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July 2018

How many seconds do you wait? – Improving medication adherence – How’s the water?


Addiction and mental health clinicians have almost all been trained in Motivational Interviewing. Even though the spirit of Motivational Interviewing upholds Partnership, Acceptance, Compassion, Evocation, treatment programs and clinicians only partially apply these principles in daily practice.
(Miller, William R; Rollnick, Stephen (2013): “Motivational Interviewing – Helping People Change” Third Edition, New York, NY. Guilford Press.)
Physicians as a whole are even worse at shared decision-making with patients, because we have been trained to be “MDeities” (That’s not original. I forget who I stole that from.) Don’t blame physicians because we want them to take command, be decisive, and not hesitate in matters of life and death.
Imagine approaching a patient having a severe heart attack with: “ I’m here to partner with you in your cardiac health and it must be frightening to be experiencing a heart attack, turning blue and passing out. Tell me more about how you are feeling and what brought you here today.”
But most of the time, even physicians need to practice partnership, acceptance, compassion and evocation in collaborative, shared decision-making.
Consider how long you wait to listen to your client’s most important goals before jumping in with your questions.
A new study was just published online this month in the Journal of General Internal Medicine. If you’ve ever been a patient or client of a physician or clinician, this study should get your attention.
The authors said: “Eliciting patient concerns and listening carefully to them contributes to patient-centered care. Yet, clinicians often fail to elicit the patient’s agenda and, when they do, they interrupt the patient’s discourse.”
The researchers analyzed “112 recorded meetings between doctors and patients at general practices in Minnesota and Wisconsin, including at the Mayo Clinic and its affiliated clinics.”

  • Physicians “only spend 11 seconds on average listening to patients before interrupting them.”
  • “The results of our study suggest that we are far from achieving patient-centered care, as barriers for adequate communication and partnership continue to limit the elicitation of the patient’s agenda and lead to quick interruptions of the patient discourse.”
“Clinicians seldom elicit the patient’s agenda; when they do, they interrupt patients sooner than previously reported. Physicians in specialty care elicited the patient’s agenda less often compared to physicians in primary care. Failure to elicit the patient’s agenda reduces the chance that clinicians will orient the priorities of a clinical encounter toward specific aspects that matter to each patient.”
Singh Ospina, N., Phillips, K.A., Rodriguez-Gutierrez, R. et al. “Eliciting the Patient’s Agenda- Secondary Analysis of Recorded Clinical Encounters”. J GEN INTERN MED (2018.)
It doesn’t take much more time to really hear what is important to clients and patients.
Many have expanding case loads, productivity expectations, documentation and managed care pressures. It is easy to feel we don’t have enough time to build the therapeutic relationship and to elicit goals and methods important to the client. But this doesn’t have to be a time-consuming process.
There have been six studies in general clinical practice evaluating communication and relationship skills.

  • “Previous studies have shown that when allowed to describe their concerns, most patients complete spontaneous talking in a mean of 92 seconds.”
    (Singh Ospina, N., Phillips, K.A., Rodriguez-Gutierrez, R. et al.)
Other studies found:

  • Average length of time before physician interrupts the patient: 18 seconds
  • Patients allowed to complete their opening statement without interruption mostly take less than 60 seconds and almost none take longer than 150 seconds (even when encouraged to continue).
These results have implications for engaging clients in a self-change process; and they don’t just apply to physicians. Addiction and mental health clinicians are also vulnerable to jumping in prematurely and being too directive with closed-ended questions. Motivational Interviewing lists this as one of the traps which inhibit building motivation for change – the “Question & Answer” trap.
Essential to developing an effective therapeutic alliance is to agree on goals and to agree on methods and strategies. Listening to clients takes time, but not as much time as you think.
Langewitz W, Denz M, Keller A, Kiss A, Ruttimann S, Wossmer B.
Spontaneous talking time at start of consultation in outpatient clinic:cohort study. BMJ. 2002;325:682-3
Rabinowitz I, Luzzati R, Tamir A, Reis S.
Length of patient’s monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care. BMJ. 2004;328:501-2.


In the United States, 3.8 billion prescriptions are written annually.

  • Approximately one in five new prescriptions are never filled.
  • Among those filled, approximately 50% are taken incorrectly, particularly with regard to timing, dosage, frequency, and duration.
  • Whereas rates of non-adherence across the United States have remained relatively stable, direct health care costs associated with non-adherence have grown to approximately $100-$300 billion of U.S. health care dollars spent annually.
  • Improving medication adherence is a public health priority and could reduce the economic and health burdens of many diseases and chronic conditions.
(CDC Grand Rounds: Improving Medication Adherence for Chronic Disease Management – Innovations and Opportunities
Weekly / November 17, 2017 / 66(45)
Medication adherence is a complex behavior influenced by factors along the continuum of care, relating to the patient, providers, and health systems.”
(CDC Grand Rounds: Improving Medication Adherence for Chronic Disease Management – Innovations and Opportunities
Weekly / November 17, 2017 / 66(45)
The article on medication adherence is related to chronic disease management in general. However, many of the issues apply to disease management for addiction and mental health as well. I excerpted factors related to medication adherence discussed in the article; and cross-walked them with the relevant ASAM Criteria assessment dimensions.
This table relates factors important to medication adherence in comprehensive, person-centered, multidimensional assessment. (These thoughts were dreamed up this week. They are not in the reference listed at the end. That is a reference just to The ASAM Criteria in general):
ASAM Criteria Assessment Dimension
Factors Related to Medication Adherence quoted from the article
1. Acute Intoxication and/or Withdrawal Potential
(a)” Medication side effects, and expectations for improvement”
In the context of medication in addiction treatment, if patients are experiencing withdrawal discomfort, they may struggle with adhering to medication taken for withdrawal management or for induction on buprenorphine/naloxone (Suboxone); or naltrexone (Vivitrol).
Hoping for a quick response, may affect how long they wait before supplementing with other street drugs to get relief.
(b)  “Substance abuse” – concurrent use of tobacco, cocaine, methamphetamine, marijuana, and alcohol can affect efficacy of medication in addiction and mental health treatment. Intoxication with other drugs can affect adherence to medication regimens.
2. Biomedical Conditions and Complications

(a) Limited coordination of care among multiple providers.”

