The questions for Dr. Charles Reznikoff are rapid-fire: How do you “work your magic” in introducing the topic of addiction? How do you approach a patient who may be a candidate for methadone maintenance? Do “pain contracts” do any good? How do you safely manage opioid painkiller conversions?
The dozen or so students in a class he taught last week were in their third and fourth years at the University of Minnesota Medical School, specializing in a range of disciplines from family practice and internal medicine to anesthesiology and cardiology. They were getting instruction in a topic that Reznikoff and others regard as seriously neglected at U.S. medical schools: the use of opioids for the treatment of chronic pain and the interplay between chronic pain, opioids, addiction and mental illness. A recent Johns Hopkins University study found that pain education alone was “limited, variable and often fragmentary” – never mind any instruction around the complications that occur when those who are taking opioids for chronic pain are vulnerable to addiction and/or diagnosed with mental health issues.
“I remember getting about 10 minutes on the topic,” Reznikoff said of his own education.
Reznikoff, an internal-medicine specialist and addiction-medicine subspecialist at Hennepin County Medical Center and assistant professor of medicine at the University of Minnesota, has made it his mission to close the knowledge gap, not only for HCMC trainees but also for U of M students and other providers in the field (with financial support from the Steve Rummler Hope Foundation). His three, one-hour lectures offer a thought-provoking tour: What is pain, and for what kinds of pain do opioids provide relief? What are opioids pharmacologically? What are the problems with opioids in America, and how can the problems be mitigated?
There is a healthy dose of science: The students learn nomenclature – the difference between opioids and opiates (the latter derives from poppy plants, the former is at least partially synthetic). They learn to check the conversion charts and lower the dose when switching from one painkiller to another – to account for individual metabolic differences and to avoid respiratory failure. They learn that children have the genetic ability to convert codeine into life-threatening and fatal amounts of morphine in the body. They learn that 30 percent of African-American patients do not respond to Vicodin (hydrocodone/acetaminophen). And they learn that pharmacogenomics, which have helped scientists tailor treatments for such things as HIV, cancer, depression and bipolar disorder, may some day be applied to more accurately treat pain.
‘It’s not magic’ — but it’s an art
Reznikoff also tackles psycho-social issues: how to have a productive conversation about addiction, what works and what doesn’t work in motivating patients, how to help patients differentiate between what is physical and what is psychological/emotional, and how to manage moral and ethical responsibilities when a patient is difficult and challenging.
“It’s not magic,” he tells the students. But they know it’s an art, and they’re very attentive as he dispenses his experience, knowledge and advice. Here’s a summary of the lessons Reznikoff imparted.
Adjust your pain lens: When talking with patients about pain, remember that their life circumstances have an impact. For example, imagine how you would feel if you won $400 million in the lottery and were jumping for joy when you slipped on the ice and broke a rib. Then imagine if your rib was broken in a car accident in which your spouse was killed. Would you experience the pain similarly? People look at pain through very different lenses. “Those whose lives have a greater amount of hope, a greater amount of freedom are more resilient to addictive forces,” says Reznikoff. “Whereas those who have less hope, less joy, less reward in their lives are more vulnerable to this artificial form of reward.”
Ask innocent questions: A surefire way to shut down conversation is to ask a patient whether he or she is addicted. Instead, ask them: What do you do for fun? Are you working? Do you envision yourself going back to work? What do you do in a typical day? Do you cook for yourself? Do you grocery shop for yourself? What are your sources of income? What are your plans for the holidays? “Actually knowing about someone’s family and their interactions with their family is almost more important to understanding their addiction [and their pain and their mental health] than sitting there and quizzing them on addiction,” Reznikoff says.
Reduce the shame factor: If you are wrestling with your own judgment of a patient’s use, try this way of thinking about chronic opioid users – even if they aren’t technically addicted: “They have a new appetite, like water, food, air. They have a daily appetite – an extra need that they’re ashamed of. They need to feed this appetite every day, without exception. Imagine if drinking water were this shameful, stigmatized thing that you had to pretend you didn’t do.” A patient is more likely to open up and disclose what is going on if you take this approach: “I get that you have this extra appetite. You are struggling with it. It causes you all sorts of problems.”
Accurately assess the opportunity: It’s pointless to impart 25 minutes of information to someone who appears intoxicated. The only appropriate response is to ask, “Did you drive here? Because I don’t want you to drive home.”
Articulate the benefits: An argument that it’s “better to be sober” or that treatment is morally the “right thing to do” will ring hollow. Instead, pitch to patients how sobriety will be better for their health, their family and their finances. “It’s your job,” says Reznikoff, who imagines a conversation going a little something like this: “What I’m hearing is that things aren’t going so good with your family. And you are really hurting for money month to month. And you are in the emergency room all the time because your pain is out of control. And on top of that, you are overusing and your doctors are worried because it might affect your breathing … and cause you to overdose. All those things are fixable, but you might have to enter this thing called addiction treatment. You might not be ready for that. But that’s the offer. … And the offer is available to you. We’re not going to force you to do anything. But you just told me about all these life stresses you have, so I’m telling you about a potential solution.”
Be a doctor, not a lawyer: Many providers use “pain contracts” to keep patients accountable. The contracts threaten to withdraw any controlled substances if the patient uses street drugs, shops for multiple prescriptions, runs out early, overdoses, sells or diverts the medication, or obtains another’s medication illicitly. Their effectiveness is not completely known, but they tend to be adversarial and confrontational, and too often lack what a patient really needs: informed consent (a full explanation of benefits, side effects and risks) and a list of patient rights (access to help, manageable control of pain, referrals to specialists). “You have an M.D., not a J.D.,” Reznikoff tells the students. “Contracts are for lawyers. Informed consent is for doctors.” Have a real conversation. For example: “Percocet is good for pain. It doesn’t make the pain go away, it just hides it. With alcohol it’s dangerous. It’s a controlled substance. If you leave it out in your house it might get stolen. You can’t drive on it. You get constipated on it. Some people are prone to addiction. Not all of them, but if you have a tendency. …”
Keep the connection: If you do discontinue opioids, “you should double down on your medical relationship,” because your patient is going to be at high risk and will need help. But first ask yourself, “Are you sure you want to terminate their opioids? What’s best for the person? What’s going to happen two weeks from now if you cut them off? To them, not to you. … They don’t suddenly get cured of pain. They don’t suddenly get cured of addiction. They don’t suddenly get cured of mental illness. They’re just suddenly in withdrawal and have no doctor.” Mentally ill pain patients in chronic pain are tough, Reznikoff admits. “But in general I really like working with patients, and you should too. You shouldn’t cut them free too easily.”
How we talk about pain
After class, the students reflected on what they had been learning.
Grant Aakre, anesthesiology, said he had become “more humanistic” in his approach.
Heather Rud, internal medicine, said she was more mindful of “what happens when we withdraw everything – how we can make that potentially worse for someone.”
Heidi Nichol, family practice, said she was giving more thought to how we talk about pain: “It’s an important challenge for people who are requiring pain medications and having pain, and also for people are prescribing the medications, to differentiate what type of pain they’re having [physical, psychological, emotional] and be proactive about treating it appropriately. If it’s not a type of pain that is treated with opioids, then don’t give opioids. If it is, then do, and do it responsibly.”