September 18, 2021 - serious draft version

Intro
You are likely here because you are exhausted by conversations with your patients about controlled substances. The following is specifically about times when it is clinically indicated to either stop or taper a benzodiazepine or stimulant (or any medication, really) and the conversation to address this with the patient is difficult. Please be mindful of ceasing these medicines - these are, after all, people's real lives and these kinds of practice decisions have real consequences. Go here to understand more about the risks of de-prescribing - this article based on a peer reviewed journal article is just but one example of this type of data. 

 The following advice or framework is to be used after you’ve listened to the client with deep empathy and after you’ve considered the context for the lives and the various structural violence forces that impact their survival. This is to use only AFTER you’ve pulled out ALL your motivational interviewing skills. This means that by the time you get to this framework, you’ve already actively listened and used open ended questions, you’ve already used elicit-provide-elicit to offer patient education on the harms of these medications, etc.

Difficult conversations happen any time collaboration isn’t smooth; this is extra common with controlled substances because it’s generally an area we can’t collaborate on the treatment plan as equals, the power differential in the relationship becomes overt AND, everyones nervous system is on high alert. The client’s nervous system is activated by shame or fear and our’s is often activated by fear around loss of our licenses (or, let’s be honest: time...the next patient is waiting!)

If you are like most of us, you land on one side of the aisle or the other: you either stigmatize (unknowingly) and criminalize (again, unknowingly and unintentionally) clients in an effort to make clear boundaries or, you find that you cross your own boundaries and prescribe when you aren’t sure if it’s appropriate, or not. If you are in the former, you may even cut patients off their benzos or stimulants when it’s not clinically indicated to do so. If you are the latter, you find that it’s nearly impossible to say no and you feel like it would just be easier to say yes and stop fighting these folks. Either way, these conversations exhaust you - you didn’t go to school for 8 plus years to be the xanax police; you went to school for 8 plus years to help folks.

Trauma Informed Care

Trauma informed care is a paradigm that helps define HOW we do things - trauma informed care isn't what you do, it’s how you do it. Trauma informed care is acknowledging that most patients who come to see us have a history of trauma, and changing our clinical systems to both not re-traumatize the patients, and to allow these patients to feel safe enough to engage and heal. Trauma informed care uses universal precautions and assumes all patients have been traumatized - we don’t transform our system for a small slice of people - we do it for all people.

Trauma informed care encourages you to consider how what feels banal to us, may harm the client experience. For example,  you may think about how to set your office chairs up in a way that makes the client feel safe (e.g. do they have rapid access to the door?) or you may think about your paperwork length (can someone with active PTSD fill out 6 forms easily?). The health care system has traumatized people, most especially people who use substances or have substance use disorders and people of color. Part of our work is to be extra attentive to not retraumatizing them. This is especially important in these difficult conversations because people often feel stigmatized, judged and criminalized when they request these medicines - and yet WE (not actually you or I, but medicine in general) created a system of 15 min visits where patients were trained to want immediate answers to things. In order words, we created the system we currently have but then have hella countertransference and anger towards them when they become dysregulated in their requests for relief. How fair is that?

At the risk of spending too much time on neurobiology, a tiny lesson in neurobiology is indicated for a better understanding of trauma informed care. Our nervous systems turns on in response to a stressor. Think about your experience if there is a cop in the rear view mirror? Does your heart speed up? What emotions do you feel? Do you feel shame?   How Does your thinking change? Do you feel less connected to your values? Have you ever done anything in a high stress moment that you later regretted?

• Gotta say it here: the cop in the rear view mirror is the perfect example within trauma informed care because racism is traumatic and police violence has been a collective trauma. It is imperative that we understand the structural forces that shape our patients' lives. Maybe that request for Xanax isn’t so nutty after all if every day feels like you are solely fighting for survival - which is the case with so many of our marginalized patients.

This sympathetic activation that you experience (above, when you think about a cop in the rearview mirror)  is the everyday norm for many people with a history of trauma. For many people with a history of trauma, they experience most of their lives as unsafe and unstable. Providers can become the cop in the rear view mirror - especially during difficult conversations where clients are likely to feel criminalized and stigmatized.

Before we move on...I want you to consider: if you were in the midst of a sympathetic response (e.g. there was a cop in the rearview mirror), how would you want someone to talk to you? How would you want someone to say no to you if you truly believed something helped you? Assume you rarely, if ever, feel safe and cared for. Assume for a moment that the first time you ever took an Ativan was one of the first times you felt safe, or that the first time you ever took a Ritalin was the first time you felt like you might survive this fucked up world.  Is there a way that someone could say no to you that would still convey care for you?

It should be noted here that an awesome social worker in Southern Oregon, Laura Heesacker (who is the inspiration for much of my work in this area) did a focus group with chronic pain patients as they were tapered  or discontinued off opioids. Overwhelmingly, the patients experienced the following things via the providers: shaming, criminalizing, stigmatizing AND, clients often felt like providers only cared about the clinic policy, and not the patients themselves. Of course, the providers didn’t mean to do this: they were decreasing opioid prescribing because we began to see the huge overdose burden that we created (with lots of thanks to the Sackler family). Providers, solely moving through the day, declined opioids and said things like “lots of folks get addicted” and patients heard that they were an addict. Providers said “it’s clinic policy to not give those” and patients heard “the policy is more important than you are”. Providers said “I’m not a pez dispenser” and patients experienced shame for needing these medicines and asking for them. Shame, as we all know well, has a loud voice - our role here, as trauma informed providers,  is to quiet that voice. 

