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Experts Identify Management Strategies for Concerning Behaviors That Arise when Taking Opioids for Chronic Pain

PITTSBURGH, Dec. 11, 2017 – Patients receiving long-term opioid therapy for chronic pain sometimes demonstrate challenging and concerning behaviors, such as using more opioid medication than prescribed or concomitant alcohol or drug use. A new study, published in the Journal of General Internal Medicine, establishes expert consensus about treatment approaches that should be implemented when these behaviors arise.
Led by Jessica S. Merlin, M.D., visiting associate professor of medicine at the University of Pittsburgh School of Medicine, the study pinpointed the common concerning behaviors, identified management strategies and established areas of consensus on the importance of each strategy.
“Due to increasing concerns about the risks of long-term opioid therapy for chronic pain and limited evidence as to their benefit, the Centers for Disease Control and Prevention released its Guideline for Prescribing Opioids for Chronic Pain in 2016,” said Merlin, who completed this research while at the University of Alabama at Birmingham. “These guidelines provide recommendations for monitoring patients with chronic pain on long-term opioid therapy, such as frequent visits and urine drug screening, but provide little guidance on how to actually address concerning behaviors.”
Clinical experts from across the country who specialize in chronic pain and opioid prescribing completed each of four rounds of the online study. Forty-two experts participated in the first round, and their responses were grouped thematically to identify six common challenging and concerning behaviors:
• Missing appointments
• Taking opioids for symptoms other than pain
• Using more opioid medication than prescribed
• Demanding or repeatedly asking for an increase in opioid dose
• Behaving aggressively toward provider or staff
• Using alcohol and other substances, including cocaine, methamphetamine, benzodiazepines and heroin
Of the experts who completed round one, 33 participants (79 percent) completed round two, which identified the management strategies they would use for each of the behaviors. Strategies that were consistent across behaviors included assessing risk and safety concerns, identifying pain symptoms, discussing the pros and cons of the behavior with the patient and providing patient education.
In the third round, thirty experts (71 percent of first round participants) were presented with the behaviors and corresponding management strategies. They rated each management strategy in terms of its importance to patient care. Of those who completed round three, 28 (93 percent) completed the final round, which used clinical scenarios to help participants generate consensus around the importance of management strategies where there was disagreement in the prior round.
Participants agreed that reducing or discontinuing the use of opioids should be a secondary step, taken only after the physician and patient had the chance to implement less drastic strategies. Merlin noted that this finding contradicts many of today’s clinical practices, which often see providers reducing or stopping opioid therapy as a first step in response to governmental policies and licensure concerns.
Referral to other pharmacologic and non-pharmacologic therapies also were agreed upon as possible management options, but access to these treatments may be limited based on availability. Access to addiction services may be limited as well, and referral to these services was not indicated as a strategy for many of the concerning behaviors outside of additional substance use.
“This study is a step in the right direction toward providing guidance for managing difficult behaviors in patients being treated with opioids for chronic pain,” said Merlin. “Additional research is needed to determine how these recommendations might be implemented in clinical practice and to understand the impact on patient outcomes.” 
Jane Liebschutz, M.D., M.P.H., division chief, Pitt School of Medicine Department of General Internal Medicine, was this study’s senior author. Merlin is funded by a K23 career development award from the National Institutes of Health. A full list of coauthors and their institutional affiliations is available in the online publication.

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