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Having a Difficult Conversation

Safina Koreishi, MD, MPH
Medical Director, Columbia Pacific CCO
Columbia, Tillamook & Clatsop counties, Oregon

It can be challenging to have  difficult conversations with patients and negotiate an opioid taper plan. Hearing the words: “You don’t care about me,” or “You are making me buy these medications from the street,” can be heart wrenching. Watching patients cry or yell because of something you are saying is deflating. Feeling threatened by the same people you are trying to help is terrifying.

For years, we were taught that most anyone with chronic pain should be treated with an opioid medication and that people are entitled to live a life free from pain. But the evidence now shows that treating most chronic pain conditions with opioid medication does not improve symptoms and function, and may actually cause harm. We inherit patients whose pain has been treated with high-dose opioids, and the work to taper these patients down and/or off of opioids may be some of the most difficult and important work that we will ever do.

And it all starts with the difficult conversation…

I close my eyes and breathe deeply before I enter the room. I find my center and focus. This is my mantra as I enter the room: “you can do this with grace and compassion.”

These visits often do not end with a satisfied patient. We have to remember that it is our job to advise and help the patient along the healthiest and safest path.

I have found that explaining to patients the change in current clinical understanding of chronic pain and the reason behind why we are advising a taper helps: there has been a change in clinical evidence regarding the benefit and risks of these medications; more people die (unintentionally) because of these medications than car accidents; the country, state and region are working together to create safer communities.

I also acknowledge the difficulty and fear of this situation for the patient, and that it is not his/her fault. The taper may be long, and difficult, but I try to give the patient some control over how it is done. I present the boundaries, depending on the situation (length of taper time, medication etc), and then allow the patient to develop the plan. I have found that given this control, many patients taper more quickly than I would have expected.  Often times we are all surprised by how much their lives improve off of these medications.

When it comes to chronic pain and opioids, we tend to remember the scary situations. I try to focus on the amazing life-changing situations, which actually happen more than we would expect, but only because we had that first difficult conversation.

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