In part one of a two-part series, St. Catharines-based chiropractor and OCA member Dr. Albert Scales discusses his experience engaging patients who are using opioids to treat their MSK pain. Tune in to hear how he raises the topic with patients and discusses contacting their prescribing health professional to coordinate their care while staying within the chiropractic profession’s scope. Dr. Scales also shares his ideas on how you can use OCA’s Opioid and Pain Reduction Collaborative tools to gently move this process forward. (25 minutes)
Key links discussed:
About Dr. Albert Scales:
Since 1981, chiropractor Dr. Albert Scales has treated many patients recovering from automobile accidents and workplace injuries, including many with opioid dependencies. He also served as a chiropractic consultant for WSIB Ontario’s Hamilton office for 10 years and has worked for 20 years as an Independent Medical Evaluator for automobile accident claims.
Dr. Scales is familiar with OCA’s Opioid and Pain Reduction Collaborative, having participated in a focus group to inform its development.
His multi-disciplinary practice is located at Lakeshore Chiropractic Group in St. Catharines, Ontario. He is also a chiropractic provider at Quest Community Health Centre.
Dr. Scales is the current president of the Niagara Chiropractic Society, a Rotarian and received OCA’s Political Service Award in 2004 and its Community Services Award in 2001. He graduated from the Canadian Memorial Chiropractic College (CMCC).
Watch for Part 2: Building Rapport with a Prescribing Health Care Professional coming on July 15, 2021.
Episode 1 – Breaking the Ice on Opioid Dependency – Transcript
Leslie: [00:00:00] Welcome to ON Spinal Chat, where we explore what OCA is doing or supporting to help enhance your patient care, grow your practice or advance the chiropractic profession.
My name's Leslie. And today I'm speaking with Dr. Albert Scales in part one of a two-part series on how you can help address the opioid crisis.
Dr. Scales practices at the Lakeshore Chiropractic Group in St. Catharines where he sees many patients who've been in a car accident or experienced a workplace injury. In this part-one episode, Breaking the Ice on Opioid Dependency, we'll discuss Dr. Scale's experience engaging patients who are using opioids to treat their MSK pain.
We'll chat about how he raises the topic of contacting their prescribing health professional so he can co-ordinate their care. And Dr. Scales will share his ideas on how you can use our Opioid and Pain Reduction Collaborative tools to gently move this process forward while staying within scope.
Thank you, Dr. Scales for joining me today. I understand that you run a full-service chiropractic clinic but that many of your patients have been in auto accidents or have had workplace injuries. What motivates you most about treating these patients?
Dr. Albert Scales: [00:01:12] I think most chiropractors will agree that we got into this profession to help people.
We all know the acute patient that we see that has hurt themselves being the weekend warrior. They come to us for some help and they're already expecting to get better because they know what they've done. My background is for many years helping as a chiropractic consultant and at the WSIB, as well as dealing with motor vehicle accident cases and treating volunteer chiropractor at the Quest Community Health Care here in St. Catharines. These patients are different than the acute patients that come in our office. Most of these people are not expecting to get better. There's a lot of ambivalence. They're scared and most, if not all of them, are not only dealing with acute pain but acute pain that develops into a chronic pain.
When somebody has an accident, they don't always have a catastrophic injury. So, the accident that they're having is usually strains and sprains, or they might have whiplash. A lot of times because the accident is such a harrowing thing to go through, they don't necessarily feel pain at the site. And I think deep down, they feel there's a stigma.
The stigma that a lot of patients, particularly people with pain (feel), if there's no objective findings; so, for example, there is not a catastrophic injury on an auto accident. They come out of the auto accident. They don't go to the hospital. They've never had X-rays done, but they have pain.
They right away feel that they’re being judged perhaps. And they may not be, but they feel that they're being judged, that their whole purpose is now to go out and take medication. The pain isn't real. it's imaginary. And that stigma just sticks with them. Most of them have reached the end of their rope. They really think that the only thing that's going to be helping them is medication.
