Titan Pharmaceuticals Inc (TTNP)

[TRUISM]

A Truly Effective Way To Deal With 'Problem Pain Patients'
Michael J. Schiesser, MD March 25, 2015
Click For Medscape.com Article



Patients Who "Must Have" Pain Medicine NOW

Physicians who manage chronic pain patients with opioids often meet pushback or resistance when talking about drug risks with their patients, who often feel those risks don't pertain to them.

Sometimes patients with pain behave erratically or emotionally, and their aberrant behavior puts doctors into the awkward position of making a judgment call, and perhaps providing arbitrary or inconsistent care. I can suggest a better way.

The Scope of the Problem

As an internist and addiction specialist, I regularly give advice to clinical leaders in primary care who are struggling with challenging patient behaviors related to potential medication abuse.

On behalf of the leadership of one clinic that asked for my help, I recently performed one-on-one, face-to-face private interviews with a dozen physicians at a small primary care clinic. What I found was relatively similar to other clinics where I have performed similar work, regardless of size.

The physicians' perception of their panel size of patients managed with chronic opioids was generally smaller than the electronic health record data indicated. Also, many physicians were very eager to discuss at least one "problem patient" with me, looking for guidance and support.

All physicians were eager to express complaints about other clinicians in the clinic, and many confessed that it was awkward to discuss these issues directly. The smaller a physician's opioid panel, the more they complained about the doctors with a large chronic opioid panel. Complaints revolved around how to deal with unexpected patient issues that arose while on call, and concerns about care they felt was unsafe, stating they "didn't want anything to do with it."

Conversely, the doctors who managed many patients, and with larger dosages, complained that physicians with smaller panels "didn't know what they were doing." They also felt that there was insufficient patient management during on-call coverage. For example, on return from holiday, they discovered the on-call physicians had "only given the patient enough medication until I get back, then the patient complains they didn't get their usual monthly refill."

It's common to externalize this phenomenon as if we play no role in it, and characterize it as "problem patients" or "pain patients." This is generally a weak perspective, especially when the variation in care among providers from group to group, county to county, or state to state is considered.

For example, in Virginia, physicians write 78 opioid prescriptions for every 100 persons, per year. That number almost doubles to 138 prescriptions per 100 people way over there in West Virginia.[1] Clearly, these variations are not evidence-based, and instead are more cultural in nature. Within any given clinic, I see even more profound differences from one provider to the next, with no shortage of reasons why.

My Own Experience With "Problem Pain Patients"

Running a busy internal medicine practice 10 years ago, my receptionist would repeatedly interrupt me with patient crises. To him, the patient's description was sufficiently horrific and appeared to warrant the doctor's immediate attention. A typical conversation would go like this:

"Doctor, I must interrupt! Ms Surname, one of Dr Jones' patients, has been robbed at gunpoint!"

"...Umm, I'm a doctor. Perhaps she should call the police."

"I think she did that, doctor. I just thought you should know."

"OK, but I'm with a patient. Please don't interrupt me again unless it's important..." (I'm feeling annoyed.)

Ten minutes later:

"Doctor! I must interrupt again! Ms Surname's prescription was stolen when she was robbed at gunpoint!"

"Really? Are you talking about the paper prescription, or had she already filled it at the pharmacy—you know, the bottle?" (I'm looking for the request, hidden in the drama.)

"I don't know; let me call her."

"OK, but like I said, I'm with a patient. Please don't interrupt me again unless it is important." (I'm still feeling annoyed.)

The telephone rings again:

"Terribly sorry to bother you, but I must take my lunch break, and this is an emergency, because I found out it was all of her medication!"

"Are you saying that Ms Surname wants me to replace her medication?"

"She didn't say that, doctor, but I think that was the point."

"What medication is Dr Jones prescribing this woman?"

"Methadone, 10 mg, three TID #270."

"Dr Jones is giving her 90 mg of methadone a day, and she wants me to replace her stolen drugs?" (Now, I'm feeling contempt, anger, fear, and irritation—and I'm hungry for lunch.)

"I believe that is what she needs, doctor."

"I can't deal with this right now. Can you just leave me to finish with my patient, please?" (I'm visibly annoyed.)

