapsaprovidercanfallintowhilehavinga“difficultconversa)on”

2) Offer4guidelinestoapplywhilehavinga“difficultconversa)on”

3) Offer4toolsthatcanbeusedduringa“difficultconversa)on”

ThePowerof4

• 4Traps• 4Guidelines• 4Tools

Doesiteverfeellikeyouhavesteppedintoatrap?

InspiredbyBradAnderson,MDKeiser

”GivenallthatIhavebeenthrough…youjustwantmetosuffer?”(CompassionTrap)

“IfyoucutmeoffIwillloosemyjobandbecome

homeless!”(AllorNothingTrap)

“Areyouaccusingmeofbeinganaddict?”

(Addic)onLabeling/GuiltTrap)

“Don’tbotherwithanyothermeds,I’lljustkill

myself.”(Desperate/Threatening

Trap)

Whatisgoingon?????•  About1in4misusingandabout1in10aredeliberatelyusinginawaythatmightresultinharm-KevinE.Vowles,UofNM

•  About1in4pa)entsreceivinglong-termopioidtherapyinaprimarycaresebngstruggleswithopioid-CDC

•  Powerof1/3rds-(Recep)ve,Ambivalent,Resistant)-M.Parchman-MacCallCenterandanecdotalexperience

ThePowerof4

• 4Traps• 4Guidelines• 4Tools

4Guidelines1)  Reframemanipula)on/Aggression(It’saboutsurvival)

2) ConfidenceinyourselfandyourPt(Mantra-”Icandothiswithcompassionandgrace”)

3) ExpectaPonsneedtoberealis)c(AgreeingtoDisagree,mostptsleaveunhappyatfirst)

4) Safetyisjob#1(StayCalmandTaketheReigns,theseptsareyourcharges)

Beitfear,addic)on,dependence...Thebrainseestheopioidassomethingnecessary

forsurvival

Whyisitseenasthis?It’snotpersonal.

TrueorFalse? Someone who is

drowning is a personality disordered manipulative jerk who is trying to hurt you?

False

ThePowerof4

• 4Traps• 4Guidelines• 4Tools

GripeandTreasureHunt!

ListeningandValida)onvs.

ProblemSolving

“ListeningisDoingSomething…Theopiumhazegraduallydrawsback.Itbecomeslesslikeaninterveningbarrierandmoreandmorelikeanauraemana)ngfromthepa)ent.”

SeeingthePaPentThroughanOpiumHazeBalintGroups-2016

JohnMuench,MD,MPHDeptofFamilyMedicine-OHSU

4Toolsforthe-“DifficultConversaPon”

Ac#vate

VEMA

PsychologicalFlexibility

VEMA

Inspired by Anthony J. Mariano, PhD-VA Health System-Clinical Director Pain Clinic

Valida)onintheExamRoom

•  “YouaretellingmethatyourpainisreallyterribleandIhearyouand…”

•  “Ibelieveyourpainisrealandthisisareallyhardsitua)onand...”

•  “IpromiseIwills)ckbyyoursideand...”•  “NothinghasworkedinthepastexceptRxopioidsand...”

“Iputmyhandovermyheart,Ileanin,andsay,“Icareaboutyouandthisisaboutyour

safety,weneedtomakesome

changes”

Thiscanbeveryhardwork!

81%ofprescriberssaidtheydon’tenjoyworkingwiththispopula)on

77%saidtheydon’thavetheskillsneeded!

Valida)onmustbeauthen)candgenuine.

Valida)onisnot

synonymouswithapproval,agreement,orsympathy.

•  Disbeliefthat“my”pa)entismisusing/abusing•  ReducedPtsa)sfac)on(pricetag)•  Theseconversa)onstakemore)me(pricetag)•  Notenoughteamsupport•  Notenoughnon-opioidtxop)ons•  Ptwon’tagreetonon-opioidtx•  Providerdoesn’t“buy”thescience•  Discomfortwithexpressedemo)ons/guilt/shame•  Itishardtobeinthefaceofsufferingandfeelhelpless

Validatethen…Educate

“Thescienceofopioidsforchronicpainisclear:forthevastmajorityofpa#ents,theknown,serious,andtoo-o>en-fatalrisksfaroutweightheunprovenandtransientbenefits.”

March15,2016

TheU.S.SurgeonGeneralTakethePledgeturnthe)derx.org

ASHEALTHCAREPROFESSIONALS,WEBELIEVEWEHAVETHEUNIQUEPOWERTOENDTHEOPIOIDCRISIS.WEPLEDGETO:1.  Educateourselvestotreatpainsafelyand

effec)vely.2.  Screenourpa)entsforopioidusedisorderand

provideorconnectthemwithevidence-basedtreatment.