So, I'm seeing a challenge of reassuring, validating and helping these people. So that's where the motivation came from. Because if you can connect with these chronic pain patients. If you can give them that hope that many of them feel is not there… It's totally different than acute pain, but certainly challenging; but at the same time, incredibly rewarding.
Leslie: [00:03:07] Okay. When a patient comes into you with pain and they're taking opioids to treat that pain, what do you usually notice first?
Dr. Albert Scales: [00:03:14] When you're talking about a patient that had been already taking opioids, and usually these could be either for acute pain or chronic pain, two words seem to come to mind: desperation and anger.
They're frustrated. They're a little ambivalent because they've gone down so many paths to try to get a handle on why they're feeling the way they are. That's probably the type of patient you're going to be dealing with.
They may be a little angry with you at times. They may say that "nobody's ever listened to me before. I don't know why I'm here. Friend of mine said I should give you a try." So, that's the type of conversation you're going to have primarily with those patients.
Leslie: [00:03:51] Does this kind of conversation come up during the assessment or at what stage do you start to hear this type of thing?
Dr. Albert Scales: [00:03:56] You may see it off the top because it's hard for them to believe that there's somebody out there that is willing to help them get through this difficult period that they're going through.
Now there's different types of patients you may see. You may also see an individual that is taking opioids that may indeed not necessarily want to be in your office for long-term care or to at least reduce their dependency on the opioids. They may be an individual just simply coming in for a quick fix.
So, they're not going to follow through in your care. They simply want a quick one or two visit adjustment and be on their way. And then they're consistently still going back to their opioid use because they really don't believe in their heart and soul that treatment in a chiropractic office is going to help them. But I'd like to say the majority of people that have taken the first step to come into your office are really there out of desperation because they literally have reached the end of their rope and they're looking for true and safe alternatives.
Leslie: [00:04:51] So at what stage do you find that a patient is willing to speak to you about their use of prescribed opioids to manage MSK pain?
Dr. Albert Scales: [00:04:58] The ones that are trying to get off of it. The ones that really feel that there may be hope in a chiropractic office will probably tell you that immediately because that's why they're there.
I think a big question is what we've all probably mentioned and ask a lot of our patients is "Why are you here?" Because that opens up a big discussion for the individual that is frustrated, that really wants change in their life. They're pretty much going to tell you. They know this is a process because they've been on this very long and arduous roller-coaster for a long period of time.
So, if Mary, for example, comes in and her family has encouraged her to come in and other friends of theirs have, let's say been to our office or at least to any other chiropractor's office... They will basically say that “I'm looking for change in my life.” So, they are hoping.
The ones that are simply there I think for “look it Doc, just give me a quick fix and I have to get out of here.” They're not going to be opening up to it as much. You're going to sense it in them right away because they're not going to be listening to your recommendations. They're going to be asking questions like "How long is this going to take? How fast will it be until I start to feel better?"
Leslie: [00:06:00] What do you do to take them to the next level so that they actually are open to pursuing treatment beyond just a couple of visits?
Dr. Albert Scales: [00:06:07] I think a lot of these patients may not come on their own accord. They may have a loved one or friend encourage them to come in for chiropractic care because they see them going down a slippery slope. They see them perhaps entering some socioeconomic issues. They see probably marriage issues, work-related issues, financial issues.
Usually what we'll do is when they come in, I will ask them: “Why are you here?” The first thing they're going to focus on is pain. Probably if they want to get off the medication will tell you right away: "Listen, I've been to my doctor and nothing helps." There's another word that will really cue you to understand that they're there for help. “Nothing helps.”
The individual that really wants a quick fix. They know the opioids are helping. These individuals just need to get out of a quick pain. You may have to work with those individuals that are wanting just the quick fix and be a little bit more direct with them. And never in a negative way but in a positive way, saying, "You know, there is going to be a little bit of work that you have to do in order to get through this as well."
And then you basically start the conversation as you would with any other patient. A lot of times what you have to do to really grab them is don't ever say the word "I understand" a lot to them because you don't understand. You have no clue what they're going through. You have to say things like: "That must be difficult for you."
