Using Motivational Interviewing to Facilitate Patient-Centered Conversations about Pain Management and Opioid Use Kathleen Reims, MD Denise Ernst ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Kathleen Reims, MD Principal/Chief Medical Officer, CSI Solutions, LLC, Bethesda, Maryland; Assistant Clinical Professor, Department of Family Medicine, University of Colorado School of Medicine, Denver. Dr. Reims is a board-certified family physician who earned her medical degree from Baylor College of Medicine, Houston, Texas, and completed her family medicine residency at Roanoke Memorial Hospital, Virginia. She is a member of the Motivational Interviewing Network of Trainers (MINT), and she currently co-directs the Centre for Collaboration, Motivation and Innovation (CCMI), a nonprofit organization dedicated to building skills and confidence for better health and health care. She has served as an improvement advisor and faculty member for numerous health systems improvement projects, and she has a strong interest in engagement that allows s' values and preferences to be respectfully included in their care. Dr. Reims is actively involved with Denver Health's Lowry Family Health Center, Denver, Colorado, as a volunteer preceptor, serving a diverse population from around the world. She was a National Health Service Corps Scholar, has more than 25 years of clinical experience with underserved populations, and has served as medical director for two federally qualified health centers. Denise Ernst Learning Objectives Owner, Denise Ernst Training and Consultation, Portland, Oregon. Ernst earned her doctorate from the University of New Mexico, Albuquerque, where she studied under William Miller, PhD, the renowned co-founder of motivational interviewing (MI). Her research focus was the application of MI in real clinical practice. She became an MI trainer in 1993 and is a member of the Motivational Interviewing Network of Trainers (MINT). Ernst has conducted MI training internationally for a wide variety of professionals working in substance abuse treatment, criminal justice, medical care, and public health. She has also been involved in efforts to increase the effectiveness of MI training, has provided structured feedback and coaching to a variety of professionals, and has developed and delivered several levels of advanced MI curriculum. 1. Identify the key components of the definition, spirit, and focus of motivational interviewing. 2. Describe the skills used to facilitate behavior change through conversation and how to apply those skills when speaking with s about pain management or opioid use. 3. Utilize one strategy to keep the conversation about pain management and opioid use -centered. 1
Audience Engagement System Step 1 Step 2 Step 3 Session Overview Focus on non-cancer pain Emphasize challenging situations those times when expectations for chronic opioid therapy (COT) do not align Assumptions Routinely use assessment tools for appropriate opioid use Use screeners and the prescribing database for potential warning signs of misuse Informed consent Systematic follow up Marty 62 year old cashier at local grocery store Twisted back picking up grandson Opioids initiated at Urgent Care three months ago following MRI which revealed mild degenerative changes Percocet 5/325, 1 2 tabs p.o. q 4 6 hours Tried to stop meds after 6 weeks, but became really nervous In fact, he has had to increase back up to 6 8 pills each day to control the pain Presents as a new with chief complaint of back pain No warning signs of abuse or misuse of medications Marty s experience with his pain He has followed his treatment plans Expectations for this visit The Dilemma with Marty Your desire to do what is best for the Clinician s guard is up Challenging conversation Time Poll: What is the best next step in addition to a complete history and physical? 1. Explain to Marty that opioids are not indicated for his pain and decline to refill them 2. Explain that you will need to wean the opioids beginning today and refer him to physical therapy 3. Decide with Marty how to best address his pain 4. Continue his current dose until you get to know him better 2
Definitions of MI How does MI work? Motivational interviewing is a collaborative, goaloriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by drawing out and exploring a person s own reasons for change within an atmosphere of acceptance and compassion MI Tip #1: Find Common ground with Agenda Mapping Allows mutual agreement about how to use the appointment time Quickly assesses what is important to the Clinicians add their thoughts and concerns as well Allows to prioritize Agenda Mapping Demo MI Tip #2 Engage the, not the problem The Spirit of MI Compassion: active promotion of the client s welfare and needs. Acceptance, including accurate empathy, affirmation, absolute worth of the person, and support of the person s autonomy. Partnership with the client; MI is done for and with a person and not to a person Evocation of clients motivation, hopes, dreams, desires, values, goals, and abilities. Empathy Engages the Patient As an essential and foundational component of the healing relationship Consists of an attitude of acceptance; respectful listening to the with the desire to understand his perspective Is conveyed to the primarily through skilled and accurate reflective listening Empathy is a way of being with our s Empathy is not: Having had the same experience or problem Identification with the Let me tell you my story 3
Words we might use How is your back pain impacting your life at this point and what you would like to be able to do again? I see how worried you are about this pain and I m here to work with you. Being able to be present and to support your family is really important to you. What gets in the way of engaging the? Righting reflex: we try to convince s or fix situations Ambivalence: we respond to ambivalence as a form of denial rather than a normal part of the change process Expert role: we do not respect the expertise of the in their own lives Q & A MI Tip #3: Giving Information Elicit-Provide-Elicit OR Ask-Tell-Ask The single biggest problem in communication is the illusion that it has taken place. George Bernard Shaw Ask Tell Ask Demo MI Tip #4: Develop care plan WITH the Re-inforce functional goals described by the Offer options, provide real choices Agree on weaning schedule and follow up Encourage self-management activities Emphasize partnership and hope 4
Words we can use.. I know that is not what you want to hear and I am here to find the best resolution possible. Since we are going to decrease by one pill a day, would morning or evening work best for you? What support do you need to move more throughout the day? We will work together to make sure that your care is safe and to focus on what is important to you. Take Home Messages Wear your CAPE not your armor! Agree on an agenda up front find that common ground Engage the not the problem Give information respectfully and listen to how it was heard Do what is right for the and include their expertise in the care plan Practice Recommendations Focus on the relationship and partnership Use active listening intentionally Use Ask-Tell-Ask as a strategy to give information in a way that can understand and to assess ho the information was heard Related Sessions Motivational Interviews Friday * 1:30-2:30 pm; Room: Mile High Ballroom 3A Thank you for joining us! Denise Ernst denise.ernst9@gmail.com Kathy Reims kreims@spreadinnovation.com 5