Bruce Springer, M.D.Pine Rest Addiction Services
……………………and on opiates orother stuff.AMBIVALENCERESISTANCE DENIAL
Everyone possess the capability formeaningful and healthy change.Accept the patients ambivalence.Avoid confrontation.R...
1.Express empathy: reflectivelistening.2.Develop discrepancy: comparepatients goals and their presentbehavior3.Avoid argum...
 “It sounds like you’re very afraid to considerlife without Oxycontin.” “I don’t expect you to change thesemedications w...
 If you argue for change the ambivalentpatient will argue against it. Labeling the patient as “an addict” isn’tnecessary...
 The patient probably has a differentperspective on this. Try to understand the patients viewpoint andgo from there. Li...
Not always easy.Listen carefullyRepeat back to the patient whatyou think they just said or how itappears they are feeli...
Simple Reflection“I don’t plan on giving up Xanax atthis time.”“So you don’t think that goingthrough your day without i...
Amplified Reflection“My family is really blowing thisout of proportion.”“I’m a bit confused. They werereally frightened...
Double Sided Reflection“I’m not going to stop takingVicodin!”“You could see that it was a bigproblem running out 10 day...
Shifting focus“I really need my Oxycontin formy shoulder pain.”“We are way ahead of ourselveshere. I want to talk about...
Agreement With a Twist“Why is it you, my husband and thepharmacist are so bent out of shapeover these Ativan prescriptio...
Agreement With a Twist“You’re making an importantpoint. Situations like this involveall kinds of people. I agree weshoul...
Reframing“I’m sick of the ER doctorscalling me an addict.”
Reframing“I understand that doesn’t feelgood. When faced with situationslike this docs and nurses getreally frustrated b...
Siding With the Negative“I really have trouble with mynerves. I can’t cut down on thisKlonopin.”
Siding with the negative“It sounds like what you aresaying here is that these changesare just too difficult for you.”
Emphasizing Personal Choice“Changing your relationship with thesepain medications is really up to you. Atthe same time o...
“Tell me what is happeningwith your family, (the police,the pharmacist,), you and yourpain medication?”
“Tell me about thegood things thatXanax does foryou.”
“What is the down sideof taking Dilaudid pills?”
“We’ve talked about theconstipation problems, having to goto the ER, the terrible withdrawalwhen you run out and having t...
“What is the worstthing that could happenif things kind of keepgoing like this?”
“What was life likebefore you had to starttaking these pain pills?”
“What are your goals foryour pain treatment?”What are some thingsthat you can do to helpmeet those goals?”
“How are the troubles with the(pain medication, opiates, nervepills, police, your family, yourboyfriend, your doctor, the...
“Nobody ever plans or volunteers orsigns up for trouble with thesemedications. This isn’t anybody’sfault certainly not yo...
“ I know it is tough to come here andtalk about this. You are doing greatand it really feels like you are beinghonest and...
Showing Concern: “It sounds like you andyour family are really hurting.” “I’m worried that you could lose your kidsover ...
 “I am sick of my life being run by these pills.” “I don’t want my children to be harmed by allthis.” “Something in all...
 Ordering and directing Warning and threatening Giving advice, forcing solutions, makingstrong suggestions Arguing, le...
 Approving or praising bad choices Shaming, labeling, name calling Interpreting, analyzing Reassuring and consoling P...
 Opiate withdrawal: Clonidine; oral or transdermal Bentyl for cramping, diarrhea NSAIDs for muscle joint and “bone pai...
 Opiates staying off: Suboxone Naltrexone Vivitrol (IM sustained release naltrexone)
 Benzodiazepine withdrawal: Slow taper over several months Gabapentin (Neurontin) Valproic acid (Depakote)
 Treatment Centers: www.findtreatment/samhsa.gov Finding local treatment centers fordetoxification and treatment of add...
Use Motivational Interviewingwith your patients with DM,HTN, compliance issues.
 Miller, W.R., and Rollnick, S. MotivationalInterviewing: Preparing People To ChangeAddictive Behavior. New York: Guilfor...
Questions?
Upcoming SlideShare
Loading in …5
×

Safe Prescribing Practices Conference for Medical Professionals june 2013

367 views

Published on

Participants will:
Report their intent to support and/or actively work towards incorporating best practices in responsible prescribing guidelines into their everyday practice of medicine.
Report an increased knowledge of the Michigan Automated Prescription System (MAPS) and the benefits of reporting regularly to MAPS.
Report intent to support and/or actively work towards incorporating consistent use of the MAPS into their everyday practice of prescribing controlled substances.
Report that at the training they received easy to use tools that can help them to better educate their patients on the importance of taking medications as prescribed.
Gain an increased knowledge of local, state, and national substance abuse and mental health treatment resources.

Published in: Education, Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
367
On SlideShare
0
From Embeds
0
Number of Embeds
9
Actions
Shares
0
Downloads
2
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Safe Prescribing Practices Conference for Medical Professionals june 2013

