Advice for Dealing With Difficult Patients

A Psychologist’s Advice for Dealing With Difficult Patients – March 2017

During his talk, Dr Mariano sought to address a common situation encountered by pain physicians in their every day practice: should they reinstate opioid treatment in patients successfully taken off these medications?

The answer is: it depends on the patient,

  • on whether they have a history of substance misuse,
  • on their functioning, and
  • whether they are actively involved in their own pain rehabilitation.

“This is the primary directive of opiate prescribing.

Yes, the primary directive of opioid prescribing is that it depends on the patient. That’s exactly why standard dose restrictions for opioids are not medically sound.

No matter what the answers to those other questions, safety always trumps pain relief,” said Dr Mariano. “So that the answer is, if you can’t use opioids safely, if you can’t guarantee appropriate risk mitigation, you shouldn’t do it.”  

According to Dr Mariano, ”What ends up happening to the average provider in the real world, trying to help people, [is that they] find themselves alone in the room with a patient who is overwhelmed and overwhelming the provider, and the only choice left for the provider seems to be to give up, give in, and get these medications.

Being caught between what they think they should do, and what they find they really can do.”

To get out of such situations, what should healthcare providers (HCPs) say? Providers need to be aware of their own reactions during this difficult process.

The doctor’s point of view is common in this publication and shows how “the other side” is thinking.

Dr Mariano identified 6 common situations and sought to provide advice for each scenario.

1. Negotiations and false hope.

  • It is important to tell patients that learning self-management strategies is a difficult process. The goal for HCPs is to develop a plan that is safe, make sense medically, and is sustainable.
  • Patients would say: “Of course I want to get off these medicines, I just need a few more for a little while longer.” But increasing doses to take people down later is nonsensical, it only worsens the issue, says Dr Mariano
  • A patient would say: “It is your job to help me. Why won’t you give me what I need to find some relief?” or: “I shouldn’t have to suffer like this, nothing else works. What am I supposed to do?”

2. Appeals and ethical confusion.

In some instances, the patient will even “absolve” their HCP, saying: “I don’t care about the risks, why should you? I need these pills to survive.” The simple fact is this, says Dr Mariano, “these are your responsibilities, not your patients’. Your duty may be to wean this person, as your duty is not to harm.”

Avoid taking complete responsibility for urgent and complete pain relief in a patient who is not going to engage in what we know is far more important: being actively engaged in dealing with other life problems. “The bottom line is, there are patients we can’t help,” he added.

The patient comes and says: “How can you take away the only thing that helps me, you’re ruining my life!” or: “I was doing just fine, now I can’t do anything.”

This brings up the “guilt scale.”

I’m disgusted that the problem of involuntary pain relief reduction is viewed as a problem the patient is causing for the doctor.

How can any doctor understand chronic pain when they are steeped in this kind of thinking?

Here, HCPs need to be careful in assuming that patients are stable. Providers need to help their patients identify problems other than pain, and try to get them the help they need.

The most common reason patients go to their doctor is because they need pain relief. If the doctor cannot or will not do that, it is NOT the patient’s problem.

3. Blame and guilt.

Sometimes, patients accuse their HCP of being responsible for all their problems: “You’re the reason I’m drinking! The only reason I’m drinking is because you won’t give me enough Percocet.” It is very easy and natural to respond defensively in such situations, however, it’s not helpful.

4. Accusations and anger.

If a person has problem with substance abuse, taking them off opioids is not synonym to refusing to help this person.

Another group of patients may be misusing, while having poor expectations as to the kind of relief they can get through medications. These patients are not looking for drugs—they are looking for relief.

That is exactly the point. If a doctor cannot relieve a patient’s pain in any other way, then opioids are appropriate. Opioids can also be necessary while the patient continues searching for a cause of their pain, which doctors rarely do outside of their specialty.

And they may say: “I’ll take what I need, and I need to use more medicines, because you are not giving me enough.”

In these situations, it is helpful to explain to people that medications do not work equally well for everybody, to provide them with realistic expectations, and to frame the issue by pointing to the fact that some people are opiate non-responders

This states that medication don’t work equally well for all people, yet this publication is constantly reporting on another guideline using standard doses of opioids.

5. Threats and fear.

Some patients start threatening their provider: “I’m going to go over your head, I’m going to call your boss, the Senator,  I’m going to file a complaint with the State Medical board…”

Although it is easy to feel intimidated in that situation…

A doctor’s job is to deal with patients and it is NOT the patient’s job to tip-toe around the doctor’s feeling. Doesn’t it occur to them that a patient might be terrified and furious when a doctor threatens to cut off their pain relief? 