You want to be empathetic. You have to validate their pain because they sometimes believe, especially when they're chronically in pain and utilizing opioids, that basically, they're not as bad as they say they are, particularly in the cases where there's not been a fracture.
They come in the office, they say, "Well, yeah, you know, I don't have a cast on, I didn't have to go to a hospital. I didn't have to have surgery. It can't be that bad." They simply want to have their pain validated and they want an answer. That's what they're there to see you for particularly now.
We're in a difficult time and everything is highlighted with COVID 19 numbers. If they go to a hospital right now, believe me and I've heard this from many of our patients that have gone there. They don't even want to see me. They say, "Look, if you're thinking you're coming here for narcotics, there's the door." They've actually even walked into walk-in clinics and that's happened as well. And what's making it exacerbated, even more, is the fact that it's very difficult for them to contact their own family doctor because everything is done virtually now.
Leslie: [00:08:15] Okay. So, I'm wondering if their friends and family, if they also will tell them that it's not real.
Dr. Albert Scales: [00:08:20] That's a very good point. And I think that's what becomes a major psychological barrier for many of them. It's bad enough that COVID is hitting us right now that we're walking around with masks and we have to sanitize ourselves properly and be safe.
But now you have somebody that's sitting at home and they're too sore to go to work. "What do you mean you can't go to work? My God, we're going to lose our home. We're going to lose our car." It just becomes a vicious cycle.
Leslie: [00:08:42] Now with all the patients you've dealt with who are depending on opioids for pain management, what's the biggest hurdle you've ever experienced, actually trying to help one?
Dr. Albert Scales: [00:08:50] I think the biggest hurdle is they're out of hope, but you can sense that they don't think this is going to work. They'll constantly talk about all the processes that they've gone through and how they've hit a dead end. And they'll constantly say things like, "So you really think this is going to help?"
So, I think the way you overcome this is simply give them reassurance, hopefully in the first few minutes through their consult, you’ve validated their pain. And I think we've all heard this over the years: ‘Learn to listen more and shut up more.’ The patient is going to tell you what they need; what they require.
You're just going to be the facilitator for that as best as possible. But you're likely to get in their camp a lot more if you reassure them and not just once, but constantly, and also keep validating their pain.
Leslie: [00:09:35] Could you share an experience where you went through that with a specific patient?
Dr. Albert Scales: [00:09:39] We had a female patient that just recently came in. She was involved in a motor vehicle accident and has gone through all the paperwork and is still having some legal counsel because their family has said, "Well, maybe you probably need to speak to a lawyer because there's so much stuff for you to go through."
She came in and she said: "Listen, I've been to my family doctor. I'm consistently going and he just keeps throwing his hands up in the air because the X-rays show normal. There's no fracture. There's no major issue happening within the neck itself. Albeit, you have some arthritic aspects happening but that just goes along with age and probably your work habits. I want you to stay on this medication."
Now, this lady we're talking about, and I'm going to shock everyone was taking upwards to six Percocets a day.
Leslie: [00:10:25] Wow.
Dr. Albert Scales: [00:10:25] And I'm going to tell you a happier story because she was in recently to see me today, but we'll get to that later. [Update follows in episode 2.] When she finally came to me, it was through, and again, we're not putting down other disciplines, she's been through physiotherapy. She's been through family doctors and an osteopath. She does find massage helpful.
I think we in the chiropractic field seem to be a little bit more empathetic and take our time listening to these people more. Again, that was the concern like, "why am I here? I don't know. My friend said I should come here. The massage therapist said I should come here."
You basically validate their pain, but you say to them, "Yeah, it's gotta be pretty difficult that you've gone through all of these treatments and you keep hitting a dead end and you're still open enough to tell me."
And to be fair, she did not say to me at that time, how many of those opioids she was taking. I basically said: "You've come through an awful lot of ideas and questions and types of treatment. And not saying these are bad. They've all been ways in which professionals are trying to look at this condition. So, thank you for sharing that with me because you know what? I don't want to duplicate the same things you've gone through."