For patients with chronic pain or other physical health problems, care coordination is important to ensure awareness of drug interactions (Prescription Monitoring Program);
and any addictive behavior in doctor-shopping for opioid pain medication etc.
3. Emotional, Behavioral or Cognitive Conditions and Complications

(a) “Impaired cognition (e.g., related to aging or disease), depression, and other mental health conditions.”  

Assess and treat co-occurring diagnostic or sub-diagnostic mental health conditions or complications. Co-occurring disorders impact medication adherence and outcomes.

(b) Increasingly complex medication regimens (e.g., forgetting to take medication or obtain refills, or inadequate understanding of dose or schedules)”

When a patient, especially on the first visit, has recently used substances or is psychotic, depressed or anxious, it is important to assess the patient’s ability to understand and follow instructions about medication regimens.
4. Readiness to Change

(a) Lack of engagement in treatment decisions”

The quality of the therapeutic alliance impacts outcomes more potently than the EBPs used.
(b)  “Beliefs and attitudes about their disease”
Patient stage of change impacts whether “discovery, dropout prevention” is warranted before “recovery, relapse prevention”.
(c)  “Active decision to stop or modify a treatment regimen” and “inadequate provider time to review benefits, risks, and alternatives to prescribed medications”
This requires collaborative care and shared decision making in treatment decisions.
5. Relapse, Continued Use or Continued Problem Potential
(a)  “Substance abuse”
Continued use of addictive substances impacts efficacy of addiction or psychotropic medications. Any positive urine drug test (UDT) results requires careful evaluation of continued use potential with psychosocial treatments to deal with cravings and develop a relapse prevention plan; and/or to do motivational work around substances a patient is not yet ready to address e.g., marijuana and tobacco.
6. Recovery Environment
(a)  “Ability to pay”
Any financial difficulties initially or as treatment proceeds can affect stabilization and maintenance on medication.

(b) Barriers to communicating with patients and their caregivers”

Involving the family and significant others teaches them about addiction or mental health and medication in addiction treatment or psychotropic medication and assesses how supportive the environment is for the patient.
(c)  “Limited availability of culturally appropriate patient education materials”
Assessing the patient’s cultural beliefs and values allows for more targeted materials to increase understanding and adherence.
Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions Third Edition. Carson City, NV: The Change Companies.


I don’t have a Twitter or Instagram account and I’m not on Facebook. It’s not that I have anything against social media or new technology.  I love how Siri can give me an answer more quickly than I can type the first two words of a question.  But I haven’t even tried out the Animoji or Augmented Reality features of my beloved iPhone X I’ve owned for over 8 months.
I have enough trouble keeping up with opening, answering and clearing out my e-mail, let alone contribute and respond to a variety of platforms I can’t list because I know they are out there, but know nothing about them.
Also, have you found yourself getting new e-newsletters and blogs almost on a daily basis? I know I didn’t sign up for them (or maybe I did when I clicked on “Agree” without really reading the fine print when installing an update to software.)
BTW (that’s “by-the-way” if you’re still classical enough to be using full words and sentences to communicate), BTW, I don’t send Tips & Topics to anyone who didn’t give me their email and ask me to send it to them; or a friend or supervisor who put someone’s email on the list.
Anyway, my point is: despite my embryonic understanding and use of social media, I continue to be amazed and served by the ease of access to so much information in a flash on the internet. With a link in an email or a text, I can quickly review so much information I would never have known existed or have had such easy access to.
That’s what happened this month when a colleague sent an email about a blog he thought I might appreciate……and I sure did. On June 29, 2018, Bill White wrote on a blog on “Changing the Water”.
In his blog, Bill quoted David Foster Wallace who opened his May 21, 2005 commencement address at Kenyon College with the following story.
“There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says “Morning, boys. How’s the water?” And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What the hell is water?”
Bill White draws on this insightful story to comment:
“Each of us swims in a near-invisible cultural stew of words, ideas, attitudes, images, and sounds that constitute the personal stage upon which the actions of our daily lives unfold. These near-invisible contextual elements of our lives are so deeply imbedded that they rarely, if ever, enter our conscious awareness. Yet, they exert a profound influence on how we view ourselves and our relationship with the world.”
It’s worth reading the whole piece at:
I am troubled by the degree of animosity, fragmentation and polarization I experience every day in the news, reading about people’s tweets; and even in the relatively tiny world of addiction treatment professionals. Bill White’s reminders of our unconscious bias and the “near-invisible contextual elements of our lives” are timely and needed.

(BTW, in June 2010, Bill White launched the website William White Papers

“with the singular goal of creating an online resource library that would serve as a repository of my collected writings on addiction recovery. My hope was to make these papers and related resources available to current and future generations interested in recovery and the recovery advocacy movement.”)

Bill White’s leadership, generosity and profound knowledge and insights are an inspiration to me and to the addiction and mental health fields. I can’t thank him enough.

For me, I am still impressed by the wonders of email and the internet. How else would I have so quickly learned about the wisdom arising from two young fish swimming along saying “ What the hell is water?”
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