Dr Mariano recommends HCPs acknowledge the fact that there is coercion, and seek advice from pain specialists, “because you know you’re not going to get in trouble if you document your rationale and show that you are seeking advice from your colleagues.”

When patients threaten of suicide, always consult a mental health professional..

Threaten? Wanting to kill yourself is now considered a threat against the doctor? What about the threat against the patients themselves?

6. Challenge and doubt.

The average practitioner has very little training in pain, and even less about the specifics of prescribing.

Here, the key is not to hesitate, and seek consultation, as it is important to believe that you are doing the right thing when a patient believes you are doing the wrong thing.

This is terribly common today: doctors doing the wrong thing, yet believing they’re doing the right thing. 

This is a problem with the doctor, NOT the patient.

Dr Mariano recommends telling patients to consult the Veterans Affairs or Centers for Disease Control websites, so as to get them to realize they’re not making this up.

But now we know how politically and financially influenced these government agencies are. They are merely spouting the same propaganda as the “addiction specialists”.

So, when tapering, “be very clear about the rationale—safety is your major concern—be very specific about the process, let the patients know about what is going to happen, and then follow through on it.

And then, be empathic but not apologetic, because bad care is not an option,” concluded Dr Mariano.

What does he mean with “bad care is not an option”? For whom and for what? Bad care happens all the time and for pain, it’s downright awful.

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5 thoughts on “Advice for Dealing With Difficult Patients

