5 steps for talking with patients about opioids

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Talking with patients about opioids and pain management is important, but it can be a difficult topic for many providers. Experts discussed how to use motivational interviewing to help make this conversation a little easier during a webinar on July 17.

The webinar, hosted by the U.S. Centers for Disease Control and Prevention (CDC) and the ADA, discussed how motivational interviewing can steer patient conversations toward best opioid prescribing practices. It featured expert presenters Sharon Tsay, MD, from the CDC Division of Unintentional Injury Prevention, and Brett Kessler, DDS, a practicing dentist and past president of the Colorado Dental Association.

"Dentists and dental professionals -- we use motivational interviewing in all sorts of scenarios in the dental world," Dr. Kessler said during the webinar.

5 steps for effective motivational interviewing

Both the ADA and CDC have released guidelines that call for limiting opioid prescriptions, and some patients may not be happy with this change. Motivational interviewing is one way to uncover patients' pain management concerns and work toward finding a solution. This patient-centered and collaborative technique can also help dentists build a stronger, more effective relationship with patients, the presenters noted.

Below are the five steps for using motivational interviewing to successfully talk to patients about opioid prescriptions.

“The basic idea here is letting the patient know that you hear them and you take their concern seriously.”
— Sharon Tsay, MD

1. Express empathy

The first step for motivational interviewing is to express empathy through reflective listening, Dr. Tsay noted. This involves asking open-ended questions, then listening thoughtfully to the patient's response.

"The basic idea here is letting the patient know that you hear them and you take their concern seriously," Dr. Tsay said.

2. Develop discrepancy between values and behavior

The second step for motivational interviewing is to develop discrepancy between a patient's goals or values and their current behavior, according to Dr. Tsay. This involves reflecting back what the patient has told you, including any ambivalent statements, in a nonjudgmental manner.

"Really get at the discrepancy you hear and explore with the patient why those beliefs might be different," Dr. Tsay said.

For instance, patients may say they need opioids after their dental surgery but may also mention they want the best pain management medication available. In this scenario, it may be ideal to let patients know studies have shown a combination of ibuprofen and acetaminophen can be more effective than opioids.

"One plus one doesn't equal two. In this case, one plus one equals five," Dr. Kessler said. "Vicodin only equals four."

3. Avoid direct confrontation

The third step for motivational interviewing is to avoid argument and direct confrontation, Dr. Tsay noted.

Arguments and confrontation can reinforce a defensive or oppositional stance with patients. If a patient is resistant, it is more productive to listen carefully to their concerns and change the direction of the conversation.

"It's important to remain patient-centered when there is a conflict," Dr. Tsay said. "They may have had a past experience where they had an opioid prescribed for a similar procedure. It's important to explore that with the patient and uncover it."

4. Adjust to client resistance

Similar to the third step, the fourth step for motivational interviewing is to adjust to client resistance rather than opposing it directly, according to Dr. Tsay. This involves reflecting what patients have said in a neutral way and reframing the conversation.

For instance, if patients are upset about not getting a certain number of opioids, you might say, "You're concerned about not having the pain adequately controlled," Dr. Tsay noted.

5. Support self-efficacy and optimism

The fifth and final step for motivational interviewing is to support self-efficacy and optimism. To do this, reinforce signals that the patient is considering alternative pain medication strategies and provide clear, credible, and actionable information.

"You want to be flexible with negotiating alternatives," Dr. Tsay said. "Explore for residual concerns."

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