So that's why it's very important to find out what they have gone through. Particularly if they've gone through another manual therapist, whether it be a physio, an osteopath, or whatever the case is, you don't want to duplicate. So, what you have to say to them is: "You know what I hear you. I'm sure those people have done the best that they anticipated to do. And thank you for sharing with me that that did not work for you. So, let's now take another path and let's see how this works. Are you game for that?"
And once they start to understand that you're not utilizing the same modalities, whether they be ultrasound, laser, heat, ice exercise ... And a lot of these people, they can't do exercise.
So, what you have to do is you have to back up the truck a little bit and go down another path. And once you've explained to them, that "let's try something different," that gives them that hope. They may still feel a little ambivalent but at the same time, that's the start of a long journey, but let's hope it's a positive one.
Leslie: [00:12:20] Now you said ‘we’ a lot. Is that key?
Dr. Albert Scales: [00:12:23] It has to be a team approach. When you say "we." We are working together on this because they've probably heard so many times: "It was your accident. You're taking these meds. You have to do this." That's a hard road to travel.
They know the road is incredibly difficult. They don't see the end of that journey for them. So, when you say "we," you're travelling together with them and they really appreciate that.
Leslie: [00:12:45] You've honed a great way to develop a rapport with patients. Did you take any special training to get to this stage or did it just evolve over time?
Dr. Albert Scales: [00:12:52] I don't know. I guess it just comes with experience. I think when you've been in practice for 40 years, you've seen the highs and the lows. For the young individuals that are out there just starting, give yourself credit. You've made it through chiropractic college. There's so much information out there. Even on a weekend, take a look at things. You can find out anything on the internet.
A lot of this is knowing how to be different than the mainstream because we need change. Look at everything that's out there that's brought to the surface now. Everything is more transparent. Opioid abuse is transparent. Racism is transparent. Alcoholism is becoming transparent. The list goes on and on.
I think with all these aspects that are starting to come to the surface, we have to learn to become more humanized and we are going to fail sometimes. A lot of this is really caring and I think that's the one unique thing that chiropractors have: We are an incredibly caring profession. That's what's put us, I think, on the map.
And I think going forward, particularly as a result of this horrible pandemic that we're all experiencing, this is a wonderful time for chiropractors to give back.
Leslie: [00:13:55] That's part of the reason we developed this opioid and pain reduction collaborative. Yes, chiropractors are well-positioned to address it. And we've worked with an advisory panel to develop the solution, but we started in response to the rise of the issue and our members grappling with: “How can we address this?” We've had people come forward, like yourself, who was involved in one of our focus groups, as well as a panel to work on this solution.
So, with the OCA's opioid and pain reduction collaborative, what do you recommend your colleagues do to get the most value from its chiropractors' tool kit?
Dr. Albert Scales: [00:14:28] Well, I guess the first thing is open up your computers or your smartphones, and just check out this wonderful website called chiropractic dot O-N dot C-A. That may sound a little tongue in cheek, but the reality is every day we get probably dozens, if not maybe hundreds of emails. Now we're getting an email from the OCA. We get it from the CCA. A lot of chiropractors really don't have the time to look at the myriad of information that is available to us online.
Every year or every other year, we have to maintain our clinical hours for CCO and I hear some colleagues saying, “Oh my goodness, I don't know how I'm going to reach these hours.” And I'm going, “Are you kidding me?” There's tons of information out there.
First thing is, if you are having a difficulty and you're listening to this broadcast and you have these types of patients in your office, for goodness sakes, open up the website.
There's tons of websites out there that will educate you on opioid abuse. This is a website that is germane to us as chiropractors. And that's one of the reasons why – utilize the OCA resources. Utilize the CCA resources. They're there for us. And in fact, I have it right here in front of me, and it's an easy, simple step-by-step approach that you will relate to as a chiropractor.
What I like about this too is, and I think you just alluded to this as well Leslie, that this isn't just been designed by chiropractors. Yes, it's talking to chiropractors, but this is a collaborative effort. And I think that that's what's exciting about this. The fact that it's collaborative indicates to other people that are not chiropractors, that we're all in this together.