  1. Kathy C

    “Bad care is not an option” That is just so absurd. This “Advice” is merely to help the Doctor avoid certain responses. The point here is that he has already made the assumption that opiates should be treated like Plutonium. He also makes the rather demeaning assumption that all patients will respond with “Difficulty.” Patients are petulant whiners, and need to be treated like children. For Psychologists the treatment of pain so a person can have some basic function and enjoy a part of their lives, is not the first priority. Their first priority is to protect the industry, in this case the Physicians from “difficult” Patients.
    These “Psychologist’ have already been taught that Pain is a Mind Body issue, some are not aware that pain even exists. They believe that pain is something that Patients make up for attention, an Imaginary pay out or some other kind of reward. Some of them make that the priority. Of course there has been no research on the number of people who fake it. They have been ‘Brainwashed” to believe pain is merely a mental disorder. This kind of “Advice” is a kind of self-preservation type, one size fits all projection. These Psychologists in many cases are merely Corporate thralls.
    This one treats the Pain Patients as one dimensional as if they have other motives than relieving their pain. There is no mention of any kind of previous relationship between the Physician and the patients, no way to quantify whether or not the Opiates had improved their lives. The positive side of Pain Reduction, is talked around. This is how they have been Gas Lighting us all. The Pain Patient is one dimensional, like a toddler that wants a cookie. The pain is a trivial issue, their quality of life doesn’t matter. The only thing that does matter is the Physician’s Liability. Psychologist have also used these strategies for dealing with ‘Difficult” employees, and justifying the Industries failures.
    The same cold “Alternate Reality” they used to justify torture, depriving children, and drugging people whose only problem is dealing with a difficult situation. The Psychologists have so many false “Beliefs.” They use these “Beliefs” to justify the mistreatment of other human beings. The “Psychology Industry’ has taken some really dark turns since the 1970’s they went from a field full of possibilities, in recognizing Human behavior, to Industry protectors. They aren’t Scientists, or even good observers. Every Patient in this situation is already described as Pathological for seeking Pain Relief. They are just confused, and selfish, as if they just woke up one morning and decided to get some Opiates. Their backstory and Medical Condition are irrelevant. The only consideration here is avoiding perceived Liability for the Physician. Here the Physician and Patients previous relationship doesn’t matter. Just like the positives of “Opiate Therapy” don’t matter either.
    One more thing stands out too. The few Physicians still Prescribing Pain Relief or practicing what was an important area of Medicine are reduced to mere Pill Dispensers or Gatekeepers here. These Physicians have Medical Degrees, and hopefully some background in reading Statistics. They already know that this “Opiate Reduction” and Hysteria is nonsense. They are only doing it to comply with arbitrary laws, and avoid Liability for their employer. This is not “Medicine” anymore, Corporate Bean Counters decided that “Pain” is deniable, and it is “expensive’ for the Industry. Since we can’t see it like we would see a cancerous growth or a fractured limb, we can deny its existence.
    Psychologists had plenty of time to work this out. They took a lot of funding from Big Pharma to promote their Products and do biased “Studies.” They went where the funding is, to Advertising, and Corporate Relations. The Highest earners, really the only indicator anymore of worth, are in the Marketing and Advertising Industries. The ones who got their names out there and got notoriety, were the ones who did “Studies” that repeated Corporate Ideology. This goes way beyond the Interactions with a Pain Physician, where both the Physician and Patient are reduced to “bargaining positions.” Psychologists have become a mere tool of Corporate America.
    They used their Unscientific Methods and “Beliefs” to justify Torture, Exploitation, and Corporate Power. They focused their “Studies” where the money was, they helped to undermine our own observations. The most disturbing realization here is that this “Psychologist” has no concept of the damage any of them have done, they have zero insight. This Industry has turned “Beliefs” into Facts. This Psychologist has never questioned the ethics or effectiveness of his position, He truly Believes that acting in the Corporations Interest, is good for all of us. This is about Gas Lighting. Any Pain Physician, really any that are left in the Field must know that they took up this area of Medicine for a reason. If they have been Prescribing medication responsibly to a patient, they would have already reduced their Medication if it was a problem. Now these Physicians are being second guessed by “Guidelines” with no basis in fact. They will be able to witness the patients decline, when they are ‘tapered off.” There are people that were probably on too much medication, perhaps after they healed from a surgery. These few Outliers were Over emphasized in the Public Consciousness, and the Medical Journals.
    They never put any of this in context, or .showed the many patients who are responsible or even the ones who did not take enough pain medication due to fear of addiction. They never showed examples of people that are able to function, and return to work once their pain was controlled. The Psychology Industry has been indispensable in the areas of Marketing, Public Relations and Propaganda. We are now in the Post Fact Era, it is not about Facts it is about Beliefs. Several Industries were able to use their excessive Profits, to market their false Ideology.
    Pain was a costly area of Medicine and Healthcare spending, they analyzed this and found a way to promote their Ideology to a gullible public and benefit the Profit seeking at all costs Industry. They rewrote their Billing manual to reflect this. Even the Emotional Distress from a Physical Health Condition is a Billable “Mental Disorder.” They changed the Language in the last 2 decades. Their primary concern is the Industry and protecting their Profits, they wrote any kind of “Distress” as a “Condition.” The Psychologists used their skills at Misdirection, Manipulation, and Marketing, because that is where the money is.
    The U.S has the most expensive and least effective healthcare System in the World. We are number 27 in the developed world. These Facts have been avoided by Corporate Media, and our Policy Makers. Healthcare is a huge chunk of our GDP and National Budget. If we ask how we got here, the answer would be the Corporations that make obscene profits, have been able to operate unimpeded. To do this they had to misdirect the public. They had to create a Marketing Campaign, put their people on Regulatory Boards, undermine Academia, and pay off our Politicians.
    The whole time they did this, they had to use Marketing Psychology, and Advertising techniques to sell this Ideology. The people that profit from this own interests in Media for a reason. With the Media under their control, they can control the message. 20 years ago, the News Outlets ran News, about the Healthcare Industry, good and bad. They were allowed to ask questions, and get facts. Now only positive stories about the Industry are allowed. On the Local Level, the few Newspapers that are left only promote Local Healthcare. They Advertise for them. Journalist don’t ask any questions, like, How are they performing. The Only Industry responses allowed are Public Relations Statements. Patients with bad Healthcare Outcomes, were explained away by Psychologists. They are Dysfunctional, because they are concerned about their health.
    People that have to live with pain have been explained away by Psychologists. Pain is the reason most people even seek medical care, other than routine Examinations, if they have Insurance. Now that they have rewritten the Billing Codes, to avoid “Government Overreach” and any potential liability, Pain can be removed from the discussion. This mostly applies to the under- Insured, including Medicare, and the VA, or those seeking care at Low Income Clinics. The Wealthy don’t have to deal with these Gatekeepers, for he most part, except if their behavior is obvious, and even then their wealth insures they will get the best care. The Corporate Media Salts us all with Stories of “Miraculous Healing, Faith, and “Triumph over impossible odds.
    Every “News Outlet” has a story of a Marathon Runner who Survived Breast Cancer, or the Veteran with multiple amputations, running a Company or “Giving Back..” These Heroes are Inspirational, but they serve a much darker purpose. Their Stories are taken out of context to illustrate a message. We don’t see the part about Pain, they overcame it for at least long enough to run that Marathon. So the Breast Cancer Survivor, or Veteran that is not running Marathons is just lacking “Faith” and Motivation. They don’t explain the Support Systems that had to be in place for these people to run a Marathon. They had to be able to get good Healthcare, have a family that supports them in the right way, and even faith in themselves. They are the Lottery Winners, so many things had to fall into place for them to run that Marathon. Psychologists have explained that away as if the Material necessities that they had access to are irrelevant, instead their message is “Faith” or “Positivity.” This is a recurring theme in popular Media, along with the “Mind Body Connection.” Pseudo Science that helps sell everything from Diets to Krill Oil , and New Age Healing.
    We are in a Fact Free world now. The Corporate Media has created a message and Ideology, with a lot of help from Psychologists. They had to manipulate Public Opinion, change the narrative over time, an Sell an ideology. They had to get people to suspend their own observations and believe their Message. They used so many clever Psychological Tactics to Market this to the public. They rewrote the Definitions, leaving out the Facts. They demonized people with Pain, among others. They took a little while obscuring the facts, as they sold a message about “Innovation,” The Medical Industry can do no wrong, they are profitable enough to control the message.
    What people Believe and facts are very different things. Psychologists first had to undermine the credibility of people with pain. They came up with a strategy that pleased the Insurance, Medical and Pharmaceutical Industries, where they can Market Psychoactive drugs for pain. Big Pharma paid for thousands of related “Studies.” on their products. As each Anti Depressant failed to relieve pain, they just tailored the Studies, and promoted the idea. They started in the Community Mental Health Clinics on people without the Financial Resources for actual healthcare. Hospitals had already decided that poor people with pain were inconvenient, they had to send them somewhere, why not the Mental Health Clinic.
    The Psychiatrists and Psychologists that would have put a stop to this or noticed, were all retiring, or the ones that could not be bought were discredited or shouted down. . The ones that went into Public Mental Health Clinics, were told they were helping. They gave people without the resources for Healthcare, who were in distress some Anti Depressants, it couldn’t hurt much. Big Pharma was Marketing them for just about everything. They ran Articles in Medical Journals about Anti Depressants for Pain. They equated the observations of a Biased Pharma funded Study with Medical facts.
    They peppered the Media with these Biased Studies, each one with a Disclaimer. The Conclusions did not match the findings, but it was to much trouble to look at the Data. The Headline and Conclusions were enough to manipulate Physicians and a gullible Public. Corporate Media was quick to promote any “Studies” that promoted their ideology or their biggest Advertisers, like Big Pharma. Facts are unimportant, perception and Beliefs are more important.

