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11 Articles in this Series
Introduction
A PAINWeek 2019 preview with EVP Debra Weiner
Comparing Marijuana and Hemp
Fibromyalgia: What’s New in Diagnosis and Pain Management
Life Hacks to Teach Patients with Chronic Pain
Managing Pain (and Function) in Osteoarthritis: Are Patients and Physicians on the Same Page?
Marijuana: How to Proceed When Controlled Substances are Involved
Menopause Comes with More than Mood Swings - It Deserves its Place Among Chronic Pain Conditions
More APPs Are Coming to the Forefront of Pain Care
Motivational Interviewing and Its Extension into Pain Management
Revisiting Documentation
Side Chat: Modern Analgesic Trials

Motivational Interviewing and Its Extension into Pain Management

A Q&A with Ravi Prasad, PhD, clinical professor of anesthesiology and pain medicine at the University of California, Davis School of Medicine. He discloses being a consultant to J&H and an advisor to Lumina Analytics.

PPM: Motivational interviewing (MI) has traditionally been associated with substance abuse therapy. It seems to be having a rebirth in pain management, along with patient education. In your view, why is motivational interviewing more important to pain practice now than perhaps just a few short years ago?

Dr. Prasad: The release of the 2016 opioid guidelines and the high visibility of opioid-related deaths in the media has made both patients and clinicians more aware of the risks associated with long-term, high dose-opioid medication use for pain. Many patients may recognize the need to reduce their medication intake but have difficulty initiating the first step, or may start an opioid taper but not be successful. A clinician merely providing additional education to patients will not necessarily facilitate moving them forward nor improve success rate; however, using patients’ own internal motivation can help to promote more sustainable change. Based on the latter, MI can serve as a powerful catalyst for change.

Motivational interviewing taps into a person's intrinsic motivation to help promote behavioral change. (Image: iStockPhoto)

PPM: If you had to describe MI with just one or two brief concepts, how would you explain it?

Dr. Prasad: Motivational interviewing is a communication approach that involves tapping into a person’s own intrinsic motivation to help promote behavioral change. Open-ended questions help elicit a person’s desire for change, and this “change talk” is reinforced to help the person move from a place of contemplating change to preparing for and acting on making said change.

 

PPM: There are some data showing that MI can improve patient outcomes; other anecdotes say it may not matter. What has been your clinical experience?

Dr. Prasad: MI is merely one of many communication tools that can be used to help improve patient outcomes. It can be immensely beneficial but it is not a panacea to be applied universally across all clinical contexts. It is important to examine each patient interaction on a case by case basis to ascertain what type of communication strategy would be most appropriate for the situation.

 

PPM: Some clinicians may presume that this type of provider-patient interaction is best left to a psychotherapist or pain psychologist. But why is MI important for every type of provider, even at the primary care level?

Dr. Prasad: When health issues arise, the first medical professional that most patients see is their primary care provider. As frontline clinicians, these physicians/NPs/PAs often see the start and gradual evolution of medical problems and are well poised to help minimize the likelihood that patients end up on harmful pathways. Waiting for maladaptive patterns to arise and then referring out to a psychologist allows the behaviors more time to settle in and become that much more resistant to change. Alternatively, MI can be used early on by primary care providers to extinguish unhealthy behaviors as they are developing and can potentially help reduce their chronicity.

 

PPM: Practically speaking, time is always a challenge for clinicians. How can they feasibly integrate MI into their already jammed schedules? Are there ways to introduce it in small bits, for instance, or to make a referral to perhaps a psychotherapist without making the patient feel stigmatized?

Dr. Prasad: Since MI is a communication approach rather than a technique that is applied in a single session, clinicians can absolutely use motivational interviewing elements across their visits with patients to help facilitate change—no matter how brief the visit. Since there may be other issues to address during a brief office visit, it may be important to allocate time in advance and prioritize items to discuss.

 

PPM: How might MI approaches change as the patient enters new phases of their disease or treatment plan?

Dr. Prasad: Motivational interviewing is a dynamic rather than linear process. As patients move into different stages in their treatment plans, their level of engagement can fluctuate. When such shifts occur, meeting a patient where they are and helping them continue to move forward is important. For example, a patient who has been on disability and on high doses of opioid medication may successfully reduce opioid medication intake through use of motivational interviewing but then may start to backslide as they consider they consider returning to work. In such a situation, the clinician may need to use other components of the motivational interviewing process to refocus patients and help them engage on a healthy course of action.

Next summary: Revisiting Documentation
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