Editor’s Note: This is the second part of an ongoing series on what emergency physicians can do to combat the opioid epidemic. The series will continue in the June issue.
Explore This IssueACEP Now: Vol 37 – No 04 – April 2018
You’re in the midst of a busy shift trying to balance multiple patients when a nurse suddenly grabs you for an unconscious 30-year-old male pulled from a car with agonal respirations. You begin to bag him while ordering a dose of intramuscular naloxone. Within minutes, the patient starts to breathe, sits up confused, and tries to get off the gurney. Before you can blink, someone tells him, “Lay back down, and by the way, you’re welcome for saving your life.” The situation deteriorates, and both you and the patient leave the encounter dissatisfied, to put it mildly. Later you wonder if things could have played out differently.
It’s probably fair to say we’ve all experienced a similar encounter. Instead of receiving an appreciative “thank you” and plugging the patient into treatment, it ends with yelling and the patient suddenly walking out while you wonder if it’s safe for them to do so. There are many reasons these encounters go poorly. The patient may be scared or embarrassed, be afraid from previous encounters in which he felt disrespected, be in withdrawal from the naloxone, or have a poorly controlled mental illness. We might make incorrect assumptions about the patient’s ability to hear what we are telling them. Sometimes we think we are helping but may be making things worse. Of course, some people are just difficult, but this is true of patients with and without a substance-use disorder.
Are They Motivated?
It’s easy to assume a near-death encounter would motivate patients to change. But if overcoming addiction were this “easy,” no one would ever need a second dose of naloxone. How many times have you thought, after something bad occurs, that it’s time to make a change? Maybe after a bad traffic accident or near miss, you tell yourself you will never speed again, but then you do speed again.
As it turns out, there are several change stages, including pre-contemplation, contemplation, preparation, action, and maintenance. People move back and forth among these stages during their lifetime and don’t always progress in a linear fashion. Unfortunately, nearly dying does not always move someone with an opioid-use disorder to the action phase no matter how much we’d like it to.
As such, we must meet the person where they are. If they are ready to change, great! If there are resources available for treatment, hand them over and encourage them to follow up. But if they aren’t, us pushing remains unlikely to move them, and a change of approach may prove necessary. Otherwise, you’ll be pounding a square peg into a round hole.
Roll with It
In addition to the message, consider how you deliver it. In our emergency department, most of the time we’re overworked, overtired, and overstressed. As such, we try to be concise and to the point. We doubt we’re the only ones who have told a patient, “You will get HIV and die if you don’t stop using,” and then sometimes become upset or annoyed when they blankly stare at us. This used to be how addiction specialists would speak with them also, until they figured out this approach doesn’t work.
Addiction specialists now use motivational interviewing. This involves a lot of reflective listening with the goal of developing discrepancies between the patient’s goals and their behavior. By evoking an individual’s reasons to change, it allows the patient to conclude that continued use will lead to them not obtaining their goals, such as keeping custody of their children, holding a job, not contracting HIV, etc. This is opposed to us telling them what their goals or outcomes should be.
Should we expect everyone to enroll in courses and become an expert at such conversations? Absolutely not. Also, we can’t expect everyone to routinely stop in the middle of a busy shift to spend 15 minutes trying to motivate patients to change, although we do this for other less deadly conditions such as low-risk chest pain.
This approach avoids confrontation. It emphasizes adjusting to or rolling with resistance, and not clashing against it with brute force. In short, don’t overtly blame the patient, don’t threaten them with a Foley or restraints, and don’t escalate an already difficult situation. If they seem really concerned that they almost died, empathize, listen, and support them in coming to the conclusion that they could die next time instead of just bluntly telling them they will die and coming across adversarially.
Keep in mind the circumstances when you try to have this conversation. If the patient is in acute withdrawal, we recommend getting them feeling better before having this discussion. Also, words are important. Refrain from using the term “addict” or calling them addicted to improve the chances they will hear you. Specialists currently recommend using the term “opioid-use disorder.” Yes, it may seem a little silly, but that’s OK.
Of course, if the patient isn’t ready to hear our message and quit using, maybe changing our approach to a harm-reduction strategy is a better use of our limited time. It would be great if everyone was ready to quit, but that’s just not realistic.
In future columns, we’ll explain harm reduction in detail, but to put it briefly, the idea is to keep the patient alive and as safe as possible until they’re ready to quit. We’re not advocating for encouraging drug use, just understanding that if the patient is going to use, we should attempt to prevent them from acquiring HIV or dying from an overdose.
Even the best of us will have encounters that don’t end well for reasons beyond our control. However, emergency physicians are very skilled at de-escalating and communicating. Hopefully with a few additional tools, you’ll more successfully relate to this population and make your life easier. And if you do, there’s a bonus: Leading by example can make a massive difference in your department.
Dr. Waller is a fellow at the National Center for Complex Health and Social Needs and managing partner at Complex Care Consulting LLC. Dr. Schwarz is assistant professor of emergency medicine and medical toxicology section chief at Washington University School of Medicine in St. Louis.