"I'm sorry, sir. I was just trying to help the patient; she's having a terrible time, and she's crying." (My colleague is dejected.)

"I'm sorry; it's not your fault. I'm just a little frustrated."

In those days, the more problems with controlled meds that were thrust upon me by my staff, the more my resentment grew. At some point, I realized this was clearly my problem to deal with.

On the one hand, I felt my staff didn't appreciate how hard I was working, how disruptive it is to get interrupted, and how confusing it felt to be suspicious of my patients (or others' patients) who were showing signs of medication abuse. I felt alone, and even angry, with the patient for the disruption caused by the report and circumstances. I could hardly avoid transferring this experience to those around me, including my staff relaying the message.

Yet, whose fault is it really if I resented the lack of support, when I had not first created clear and unambiguous direction for my staff to follow in these situations? Without a structure for communication designed for my office, the patients' aberrant behaviors were eating away at my quality of life, and that of the people around me.

A Deeper Problem—and a Solution

In this case, it's not that I didn't care about my patient's concerns, nor was it my assumption that my staff didn't have the desire to genuinely support me, but you can probably relate to the whole drama—the disruption, the suspicion, the insufficient information, and the frustration when support staff are not properly oriented to the tasks that can truly support the physician.

It's not unusual to feel annoyed about an interruption relating to a patient problem we believe either shouldn't happen, or we wish weren't happening. Or perhaps we don't even believe the story to be true in the first place. It feels like the patient and everyone around me are conspiring to get me to press the "easy button" (that is, replace the medication).

I find it's not just the people around me who are part of the (imagined) conspiracy. My own emotions start to work on me too. Like, "What kind of mean doctor are you, that you don't care about this patient crisis?" or "This patient is not an abuser" or "Don't you realize your staff are just trying to help? Show your appreciation by stopping what you are doing and giving them a response. Don't lose their trust because you are annoyed."

It took me some time to realize that I wasn't annoyed because I didn't want to help my patients. I also appreciate having staff to help me with my patients. I realized the reason I was annoyed was because there was no structured system in place to organize my staff's work, so that they could actually be helpful.

Improvised Care: The Elephant in the Room

Introducing some sort of guidance or policy for my staff as to when or how to message me in the face of these aberrant behaviors seemed doomed from the start. Every curve ball thrown at our clinic by our patients was a new twist—and nearly every response was ad hoc and improvised. Sometimes I would end up replacing medications; sometimes I would not.

When certain patients reported a compromise to their medication supply, I felt compelled to respond right away with deep concern. Others I perceived as "abusers." This was the category of patients whom I didn't want disrupting my day, or my scheduled appointments. However, there was no way to codify this with support staff, nor would I really want to.

I ultimately determined that one of the biggest issues was the ease of getting my attention, and the lack of actionable information that went along with that. The patient could merely call and leave a message suggesting that there was a circumstance that compromised their medication supply (then "just add drama"). Some minutes later, a communication was given to me, typically minus sufficient information to understand the scope of the circumstance, or to follow through with any diligence.

I realized that some standard questions typically came to mind for me right away, as I tried to better understand what was being requested of me. Without this information, a highly inefficient back-and-forth communication among me, my staff, and the patient might take place. The painful exchange above, vintage 2005, is an example of that.

The solution that emerged from that turned out to be a simple form. Whenever a patient was making an unexpected request to replace medications, I told my staff I didn't want to hear about it until a form was completed in the patient's own handwriting.


Use of the form provided no guarantee that the medication would be replaced. Rather, it simply required the patient give me some basic information that I may need to define action steps; this included the pharmacy where they last filled their prescription, the date, what they are asking me to do about it, and why they think that is reasonable. If it involved someone else taking their medication, I asked them to identify that person, and the form reminded them that transferring possession of a scheduled medication from one person to another for consumption or resale was a violation of federal law.

If they took more medication than authorized, there was a check box for that. There are 16,000 unintended deaths each year from prescription opioid overdose. Not good.

