MOTIVATING BEHAVIOUR CHANGE IN PATIENTS USING OPIOIDS

Transcription

1 MOTIVATING BEHAVIOUR CHANGE IN PATIENTS USING OPIOIDS Opioid Webinar Series Laura Murphy, PharmD Disclosures No conflict of interest Acknowledgements Andrea Fernandes Anne Kalvik Pearl Isaac Karen Ng Beth Sproule Learning Objectives 1. Define Motivational Interviewing (MI) 2. Introduce the principles and spirit of MI 3. Apply OARS communication skills Open ended questions Affirmations Reflections Summary 4. Demonstrate application of MI to a patient interaction about opioid therapy

2 What is MI? A collaborative, person-centered form of guiding conversation to elicit and strengthen a person s own motivation for change. It addresses the common problem of ambivalence about change, by paying particular attention to the language of change. MI Evidence based Initially for Substance Use Disorders Increasing focus on brief interventions in health care Acknowledge better outcomes through behavioural management of chronic diseases Diabetes, hypertension, heart failure, etc. MI Research in pain management Cancer Pain Fibromyalgia Chronic pain in elderly patients Low back pain Research in Methadone Maintenance Treatment (MMT) Treatment retention, time to relapse Smoking cessation Reduction of concurrent drug/alcohol use Adherence to HIV medications Improved knowledge of HBV and HCV

3 MI by Pharmacists Growing body of literature MI interventions created to improve patient adherence Diabetes, rheumatoid arthritis, HIV, multiple sclerosis Inclusion in pharmacy curriculums 1. Pharm World Sci 2009;31: J Am Pharm Assoc 2012;52: Patient Education and Counselling 2012;in press 4. AIDS Care; 2011;23: J Am Pharm Assoc 2003;45: Ambivalence Co-existance of opposing attitudes or feelings, such as love and hate toward a person, object or idea. Defined by characteristic behaviours i.e. procrastinating, inconsistency between attitudes and behaviours PSAP VII, Book 8, 2011

4 Change Scale 0 to 10 ambivalence 10 0 Yes! I m ready to change, I m committed I want to change! BUT No way, I am not changing Ambivalence Patient Statements I know I shouldn t use more pills than prescribed but the pain gets so bad. I couldn t manage without my opioids, but I have had to disimpact myself regularly for several months My family doesn t like when that I take opioids, but it s the only thing that helps the pain. Ambivalence in Patients Taking Opioids Ambivalence Towards Staying on opioid therapy despite Side effects (constipation, sexual dysfunction, sedation) Limited function Limited or zero pain relief Structured opioid therapy Changes to opioid medication Schedule Polypharmacy Dose Methadone as a treatment option Concurrent alcohol, benzodiazepine or cannibis use

5 Resistance Easier to identify than ambivalence Overt behaviours Arguing, raising their voice, blaming, excusing, discounting, hostility, interrupting, ignoring PSAP VII, Book 8, 2011 Resistance Patient Statements Don t tell me how to take my opioids, I know what works for me! You don t know how I suffer all day; I am not going to give up these opioids just because some people are addicted I have been in pain my whole life, it never gets better than this. Every time I have changed before, I was in agony MI is dancing instead of wrestling

6 Change Talk (DARN CAT) Desire: want, wish Ability: might, could Reason: specific arguments Need: must, should Commitment: will, try, am ready to Action Taking Steps Patient Education Clinical interview training is well intended but may be harmful Patients may feel disrespected, which exacerbates ambivalence or resistance Traditional patient education usually relies on external motivation Inadvertent shaming, judgments, scare tactics, and arguments Patients may not take away important information Instead 1.Ask permission 2.Provide some education 3.Check in with the patient 1. PSAP VII, Book 8, Case Example: Mike

7 Mike is 46 years old, with a history of back pain for 10 years, since a workplace injury. He comes to your pharmacy to refill his prescriptions. He describes his baseline pain as constant, 8/10 (on current medications), and he spends most of his time on the couch limiting his activities. He smokes cigarettes, 1 ppd. Medications Morphine CR 60mg BID Pregabalin 150mg BID, though his refills indicate poor adherence. He shows up for an early refill because he has run out of his morphine after taking a few extra morphine pills this weekend because his son was practicing slap shots on him in net. Principles of MI : RULE Resist the righting reflex Understand patient motivations Listen to your patient Empower your patient Resist the Righting Reflex Pharmacist to the rescue!!!!

8 Spirit of MI Collaboration Joint decision-making process Evocation What are the patient s values and concerns Autonomy It is ultimately the patient s choice Core Communicating Skills Ask Guiding questions to elicit change talk Scaling questions Avoid the question-answer trap! Listen Gather important information to promote the relationship Inform Skillful information exchange Necessary in many situations Check in with patients OARS Communication Microskills Open Questions Affirmations Reflections Summary

9 Open Ended Questions Describe a typical day and how your opioids fit in. Tell me about the benefits your opioid therapy provides. What are some of the down sides of taking opioids for you? How important is it for you to be able to drive again? Affirmations W5 Affirmations Statements that recognize client strengths Must be done sincerely Not praising Reframe difficulties or concerns the patient has experienced Validate the patient s experience and feelings

10 Slide 27 W5 bullet one: statements Weinberg, 1/13/2013

11 Affirmations: Examples You have given this a lot of thought You have been very committed writing in your pain diary to document your pain You have hung in there to see if you will become tolerant to some of these side effects You are very organized keeping track of all of your insurance correspondence You have made the decision to come in for treatment You have been a role model to other patients sharing what you have gone through Practice I can t believe my doctor is still making me come in every day to pick up my morphine! You have spent a lot of time coming here every day to rebuild the trust with your physician. Reflective Listening Proof that you are listening, hearing and understanding Form a hypothesis about what the patient means Different levels of reflective listening: simple to complex

12 Reflective Listening Reflective Listening: Example How I live my life is my own business You don t think anyone should have a say in your decisions but you. You wish everyone would stop telling you what to do. Reflective Listening: Example I don t want to make any changes, the last time my doctor tried to cut down my opioid dose, my pain went through the roof! You are afraid that if we make any changes, or try to taper your dose, you will really suffer

13 Summarize A summary reinforces what has been said Checks your understanding of the patient s situation as a whole Can link together patient s feelings of ambivalence and change talk Case Example Using MI Skills: Mike How it can fit into your practice Identify opportunities to use MI when you hear patients expressing ambivalence and resistance Embrace the spirit of MI Try a guiding style Let go of the Righting Reflex

14 Motivational Interviewing Training For more training: Courses through CAMH MINT events Importance of access to and feedback from experienced MI practitioner/trainer References & Resources Rollnick S, Miller WR, Butler C. Motivational Interviewing in Health Care. New York: Guilford Press, MINT Website PSAP Module Kavookjian J. Motivational Interviewing. PSAP- VII Science and Practice of Pharmacotherapy. 7 th edition, 2011.