According to an expert consensus recently published in the Journal of General Internal Medicine, patient education and information gathering were considered important initial approaches to managing concerning behaviors such as missing appointments or taking more opioid medication than prescribed. If initial approaches did not work, experts recommended tapering or stopping opioids.

Researchers used the Delphi process to establish expert consensus on management approaches for common and challenging concerning behaviors in patients receiving long-term opioid therapy. Clinical experts in chronic pain and opioid prescribing participated in the study.

After an initial brainstorming round gathering 42 experts and aimed at identifying concerning behaviors, 22 experts participated in a second round that sought to establish management strategies. Another 2 rounds with 30 and 28 participants, respectively, were organized to establish consensus and explore disagreement and uncertainty.

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The most common and challenging concerning behaviors identified by participants included missing appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, asking for an increase in opioid dose, aggressive behavior, and alcohol and other substance abuse.

For the most concerning behaviors, a consensus was reached among participants that patient education and information gathering should be important initial steps. For example, for missed appointments, participants agreed that clinicians should determine whether a pattern of behavior is present, review the opioid treatment agreement with patients, and require appointment attendance if opioids are to be continued.

For cocaine use, participants achieved consensus that stopping opioids immediately was important if a urine drug screen was repeatedly negative for opioids, suggesting that the patient was not taking the medication.

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The study investigators explained that the results “are an important first step in a new program of research that could provide clinical guidance in managing concerning behaviors among patients on [long-term opioid therapy] for chronic pain.”

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Merlin JS, Young SR, Starrels JL, et al. Managing concerning behaviors in patients prescribed opioids for chronic pain: A Delphi study [published online December 4, 2017]. J Gen Intern Med. doi:10.1007/s11606-017-4211-y