3.  Talkaboutandtreataddic)onasachronicillness,notamoralfailing.

6thAnnualPainConferenceMay4,5,and6,2017

•  Free-XWaiverCMEbyOHSU•  DayofDifficultConversa)onsWkShops•  BehavioralMedicine-CBTandMindfulness•  CommunityForum-forthepublic•  Dr.DanielClauw-CentralSensi)za)on•  WorkshopsbyleadingexpertsintheNa)onNewAshlandVenue-Shakespeare-Winery's,etc.

ThankYouHeesackerl@Careoregon.org/OregonPainGuidance.com

Whenyouchangethewayyoulookatthings…

thethingsyoulookatchange.

TheLateDr.WayneDyer

Conversa)onsasMedicine

Theparadigmshia

ThankYouHeesackerl@Careoregon.org

7thAnnualPainConferenceinAshlandonMay4,5,and6,2017-Oregonpainguidence.com

CompassionTraps•  Pa)ent: “Doyouwantmetolosemyjob,doyouwantmetobeonthestreet?”

•  Provider: Iwantyoutohavesafeandeffec6vepaincontrolanditismymedicalopinionthatyourcurrentmedicinewon’tgiveyouthat.

•  Pa)ent: “Doyouhavepain?”•  Provider: Iwanttouseeveryminuteofour6metodaytotalkaboutyourpainmanagementplan.

•  Pa)ent: “Iwishyoucouldfeelmypain.”•  Provider: Iknowyou’resufferingandI’msurethatwecanworktogethertoreducepain,soyoudon’thavetosuffer.

AllorNothingTraps•  PaPent: “Soyou’regoingtodonothingformethen?”•  Provider: “Iamconfidentthattogetherwewillfindsafe

andeffecPveopPons”•  Pa)ent:“You’recubngmeoffandIhavetolivewithmy

pain?”•  Provider: Therearemany,manythingsthatpeoplewith

chronicpaincandootherthanopiatestomanagetheirpain.Wouldyouliketohearaboutthem?

•  Pa)ent:“I’vetriedallofthatstuff,noneofitworks.”•  Provider: Iwanttohearwhatyou’vetriedsowecanfind

awayforittobemorehelpfulthis6me.

AddicPonLabelingTraps:•  Pa)ent:“Areyouaccusingmeofbeinganaddict?”•  Provider: Ihaveneveraccusedanyoneofdiabetesbut

I’vediagnosedhimorherwithitandthatiswhatIamtryingtonow,diagnose.

•  Pa)ent:“Don’tlabelmeasadruggie”•  Provider: Ihavenointerestinlabelsatall;Iam

interestedinhelpingpeoplewhoarestrugglingwithmedicalproblems.

•  Pa)ent:“Soyou’rebasicallysayingthatI’majunkie.”•  Provider: I’msayingthataddic6onisamedicalproblem

thatrespondstotreatmentnotaproblemofbadmoralsorbehavior.

DesperateandThreateningTraps•  Pa)ent: “Iheardit’sillegalforyoutoletmegointowithdrawal.”•  Provider: Withdrawalisuncomfortablebutnotlife-threatening,Ican

prescribeyoumedicinestohelpwiththewithdrawalsymptoms.•  Pa)ent: “I’lljustgoanduseheroin.”•  Provider: IfthereisanypossibilityofthatIwouldliketotakeaminuteand

exploreyourrela6onshipwithopioids…doyoucurretnlyuseherioin,haveyouuseditinthepast,doyouhaveaccesstoit?”

•  Pa)ent: “Don’tbotherwithanyothermeds,I’lljustkillmyself.”•  Provider: Ineedtoaskyousomemoreques6onsaboutyourthoughts

aboutsuicide.•  Pa)ent: “I’mgebngalawyer(themedicalboard,yourboss,etc..”•  Provider: Youdowhatyoufeelisright,ofcourse.That’swhatI’mdoingfor

you,too.•  Pa)ent: “Iamgoingtofindoutwhoyoulovemostintheworld,killthem

andthenkillmyself”•  Provider: Pickupyourcellphoneandcallthe911,withaslidleemoPonas

possible.

Endgame•  Pa)ent:Behaviorisangry,despondent,avoidant,etc…•  Provider:“Atthispoint,Isuggestweagreetodisagree,

whatIhavelaidoutiswhatIbelievetobethesafestandmosteffec)vecourseofac)onrightnow.Now,howdoyouwanttospendtherestofour)me?”