At first, my staff didn't entirely understand, so I would continue to get interrupted with crises. I calmly reminded them about the new form, and that I wasn't going to address requests for controlled medications because they had been lost or stolen unless the patient first filled out the form. I suppose I should have expected it, but as a result of requesting the form, I experienced a precipitous drop in the number of requests to replace medication.

I actually had to change the process quite soon after that, so that staff would document at least something of what the patients said on the phone before they declined to fill out the form. This saved the front desk staff a lot of time, too.

Important Lessons That Changed the Dynamic

Although it makes sense on a superficial level to feel frustration toward patients whom we perceive as "abusers," this was merely a distraction from the fact that I had neglected to create an appropriate communication protocol between me and my staff.

The improvements didn't end there. I eventually automated delivery of the patient agreement through a video orientation, eliminating the all-too-frequent "nobody told me that" or "I just signed it; I didn't realize what it said." Now I work with 60 doctors, and I never need to hear "Dr Smith didn't tell me that," because the expectations and accountability around that are universal and standard throughout the clinic, and I can see the date when the patient watched the video and a scanned copy of their signed agreement. It doesn't prevent the patient behaviors, but it unambiguously defines accountability when problems do arise.

More important, it's obvious that patients with undiagnosed addiction to painkillers who exhibit abuse and misuse behaviors are emotionally challenging for the entire clinic.

What's not obvious is that the lack of organized infrastructure within the clinic was amplifying my frustrations, making my staff appear unsupportive and difficult to replace and contributing to provider burnout. These solutions were within my grasp. It didn't depend on my patients changing their behavior. Rather, it required that I design simple, organized processes within my clinic to better equip my organization for the emerging and complex needs of the patients.

For example, the "lost/stolen" form described above is a means of capturing objective data in the patient's own handwriting that previously would have been relayed via a phone message from reception staff. When the patient checks a box that says, "I took more medication that the physician authorized" (for example), it serves as an unambiguous indicator when considering the question: Does this patient's existing care plan represent an unreasonable risk?

When faced with such data, in this format, clinicians can more easily generate a thoughtful care plan in response to aberrant behavior. This process also helps to make follow-up communications with the patient less awkward, because the patient now fully "owns" the narrative on the paper (and truth or not, it's less likely to spiral into time-consuming modification).

A review process that, for example, involves consulting with a colleague can also be defined as standard when a patient fills out the form. This generates further objectivity, and it can provide a more reasonable basis for what are often emotionally charged interactions.

For example, a very authoritative and professional delivery of an unwelcome message to the patient might be, "I spoke with a colleague (eg, pain specialist, addiction specialist, medical director) about your situation, and we agreed that [new care plan]." A pause in decision-making, or conferring with colleagues, protects the patient from bad outcomes that occur as a result of on-the-fly, ad hoc, or improvised care that otherwise requires more careful consideration.


Fast-Forward and Multiply

I have shared these solutions with thousands of primary care doctors over the past 7 years.

Process solutions and resource development require committed leadership where the details are informed by clinicians. When "care as usual" presents an unreasonable risk to the patient, how common is it that a primary care clinic has a detailed and coordinated response in place, drafted in advance of when a given patient actually shows signs of needing it? When primary care clinics fail to design support resources to effectively transition a patient away from chronic opioid analgesics, then the panic button and the easy button appear a lot alike. We wonder why so many patients are addicted to their meds, and so many physicians are burned out with resentment.

As I performed my one-to-one hour-long interviews with the small primary care clinic, I couldn't help but feel a great sense of compassion for these providers who are dealing with a major epidemic in prescription drug abuse, misuse, and addiction. Their accounts suggest their patients are experiencing distress from neuroplastic changes, regardless of whether they are following the rules. The physicians fear regulatory actions, civil suits, and unintended deaths. Layered on top of that is contempt toward one another, and burnout.

In many cases, simple conversations related to controlled medications that need to happen between doctors, and between doctors and staff—for example, regarding what to reasonably expect when a doctor is on call or what to reasonably expect when a physician goes on vacation—never get discussed or codified. Somebody may not like what is ultimately decided on a clinic-wide basis, but at least it's clear and on the table. The creation of organized clinic communications and policy structure is a critical first step to regaining physician quality of life in the face of an epidemic of painkiller addiction.






TRUTH