  1. 1. Bruce Springer, M.D.Pine Rest Addiction Services
  2. 2. ……………………and on opiates orother stuff.AMBIVALENCERESISTANCE DENIAL
  3. 3. Everyone possess the capability formeaningful and healthy change.Accept the patients ambivalence.Avoid confrontation.Recovering women and men dealwith their personal ambivalence allthe time.
  4. 4. 1.Express empathy: reflectivelistening.2.Develop discrepancy: comparepatients goals and their presentbehavior3.Avoid arguments and confrontation4.Roll with resistance5.Support self-efficacy and optimism.
  5. 5.  “It sounds like you’re very afraid to considerlife without Oxycontin.” “I don’t expect you to change thesemedications without a lot of support fromother modalities.” “I realize that this is difficult and confusingbecause we are talking about how you seethe quality of your life.”
  6. 6.  If you argue for change the ambivalentpatient will argue against it. Labeling the patient as “an addict” isn’tnecessary to move in a positive direction. Avoid becoming defensive in approachingthe patient. Meet the patient wherever they are at thatmoment.
  7. 7.  The patient probably has a differentperspective on this. Try to understand the patients viewpoint andgo from there. Listen carefully and use reflective listening.
  8. 8. Not always easy.Listen carefullyRepeat back to the patient whatyou think they just said or how itappears they are feeling.
  9. 9. Simple Reflection“I don’t plan on giving up Xanax atthis time.”“So you don’t think that goingthrough your day without it is goingto work for you.”
  10. 10. Amplified Reflection“My family is really blowing thisout of proportion.”“I’m a bit confused. They werereally frightened when you fellasleep at the dinner table.”
  11. 11. Double Sided Reflection“I’m not going to stop takingVicodin!”“You could see that it was a bigproblem running out 10 days early,but you are not willing to talk abouta safe program to taper Vicodin.”
  12. 12. Shifting focus“I really need my Oxycontin formy shoulder pain.”“We are way ahead of ourselveshere. I want to talk about thisconcern with your cleanliness.”
  13. 13. Agreement With a Twist“Why is it you, my husband and thepharmacist are so bent out of shapeover these Ativan prescriptions.”
  14. 14. Agreement With a Twist“You’re making an importantpoint. Situations like this involveall kinds of people. I agree weshouldn’t single anyone out forblame. Medication problems likethis do involve the whole family.”
  15. 15. Reframing“I’m sick of the ER doctorscalling me an addict.”
  16. 16. Reframing“I understand that doesn’t feelgood. When faced with situationslike this docs and nurses getreally frustrated because they’reseeing a problem they can’t helpsolve in the ER.”
  17. 17. Siding With the Negative“I really have trouble with mynerves. I can’t cut down on thisKlonopin.”
  18. 18. Siding with the negative“It sounds like what you aresaying here is that these changesare just too difficult for you.”
  19. 19. Emphasizing Personal Choice“Changing your relationship with thesepain medications is really up to you. Atthe same time other people such asyour husband, your kids, me and eventhe pharmacist might have to makeimportant choices around thissituation.”
  20. 20. “Tell me what is happeningwith your family, (the police,the pharmacist,), you and yourpain medication?”
  21. 21. “Tell me about thegood things thatXanax does foryou.”
  22. 22. “What is the down sideof taking Dilaudid pills?”
  23. 23. “We’ve talked about theconstipation problems, having to goto the ER, the terrible withdrawalwhen you run out and having tocount pills. How is this affectingyour life?”
  24. 24. “What is the worstthing that could happenif things kind of keepgoing like this?”
  25. 25. “What was life likebefore you had to starttaking these pain pills?”
  26. 26. “What are your goals foryour pain treatment?”What are some thingsthat you can do to helpmeet those goals?”
  27. 27. “How are the troubles with the(pain medication, opiates, nervepills, police, your family, yourboyfriend, your doctor, thepharmacist, your boss, etc.)going to help you meet yourgoals?”
  28. 28. “Nobody ever plans or volunteers orsigns up for trouble with thesemedications. This isn’t anybody’sfault certainly not yours. This isabout the brain chemistry in allhuman beings.!”
  29. 29. “ I know it is tough to come here andtalk about this. You are doing greatand it really feels like you are beinghonest and thinking abouteverything that‘s going on.”
  30. 30. Showing Concern: “It sounds like you andyour family are really hurting.” “I’m worried that you could lose your kidsover this.” “I’ve lost patients to overdose on thesemedications.” “You don’t deserve the consequences thatthese pills hold for people who have lostcontrol.”
  31. 31.  “I am sick of my life being run by these pills.” “I don’t want my children to be harmed by allthis.” “Something in all this has to change.” “I really need to stop behaving this way.” “I think with some help I can do this.” “Tell me abut getting off this stuff.”
  32. 32.  Ordering and directing Warning and threatening Giving advice, forcing solutions, makingstrong suggestions Arguing, lecturing Moralizing, preaching Judging, criticizing, blaming
  33. 33.  Approving or praising bad choices Shaming, labeling, name calling Interpreting, analyzing Reassuring and consoling Probing, questioning Withdrawing, distracting, humoring,changing the subject
  34. 34.  Opiate withdrawal: Clonidine; oral or transdermal Bentyl for cramping, diarrhea NSAIDs for muscle joint and “bone pain.” Hydroxyzine for anxiety, sleep, nausea Trazadone for sleep Opiate withdrawal: Suboxone (buprenorphine/naltrexone)
  35. 35.  Opiates staying off: Suboxone Naltrexone Vivitrol (IM sustained release naltrexone)
  36. 36.  Benzodiazepine withdrawal: Slow taper over several months Gabapentin (Neurontin) Valproic acid (Depakote)
  37. 37.  Treatment Centers: www.findtreatment/samhsa.gov Finding local treatment centers fordetoxification and treatment of addiction. Keep lists of 12 step meetings; aa.org, na.org. Keep lists of other docs to call for help. Don’t do this alone.
  38. 38. Use Motivational Interviewingwith your patients with DM,HTN, compliance issues.
  39. 39.  Miller, W.R., and Rollnick, S. MotivationalInterviewing: Preparing People To ChangeAddictive Behavior. New York: Guilford Press,1991. Center for Substance Abuse Treatment.Enhancing Motivation for Change in SubstanceAbuse Treatment. Treatment ImprovementProtocol Series Number 35. Rockville MD:SAMHSA, 1999.
  40. 40. Questions?

×