Whether it be a physician, a nurse practitioner, a physio, any other treating provider that may be seeing these people. Go to the website, review this information. In fact, what I did, is I just print it out and I keep it in our back office. It's an easy step-by-step form to guide you through this dialogue.
Leslie: [00:16:16] Thank you. So, I'd like to probe a little further, how can you use this tool kit to begin a conversation with a patient about their opioid use if you've never gone down that path before?
Dr. Albert Scales: [00:16:27] If they do go to the website and take a look at the opioid and pain reduction collaborative, there's an example of a chiropractor dialogue map.
And if anyone's ever done public speaking or if you've had to discuss an issue in public, we all role play. When you're dealing with a chronic care patient, these people are going to hit you with anything and everything. You can do this in your car. Do this in your backroom. But don't be afraid to role play this because it's so nice to see on the website questions that you're probably going to come across, that you really want to discuss in a very easy and flowing manner.
You don't want these patients, and even treating providers, to feel that this is scripted. You want to be as smooth as possible. You want to sound that, that this is coming truly from the heart. And I'm just going to read it out. This could be you saying this to a patient: Prescriptions are outside of my scope of practice. However, would you permit me to contact your doctor specialist to discuss a co-ordinated care plan that might help better manage or reduce pain?”
That may be a little difficult for many of the members to do right from the get-go. We have patients come into the office and you may say, "Oh, you're on Advil." I've actually had patients look at me and they say, "Yes, I just take the odd Advil. I don't really take it an awful lot.” And I say, "okay" and all of a sudden, they look shocked because they think I'm going to chastise him for that. And I go, "No," I said, "Listen, even though we cannot prescribe medication, I mean, obviously people are going to be taking over-the-counter medication. Unfortunately, what you're going through is an opioid use. How do you feel taking these?”
Now a lot of them will actually openly say "that's the only thing that helps me." And you'll hear this from a lot of people. How many times over the years I've heard, "You know, Tylenol doesn't work. So, I resorted to Advil. I find now I'm going to the extra strength Advil. And now my doctor has given me a prescription and I'm now taking opioids."
It amazes me how many of our patients are taking Tylenol three on a regular basis. So, I think even though chiropractors feel that they might be uncomfortable discussing a medication, a patient's taking, you're not prescribing medication. You're not even suggesting how they should be taking it. That certainly is outside of our scope of practice.
But it is part of the picture. You can't also blame them for taking the medication because we don't understand their pain. Pain is subjective. So, don't be afraid. I remember some chiropractors actually said they don't even put down on the intake form, align for medications because they go, “I don't care about medications. I'm a chiropractor and I'm here to get the patient better." I'm not against your philosophy, but the reality is that medication is a way of life. Pharmaceutical companies are not going to be going away.
So, make sure you understand and maybe explain that to them because here's another thing I've done: "Take a look and we'll go through the medication. By the way, Mary, I see you're taking this. I see you take some Tylenol, but you've now resorted to Advil. Is there any other medication you're taking?" You'll be amazed at how many people will say "Well, yeah, my doctor gave me um, that wasn't my doctor. My dentist gave me some Percocet once for this terrible dental pain and I got to tell you, I do resort to that sometimes."
And they’ll be nervous telling you that, but you have to understand what medication they're on. And particularly now, because now people are taking cannabis. They may not necessarily tell you they're taking cannabis oil. Now you're literally seeing so many people picking up a CBD and THC. They're going to tell you they're taking things like Bengay or A-5-3-5 or Biofreeze or some of the other topicals. But you really have a right and an obligation to really understand what medication they're taking. Understanding where they are with their medication, how they feel about their medication, what it's doing for them is paramount.
Leslie: [00:20:03] Have you ever had a patient who starts off with you and then decides fairly early on they want to give up on manual therapy for MSK pain and switch back to solely using medication and looks to you for help to achieve this?
Dr. Albert Scales: [00:20:16] Yeah, I think that's where you need to reassure them. I think you have to go back to the beginning of the book again and say: "What brought you here in the first place?"