•  Pa)ent:“Ihateyou,Iamleaving,yousuck,etc.”•  Provider:Itisunderstandablethatyouareupset,itismy

jobtokeepyousafeandIcareaboutyou.Youarefreetogoany)me,IwillbehavingmyMedicalAssistantcallyouinthenextcoupleofdaystocheckonyouandinviteyoutocomebackintotalktoaboutnextsteps.

ThankYouHeesackerl@Careoregon.org

7thAnnualPainConferenceinAshlandonMay4,5,and6,2017-Oregonpainguidence.com

“Confidenceandbeliefare#1”MichelleMarikos,PLCP,PeerSpecialistExtraordinaire

ConfidenceandBeliefs

BELIEFinyourpa)ent’sability

toliveopioidfree

BELIEFinnon-opioid

managementstrategies

BELIEFinyourabilitytohavethisconversa)on

CONFIDENCEinpartnershipwith

yourpa)ent

CONFIDENCETocon)nuecaringfor

yourpa)ent

CONFIDENCEtotaperwithyourpa)ent

“It’sNotLikelyWeWillBeSibngAround

SingingKumbaya”

HaveRealis)cExpecta)onsofaposi)veoutcome

ReframingSuccess

AgreeingtoDisagree

•  LayingtheGroundworkforfutureappointments,whenyoudon’tgetbuyin

•  Tellthepa)entyouwillbehavingyourMAcallinthenextfewdays

•  Invitethepa)enttocon)nuetobeyourpa)enteveniftheyfireyou

AVaria)on

FindaPartner(youdon’tknow)

PersonA:Yourpartnerhas“thekey”youneed,useaformofthe“CompassionTrap”toaFempttogetit.PersonB:Youhold“akey”anditisnotsafetogiveittoyourpartner,use:•  Valida)on•  Safetyis#1•  Createamantra

WordsMaFerJANINEBERA,MD,,KAISERPERMANENTEWhenItalkwithmypa)entsaboutopioids,I’vefoundthatwordsreallycount.Howwetalkaboutopioidsaffectsthewaythatpa)entsunderstandtherisksandbenefits.Butusingtherightwordsisalsoaboutconveyingempathyandshowingthatmypa)entandIareworkingtogethertowardsthepa)ent’sgoal.Thegoalisprobablynotaboutbeingpainfree,butabouthelpingthepa)entdothethingstheywanttodoevenifpainispresent.Forexample,whendiscussingtaperingoffopioidsinmyownprac)ce,I’vebeenusingtheword“habituated”–andit’sbeenworkingmuchbeFerthan“addictedoroverusing.”Thishelpstokeepmypa)entlisteningandopentoop)ons.Theydon’tfeelshamefulorlikeadrugaddicttheyhaveseenonTV.Ithelpsthemtounderstandthatthereasontheyareusinghigherdosesmaybebecauseofthewaythedrugworksintheirbodyandnotthattheyaregebngintoxicated.Sayingtheyarehabituatedalsohelpsthemtounderstandwithdrawalandtoprepareforit.

Avoid “hot” phrases (6 of 6)

46

BlindSpots/Triggers

Thesubstance(andassociatedcontextsandbehaviors)becomeserroneouslyvalued(rewardedandremembered)aswouldsomethingnecessary

forsurvival.

DifficultConversa)onYouTubesPosiPveUDS-Version1hFps://www.youtube.com/watch?v=Yua_g587x8(2.23min.)Contractviola)on,earlyrefiland+THC-PCPConfron)vePosiPveUDS-Version2hFps://youtu.be/_-U-McHl_EY(4:22Min)Contractviola)on,earlyrefiland+THC-PCPCompassionateDetachmentDiversionhFps://www.youtube.com/watch?v=qsVmetxWWIM&feature=youtu.be(3.10min)-UnexpectedUDS(nega)veforRxopioids)DifficultconversaPons(Erin’sscenario)hFps://www.youtube.com/watch?v=WMASyreKIIc&feature=youtu.be(5min)E.Krebs-QualityofLife,Value-DrivenChangestoRx(tapering)

GuidingPrincipals-ErinKrebs

•  KeeptheprimaryfocusonoutcomespaPentscareabout

•  RedirecttheconversaPontofocusonwhatpaPentscandotoimprovetheirqualityoflife.

•  Whendiscussingrisk,focusonthedrugsandtheharms/sideeffectsopioidscancause.

•  AvoidbackingthepaPentintoacornerandusedshareddecision-makingtoaddresspaPentconcerns

•  BeyourpaPent’sallybyexpressingempathyandsupportfortheirconcernsanduncertainPes.

ParallelProcess/Countertransference

“Neitheroneofuscouldstandtobewiththehorrific

emo)onalpainshelivedwitheveryday!”