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    1. Zyp Czyk Post author

      Oh yes, the insistence that our attitude is responsible for much of our pain makes me furious. That’s the view touted by Stanford, blaming our suffering on our “catastrophizing”. I’ve collected quite a few articles about this insulting “diagnosis” under the tag “catastrophizing“.

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      1. Kathy C

        The worst one has to be ‘Hysterical.” They keep trying to prove that pain is all in our heads, our fault, or due to some Character Flaw. That catastophizing is ridiculous. One more attempt to deny the existence of pain. It is really hard to believe they can say this with a straight face. That Psychologist sure has a lot of nerve, telling Physicians how to do their Jobs. It is not the Physicians fault anyway, their Livelihoods and freedom have been threatened The competent ones know that their Patients know that. That Psychologist treats the Physicians as if they prescribed those medications on a whim. He also assumes Patients will respond like that, most will just accept it, with quiet resignation.

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  2. Emily Raven

    Ah, the good ol “you’re telling me you can’t do all these things and all that happened just because your meds were reduced?” (And similar)

    This was what was pulled on me to likely put it in my file I’m non compliant and all that other garbage. I’d lost 20 pounds in 2 months due to being unable to eat from the pain and symptoms and already been normal side of thin.

    All this does is revamp the no matter what the argument you must be making it because you’re addicted spiel. Gross. What a gross little person this doctor is. Even if someone shot heroin every day for 10 years and ended up injured or sick later in life it doesn’t mean they’re lying but this makes it so no matter what they say it MUST be guilting/bargaining not a plea for being able to live somewhat comfortably.

    Liked by 1 person

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    1. Zyp Czyk Post author

      I agree, this situation and these doctors are gross.

      Thank goodness other doctors, like Dr. Stefan Kertesz, are speaking up for us – and he’s even an addiction specialist! (You can find posts referring to his articles at https://edsinfo.wordpress.com/?s=Kertesz)

      Also, Dr Lynne Webster, is another reputable physician advocating for pain patients. Both these docs are publishing articles all over the medical news sites and I’ve covered many of them.

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