Table 2.
Delphi Round 3 Results: Management Strategies for the Most Common and Challenging Concerning Behaviors in Patients on Long-Term Opioid Therapy
| Behavior | Management strategy | Median |
|---|---|---|
| Strategies found to be “important” (recommend) | ||
| Behavior 1: Missing appointment | Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | 9 |
| Review opioid treatment agreement with the patient | 9 | |
| Require appointment attendance if opioids are to be continued | 9 | |
| Give patient at least one chance to change behavior | 8 | |
| Behavior 2: Taking opioids for symptoms other than pain (e.g., anxiety, depression, sleep, or to produce euphoria) | Discuss or refer for non-opioid therapies (non-opioid pharmacologic therapies, non-opioid non-pharmacologic therapies) | 9 |
| Make a referral (e.g., to a psychologist, psychiatrist, or to an addiction treatment program) | 8.5 | |
| Behavior 3: Using more opioid medication than prescribed (e.g., unsanctioned dose escalation, early refill requests, running out of medication early) | Determine whether pattern of behavior is present | 9 |
| Review opioid treatment agreement | 8 | |
| Order urine toxicology test that day | ||
| Order urine toxicology tests more frequently | 7 | |
| Provide prescriptions in shorter intervals | 8 | |
| Discuss or refer for non-opioid therapies (e.g., non-opioid pharmacologic therapies, non-opioid non-pharmacologic therapies) | 8 | |
| Discuss or assess for a substance use disorder | 8.5 | |
| Individualize my response to the patient’s behavior | 9 | |
| Behavior 4: Asking for increase in opioid dose (e.g., demanding, repeatedly asking, or asking in the absence of a clinical change in pain) | Avoid dose escalation | 7 |
| Discuss or refer for non-opioid therapies (e.g., non-opioid pharmacologic therapies, non-opioid non-pharmacologic therapies) | 9 | |
| Make a referral to a pain specialist | 7 | |
| Behavior 5: Aggressive behavior towards provider or staff (e.g., outbursts of anger, rude or demanding behavior, threats towards staff) | Listen to patient’s concerns | 9 |
| Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | 9 | |
| Ask for third party to be present (e.g., clinic manager, nurse, social worker) | 7 | |
| Let patient know that behavior will not be tolerated | 9 | |
| Behavior 6: Substance use—alcohol | Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | 9 |
| Discuss or assess for a substance use disorder | 9 | |
| Refer to addiction treatment or related services | 9 | |
| Review opioid treatment agreement with the patient | 8.5 | |
| Order urine toxicology tests more frequently | 8 | |
| Behavior 6: Substance use—methamphetamine | Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | 9 |
| Discuss or assess for a substance use disorder | 9 | |
| Refer to addiction treatment or related services | 9 | |
| Review opioid treatment agreement with the patient | 9 | |
| Order urine toxicology tests more frequently | 9 | |
| Taper opioids | 7 | |
| Behavior 6: Substance use—cocaine | Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | 9 |
| Discuss or assess for a substance use disorder | 9 | |
| Refer to addiction treatment or related services | 9 | |
| Review opioid treatment agreement with the patient | 9 | |
| Order urine toxicology tests more frequently | 9 | |
| Behavior 6: Substance use—benzodiazepine | Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | 9 |
| Discuss or assess for a substance use disorder | 9 | |
| Refer to addiction treatment or related services | 7.5 | |
| Review opioid treatment agreement with the patient | 9 | |
| Order urine toxicology tests more frequently | 9 | |
| Behavior 6: Substance use—heroin | Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | 9 |
| Discuss or assess for a substance use disorder | 9 | |
| Consider pharmacotherapy for opioid use disorder (buprenorphine, methadone) | 9 | |
| Refer to addiction treatment or related services | 9 | |
| Review opioid treatment agreement with the patient | 9 | |
| Order urine toxicology tests more frequently | 9 | |
| Taper opioids | 8 | |
| Strategies found to be of “uncertain” importance (consider) | ||
| Behavior 1: Missing appointments | Taper opioids | 6 |
| Behavior 2: Taking opioids for symptoms other than pain (e.g., anxiety, depression, sleep, or to produce euphoria) | Taper opioids | 6 |
| Behavior 3: Using more opioid medication than prescribed (e.g., unsanctioned dose escalation, early refill requests, running out of medication early) | Utilize pill counts | 6 |
| Make a referral to addiction treatment | 5.5 | |
| Make a referral to a pain specialist | 5 | |
| Deny early refill request, even on first ask | 5 | |
| Taper opioids | 5 | |
| Behavior 4: Asking for increase in opioid dose (e.g., demanding, repeatedly asking, or asking in the absence of a clinical change in pain) | Increase dose if reasonable (including time-limited trial of dose increase) | 5 |
| Make a referral to addiction treatment services | 5 | |
| Behavior 5: Aggressive behavior towards provider or staff (e.g., outbursts of anger, rude or demanding behavior, threats towards staff) | Call security | 6 |
| Taper opioids | 6 | |
| Stop opioids immediately (no additional prescriptions) | 5 | |
| Discharge patient from the practice | 5 | |
| Behavior 6: Substance use—alcohol | Taper opioids | 6.5 |
| Alcohol: Stop opioid therapy immediately (no additional prescriptions | 6.5 | |
| Behavior 6: Substance use—methamphetamine | Stop opioid therapy immediately (no additional prescriptions) | 5 |
| Behavior 6: Substance use—cocaine | Taper opioids | 6 |
| Behavior 6: Substance use—benzodiazepine | Taper opioids | 6 |
| Stop opioid therapy immediately (no additional prescriptions) | 5 | |
| Behavior 6: Substance use—alcohol | Taper opioids | 6.5 |
| Alcohol: Stop opioid therapy immediately (no additional prescriptions | 6.5 | |
| Strategies found to be “not important” (not recommended) | ||
| Behavior 1: Missing appointments | Stop opioid therapy immediately (no additional prescriptions) | 3 |
| Behavior 2: Taking opioids for symptoms other than pain (e.g., anxiety, depression, sleep, or to produce euphoria) | Stop opioids immediately (no additional prescriptions) | 3 |
| Behavior 3: Using more opioid medication than prescribed (e.g., unsanctioned dose escalation, early refill requests, running out of medication early) | Stop opioids immediately (no additional prescriptions) | 3 |
| Strategies for which there was disagreement | ||
| Behavior 6: Substance use—cocaine | Cocaine: Stop opioid therapy immediately (no additional prescriptions) | N/A |