I realize that they may be frustrated with the rate of progress that's been taking place, but a lot of times pain is kind of black and white. Patients feel my pain is either there or not there.
And you have to remind them sometimes: "What were you not able to do before?" And they'll say, "You know what, I couldn't go golfing. I couldn't go walking. I couldn't stand and even cook a meal without having to sit down."
“Well, how are you doing now?” "Well, okay. I guess I'm able to get through the meals."
So, a lot of times we can't focus on the pain, even though pain is what brought them there in the first place. Because pain and opioid abuse go hand in hand. They take medication to address and stop the pain.
What's really difficult is when you say to them that pain is there for a purpose. It's a warning sign. The problem is they look at you and they'll say, "Look, I'm tired of this warning sign because it's hitting me over the head all the time."
So, what we're trying to do is take them on a different tangent, like how they're functioning now, compared to when they were at first. But you have to reassure them: “How long, by the way, have you been on a medication for it?” A lot of times, they'll say "for years." So, I said: "It's not going to take years to get this under control, but you've already now told me that you're able to stand and cook dinner a little longer. You're able to sit a little longer. You're now going for short walks. How do you feel about that?"
"Well, I guess that's great, but you know, doc, I'm still in pain."
So, they always revert back to the paint. See if you can bring it over to how they function; how their function is improving.
But at the end of the day, if they really are upset about using an opioid and they really want change and you can guide them into the aspect of how better they're functioning, they usually will waver a little bit, but they'll come back to your side.
If the individual is really focused on, look pain, I got to take something pain's gone. That's a hard one to deal with because they're usually the ones that want a quick fix anyway, but never, never force that patient that they have to stay because that is always their prerogative. But I think if you can sit down and explain to them that” "What do you think are the other options out there?"
Because a lot of times, that's why they're there in your office. They had no other options. So, they may go down that path, but you have to respect that. Chances are, if they do, if you've respected them, if you validated their pain, believe me, they'll come back because they know that's been a bad move on their part. And they say, "I know I was a little stupid. Maybe I didn't give it enough time. Will you take me back?" And I've seen that happen in our office too. So, give it time.
Leslie: [00:22:38] So they'll sometimes leave for months at a time and then come back to you or weeks?
Dr. Albert Scales: [00:22:42] It varies because they get on a path and whether it be a friend that encourages a return or a loved one or just themselves because they realized they're hitting roadblocks again and they get tired of it.
They remember very much the dialogue they had with you. Your dialogue is totally different than what they've usually heard before and believe me, it makes an impression on them. So yeah, they will come back. But you're exactly right. It may be a few weeks.
Here's a little tip I want to give the chiropractors too. When they come back, don't tell them, “Well, you know, John, you left here before and you didn't complete your treatment plan. So, I don't want you doing that again." They've already berated themselves. I don't have to berate any of my patients.
They come in and if I haven't seen them for a few weeks or several months and they berate themselves. "Hey, doc, I'm glad you took me back. I was a real fool. I didn't realize." And they'll go on and on for five minutes or so. And I say, "Are you done? So, let's get working on getting you feeling better again. How does that sound?" That's how you have to deal with it. If they really think you've been there for them, they will come back.
Leslie: [00:23:39] Do you have a favourite word or an expression that you often find yourself saying with patients that seems to work?
Dr. Albert Scales: [00:23:45] Well, the favourite word that I use is: "What you must be going through has gotta be difficult." A lot of this is just understanding and empathizing what they're going through. Don't say "I understand" because unless you've been down their exact path and even if you have a family member and you clearly understand what opioid abuse is about, it's not the same.
Sometimes I've actually shared stories with them because we've all had stories of perhaps a loved one or someone that you know that have gone through this. So, I think that becomes empathetic. Just be on their side as much as possible.
Leslie: [00:24:19] Thank you Dr. Scales for sharing your experience on building trust with these patients.
In the second episode of this series, Dr. Scales will discuss how he initiates contact and works with the prescribing health professional to co-ordinate care for their shared patient with an opioid dependency.
I hope you'll join us.