Dealing with 'Dread to Treat' Patients Requires Seeing the Person, Not the Addiction

LAS VEGAS—One of the most difficult “dread to treat” populations is patients with substance use disorders. Yet, if providers cannot learn to see the person who exists under his or her illness—and addiction is a primary, chronic illness—they will not be able to provide effective care, nor will they ever be able to help such patients with their pain completely.

That was the message of this highly interactive session, presented by Heidi Allespach, PhD, and Bernd Wollschlaeger, MD, FAAFP, FASAM, MRO, of the Department of Family Medicine & Community Health at the University of Miami Miller School of Medicine, Miami, Florida at PAINWeek 2014.

The presenters, both of whom specialize in treating patients with alcohol or drug addiction, helped clinicians differentiate between patients who present with “real” pain versus addiction or drug-seeking behavior, noting that patients may experience both emotional as well as physical pain because of their addiction.

They began by asking, “How do your addicted patients make you feel?” Attendees were encouraged to think about their own past experiences with addiction; for example, with family, friends, colleagues, or even themselves. They were then asked, “How might your feelings and past experiences affect the treatment you provide to these patients?” For example, do they label them, whether consciously or not, as “Dread to Treat, Heartsink, Frequent Flyers, Thick Chart, GOMERS, or others”?

This can be a very draining population, and clinicians may feel inadequate, frustrated, hopeless, and angry, they pointed out. Unless the clinician can develop an understanding of what addiction is and how best to interact with patients who have this disease, they will find these relationships very troublesome. Unfortunately, in pain management, addictive behaviors and drug seeking are very common; yet, most clinicians get very little, if any, training in how to work effectively with what can be an extremely difficult population.

During the session, providers learned how to care for themselves when dealing with patients with substance abuse disorders, including how and when to set appropriate boundaries. One example: enforcing medication agreements at a level of comfort for the provider in terms of prescribing and/or patient care.

Drs. Allespach and Wollschlaeger concluded with three points to remember:
  1. Chances are, your addicted patient is judging himself or herself much more harshly than anyone else ever could. Use empathy and support to create a safe place for your patient to discuss their struggles, while also maintaining clear boundaries to avoid being manipulated by the active alcoholic/addict.
  2. You can act as a catalyst for assisting with change, but it is ultimately the patient who must stop drinking/using. Do not take personal responsibility for your patient's success or failures in cessation of substance use. Don't ‘personalize!!!
  3. Take care of yourself! Seek support if you find yourself often angry, frustrated, disgusted, anxious, or even apathetic when seeing patients who are alcoholic/addicts. Be aware of how your past experiences contribute to your current thoughts and, in turn, your feelings. Remember…never give up hope. Even though these are some of the most difficult patients you will see, you can make a huge difference in their lives!
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