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Bruce Springer, M.D.
Pine Rest Addiction Services

……………………and on opiates or
other stuff.
AMBIVALENCE
RESISTANCE DENIAL

Everyone possess the capability for
meaningful and healthy change.
Accept the patients ambivalence.
Avoid confrontation.
Recovering women and men deal
with their personal ambivalence all
the time.

1.Express empathy: reflective
listening.
2.Develop discrepancy: compare
patients goals and their present
behavior
3.Avoid arguments and confrontation
4.Roll with resistance
5.Support self-efficacy and optimism.

 “It sounds like you’re very afraid to consider
life without Oxycontin.”
 “I don’t expect you to change these
medications without a lot of support from
other modalities.”
 “I realize that this is difficult and confusing
because we are talking about how you see
the quality of your life.”

 If you argue for change the ambivalent
patient will argue against it.
 Labeling the patient as “an addict” isn’t
necessary to move in a positive direction.
 Avoid becoming defensive in approaching
the patient.
 Meet the patient wherever they are at that
moment.

 The patient probably has a different
perspective on this.
 Try to understand the patients viewpoint and
go from there.
 Listen carefully and use reflective listening.

Not always easy.
Listen carefully
Repeat back to the patient what
you think they just said or how it
appears they are feeling.

Simple Reflection
“I don’t plan on giving up Xanax at
this time.”
“So you don’t think that going
through your day without it is going
to work for you.”

Amplified Reflection
“My family is really blowing this
out of proportion.”
“I’m a bit confused. They were
really frightened when you fell
asleep at the dinner table.”

Double Sided Reflection
“I’m not going to stop taking
Vicodin!”
“You could see that it was a big
problem running out 10 days early,
but you are not willing to talk about
a safe program to taper Vicodin.”

Shifting focus
“I really need my Oxycontin for
my shoulder pain.”
“We are way ahead of ourselves
here. I want to talk about this
concern with your cleanliness.”

Agreement With a Twist
“Why is it you, my husband and the
pharmacist are so bent out of shape
over these Ativan prescriptions.”

Agreement With a Twist
“You’re making an important
point. Situations like this involve
all kinds of people. I agree we
shouldn’t single anyone out for
blame. Medication problems like
this do involve the whole family.”

Reframing
“I’m sick of the ER doctors
calling me an addict.”

Reframing
“I understand that doesn’t feel
good. When faced with situations
like this docs and nurses get
really frustrated because they’re
seeing a problem they can’t help
solve in the ER.”

Siding With the Negative
“I really have trouble with my
nerves. I can’t cut down on this
Klonopin.”

Siding with the negative
“It sounds like what you are
saying here is that these changes
are just too difficult for you.”

Emphasizing Personal Choice
“Changing your relationship with these
pain medications is really up to you. At
the same time other people such as
your husband, your kids, me and even
the pharmacist might have to make
important choices around this
situation.”

“Tell me what is happening
with your family, (the police,
the pharmacist,), you and your
pain medication?”

“Tell me about the
good things that
Xanax does for
you.”

“What is the down side
of taking Dilaudid pills?”

“We’ve talked about the
constipation problems, having to go
to the ER, the terrible withdrawal
when you run out and having to
count pills. How is this affecting
your life?”

“What is the worst
thing that could happen
if things kind of keep
going like this?”

“What was life like
before you had to start
taking these pain pills?”

“What are your goals for
your pain treatment?”
What are some things
that you can do to help
meet those goals?”

“How are the troubles with the
(pain medication, opiates, nerve
pills, police, your family, your
boyfriend, your doctor, the
pharmacist, your boss, etc.)
going to help you meet your
goals?”

“Nobody ever plans or volunteers or
signs up for trouble with these
medications. This isn’t anybody’s
fault certainly not yours. This is
about the brain chemistry in all
human beings.!”

“ I know it is tough to come here and
talk about this. You are doing great
and it really feels like you are being
honest and thinking about
everything that‘s going on.”

Showing Concern: “It sounds like you and
your family are really hurting.”
 “I’m worried that you could lose your kids
over this.”
 “I’ve lost patients to overdose on these
medications.”
 “You don’t deserve the consequences that
these pills hold for people who have lost
control.”

 “I am sick of my life being run by these pills.”
 “I don’t want my children to be harmed by all
this.”
 “Something in all this has to change.”
 “I really need to stop behaving this way.”
 “I think with some help I can do this.”
 “Tell me abut getting off this stuff.”

 Ordering and directing
 Warning and threatening
 Giving advice, forcing solutions, making
strong suggestions
 Arguing, lecturing
 Moralizing, preaching
 Judging, criticizing, blaming

 Approving or praising bad choices
 Shaming, labeling, name calling
 Interpreting, analyzing
 Reassuring and consoling
 Probing, questioning
 Withdrawing, distracting, humoring,
changing the subject

 Opiate withdrawal:
 Clonidine; oral or transdermal
 Bentyl for cramping, diarrhea
 NSAIDs for muscle joint and “bone pain.”
 Hydroxyzine for anxiety, sleep, nausea
 Trazadone for sleep
 Opiate withdrawal:
 Suboxone (buprenorphine/naltrexone)

 Opiates staying off:
 Suboxone
 Naltrexone
 Vivitrol (IM sustained release naltrexone)

 Benzodiazepine withdrawal:
 Slow taper over several months
 Gabapentin (Neurontin)
 Valproic acid (Depakote)

 Treatment Centers:
 www.findtreatment/samhsa.gov
 Finding local treatment centers for
detoxification and treatment of addiction.
 Keep lists of 12 step meetings; aa.org, na.org.
 Keep lists of other docs to call for help.
 Don’t do this alone.

Use Motivational Interviewing
with your patients with DM,
HTN, compliance issues.

 Miller, W.R., and Rollnick, S. Motivational
Interviewing: Preparing People To Change
Addictive Behavior. New York: Guilford Press,
1991.
 Center for Substance Abuse Treatment.
Enhancing Motivation for Change in Substance
Abuse Treatment. Treatment Improvement
Protocol Series Number 35. Rockville MD:
SAMHSA, 1999.

�ݺ�ߣ

Safe Prescribing Practices Conference for Medical Professionals june 2013

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Safe Prescribing Practices Conference for Medical Professionals june 2013