Nicholas Box, PA-C, Physician Assistant at Clearwater Valley Hospital and Clinics
Photo credit: Clearwater Valley Hospital and Clinics

How to talk about opioids so patients will listen, and how to listen so patients will talk

By Nicholas Box, PA-C, Physician Assistant at Clearwater Valley Hospital and Clinics in Orofino, Idaho.

Like many of you, I work with a lot of patients who are on chronic pain medications. Our rural Idaho clinic hosts a community outreach event series called Doc talks.  Two of our providers, Dr. Phil Peterson and Dr. Ann Lima, created a presentation for Doc talks aimed educating patients about opioids. I’ve adopted their slideshow for clinical use, and have found it to be an extremely helpful practice tool. I’ll walk you through how I use it to engage patients in conversations about their use of chronic pain medications..

Separate chronic conditions from pain

Pain isn’t something you can add in with other conditions and manage in a 15-20 minute slot. We offer 40-minute appointments that are focused solely on pain and medication management. When new patients come in who have multiple medical conditions along with chronic pain, the first thing our clinic does is establish the priority for their first visit: will we focus on pain or their chronic conditions? 

Patients help drive this process from the start. Our scheduling staff asks what they want to discuss first: pain or their chronic conditions. Sometimes patients are here because they need refills for metformin, so we’ll schedule a second appointment dedicated to chronic pain.

Organize your appointments

During the work week I review all of the charts for upcoming patient visits. I notice which patients have pain complaints and are on chronic medications. Part of what I look for is whether the patient is new  or someone whom I’ve seen before. If electronic medical records (EMR) are available, I’ll flip through the notes to gather the patient’s history and see if the pain conversation has already taken place.

Use electronic medical records

We’ve built standard screening tools into our EMR, such as depression and anxiety scales, along with functional pain assessments. We’re moving away from a subjective 1–10 scale report (the one where everybody says they’re at a 12), and towards more objective information to document functional improvements. We also document the 40-minute pain appointments so they’re a part of our patients’ medical records.   

Connect with patients right away

Pain is really such an emotional and scary topic for patients. When I first meet with a new patient with chronic pain, I introduce myself and set a collaborative tone right off the bat. I tell patients that together we’ll walk through a presentation about pain, and we’ll talk about their experience as we go.

Embrace technology

We work in rural communities without ready access to psychologists or rheumatologists, so we have a strong telemedicine program. We’ve embraced technology in part out of necessity. 

We’ve got a wall-mount television screen in the exam room that functions as a large monitor. Of course, we’ve also got desktop computers, but when I show the chronic pain presentation it’s projected onto the wall so the patient and I can watch together. We have a conversation, going slide by slide. I’ve found this to be an easier way to maintain a neutral tone of imparting information.

Look for “a-ha” moments

We’ve got one slide that many patients respond to, “A Tale of Two Thumbs.” It’s the story of two patients who are both in the ER after slamming their thumbs in the car door. They both have purple thumbs. It poses a question: whose pain is worse—the person who takes opioids for chronic low back pain or the person who doesn’t? Even though both patients have the exact same injury, the person who’s already on pain medications has worse pain. People get it. It helps patients realize that the pain medications they’ve been taking for low back pain over the years haven’t improved their ability to tolerate pain. I see my patients suddenly realize why they are where they are with their chronic pain. It’s a powerful moment.

Recognize incremental success

I have a patient, mid-50s, who established care with me over the last few  years. As I was prepping for the initial pain appointment, I saw that she had a history of narcotic use. It was the almost predictable pattern of augmenting medications for pain: Her dose started low, then steadily increased.  During the presentation and in our conversation, I used that history to help her understand why it is that the meds don’t seem to be improving her quality of life. She was motivated to take the first step to tapering down on her chronic opioids. I simply offered the opportunity to work together on cutting back, and asked her how much.  She made the decision, not me. She was motivated to do it. She recognized that getting active was the one thing that really helps with pain. So she tapered down her medications. She hasn’t tapered completely off, but she’s at safer levels. 

It’s encouraging for patients to realize they actually can do this, with our help, with us coaching them. The benefit of having a dedicated presentation to walk through during pain-focused special office visits is that my patients realize I’m not doing this just because the government or regulations tell me to. I think our approach helps them believe in their own abilities as they go further down the road. It’s something they can take pride in. 

See “A Tale of Two Thumbs

Practical help for how to talk with patients about pain & medication use:

Nicholas Box, PA-C enrolled in the National Health Service Corps and served in rural northern Idaho. He joined the Clearwater Valley Hospital and Clinics in 2012, and staffs the Kooskia and Orofino Clinics. He holds a Masters in Physician Assistant Studies from Idaho State University. 

Add new comment