Anatomy of the Conversation - the trauma informed “no” focuses on safety

The trauma informed no, in response to requests for controlled substances, focuses on saying no because you (the provider) don’t think these medications are safe and you care about their safety and wellbeing. If you dig into why these medications are clinically inappropriate in most situations, the core answer is that they are unsafe. Thus, we are showing care for the patient, and transparency.
The following are some examples on how this focus on safety and care may look, with some additional therapeutic  skills thrown in (e.g. validation and reflection):

Scenario 1:

Patient: I just, like, really need my xanax, I don’t function well without it. I feel like you're not listening to me. It really works for me and nothing else really does.

Provider: I really hear you. It sounds like xanax has worked in the past. And, as your medical provider, your safety is my biggest concern. I don’t consider these medications safe to use on a daily basis. I think you deserve better than Xanax...I think you deserve to be safe and experience less anxiety and I think I can help get you there.

Scenario 2:

Patient: My old doctor used to give me 84 xanax a month at the same time as gabapentin and clonidine. I really liked my old doctor.  I don’t understand why you keep dropping me down in my number each month?
Provider: We have so much new data about the long term effects of medications like Xanax, especially in combination with medications like gabapentin. I know you’ve been on these a long time and I imagine it can be hard to change providers. And*, I really want you to be safe and healthy for a long time. As your medical provider, my job is to do no harm,  right?

Notice that both of these examples have clear boundaries (in a place where we actually can’t be collaborative) but are transparent, kind and patient centered. They don’t talk about a big public health crisis (which feels abstract to our patients) or clinic policy (which feels impersonal and cold). They use active listening, reflection and affirmation. One of the examples even manages to convey some hope - that is what you want to convey! Also, notice that the word “but” is never used. Instead, the word “and” is used. What does this offer that “but” doesn’t?

Side note: Many patients will say “HEY! I’ve been on both oxy and ativan and provigil for almost 7 years now...and I’ve been safe the whole time? This safety thing is bullshit”. Here’s how to shape their thinking around this --- “Taking these medicines together is similar to driving without a seat belt. 199 times out of 200 it is fine...but the 200th time it is REALLY not fine. As your medical provider I would never suggest driving without a seat belt, right? Because I care about your safety”.

And if that doesn’t work…(much of the below is inspired by Dr. Brad Anderson at Kaiser NW).

Seven times out of ten, using a focus on safety and really leaning in to the care you have for the patient will avert escalation of these conversations.. However, there’s no guarantee that a focus on safety will diffuse an extra difficult conversation.  Salient substances offer powerful and instantaneous relief for multiple psychiatric maladies. Simultaneously, we created a medical culture of 15 min visits wherein there is an expectation of a script to fix it at the end. We can’t fully fault our clients for finding frustration in - and getting activated by -   a system that they view as failing them. Still, our job is to keep our clients safe. Thus, if they persist in their desire for benzos/stimulants/etc and we do not think it is clinically appropriate, the focus shifts to the following boundary and inquiry: “Xanax/Adderall/XYZ is off the table. How else can I support you today in our time together?”

Let’s look at some examples:

Scenario 1:
Patient: Xanax is the only thing that works for me. I’ve tried so many things and I’m so sick of feeling like a lab rat. I just need to get my Xanax and get out of here, ok?
Provider: It sounds like it's been a long and frustrating process to find something that helps your anxiety. And I hear that from a lot of people -  Xanax really works for immediate relief. Unfortunately, all of the medicines in that class are unsafe in multiple ways. As your medical provider, my goal is to keep you safe. 

Patient (interrupting): So you are not going to give me Xanax? Because other people abuse it? Man, fuck this. I just need some xanax and then I’ll go somewhere else!

Provider: As your provider, safety is my focus which means I can’t prescribe Xanax because I do not think it is safe for you. And, I would like to work with you to understand how I can otherwise support you. 

Patient: This is so fucked up. I heard you were a good provider. I just need xanax right now and then I’ll leave.

Provider: A xanax prescription is off the table. How else would you like to spend our time today?

During these interactions, it’s easy to get pulled into conversations that move outside of the medical scope or get personal. Remember to keep coming back to your role in their life (keep them safe, relieve their suffering) as their medical provider and stay grounded in your medical knowledge.
Some examples of staying grounded in your medical knowledge and role:

Patient: If you don’t give me Ritalin, I’m just gonna go do meth!

Provider: As your provider, I’d hate for you to do meth - it’s not safe or healthy...especially because it’s cut with so much fentanyl these days. And, that is ultimately your choice. (you could even add: Would you like to spend the rest of the time today talking about safer meth use strategies?) 

Notice in this example that you've avoided a tangled, emotional web by staying grounded in your medical knowledge and role. Your boundaries are crystal clear, and your care for the client is still evident.

Let’s look at another example of staying grounded in your medical knowledge and role:

Patient: If you don’t restart my klonopin, I’m going to kill myself.

Provider:  Wow. It sounds like this is really hard and scary. When patients feel suicidal, it’s important for me to follow up on those thoughts, sometimes I even need to encourage hospitalization in order to ensure that you are safe. Let’s spend more time talking about these thoughts…(start suicide assessment)

What do you notice in this example? What does the patient want from you at this moment? What do you give them instead?

In Sum

This is a tricky conversation to have. We all want to do our best. Focus on deep empathy for the patient (remember that in this moment, YOU are the cop in the rear view mirror and they’ve just taken time off work to come see you, and then taken a bus perhaps, their kids are in trouble at school...and they feel like this medicine really helps them!).. Don’t discontinue these medicines without a deep risk/benefit analysis (e.g. the legacy benzo patient is a real thing). If you do need to discontinue, focus on safety and doing no harm. Practice radical empathy. Hold the kindest boundaries you have ever held. And if all else fails “that drug is off the table for today’s visit. How else can I be of service to you?”  and then please, please be of service.