Table 3.
Delphi Round 4 Results: Management Strategies for the Most Common and Challenging Concerning Behaviors in Patients on Long-Term Opioid Therapy
| Scenario | Case | Strategy | Consensus or disagreement? | Median |
|---|---|---|---|---|
| Behavior 1: Missing appointments You are seeing a patient in clinic with the following behavior: Missing appointments. In the previous round, participants agreed that the following management strategies are an important response to this behavior: • Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records). • Review opioid treatment agreement with the patient • Require appointment attendance if opioids are to be continued • Give patient at least one chance to change behavior Now imagine that you have implemented all of the above strategies while continuing to prescribe opioids. Please consider the following case: |
Case 1. You continue to use these strategies for a reasonable period of time and the patient continues to miss appointments. Given this information: | Taper opioids | C | 7 |
| Behavior 2: Taking opioids for symptoms other than pain (e.g., anxiety, depression, sleep, or to produce euphoria) You are seeing a patient in clinic with the following behavior: Taking opioids for symptoms other than pain (e.g., for anxiety, depression, sleep, or to produce euphoria). In the previous round, participants agreed that the following management strategies are an important response to this behavior: • Discuss or refer for non-opioid therapies (e.g., non-opioid pharmacologic therapies, non-opioid non-pharmacologic therapies) • Make a referral (e.g., to a psychologist, psychiatrist, or to addiction treatment program) Now please imagine that you have implemented these strategies. Please consider the following case: |
Case 1. You continue to use the above strategies for a reasonable period of time and the patient continues to take opioids for symptoms other than pain. Given this information: | Taper opioids | C | 8 |
| Stop opioid therapy immediately (no additional prescriptions) | C | 4 | ||
| Behavior 3: Using more opioid medication than prescribed (e.g., unsanctioned dose escalation, early refill requests, running out of medication early) You are seeing a patient in clinic with the following behavior: Using more opioid medication than prescribed (e.g., unsanctioned dose escalation, early refill requests, running out of medication early). In the previous round, participants agreed that the following management strategies are an important response to this behavior: • Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) • Review opioid treatment agreement with the patient. • Order urine toxicology tests that day • Order urine toxicology tests more frequently • Provide prescriptions at shorter intervals (e.g., 2-week supply) • Discuss or refer for non-opioid therapies (non-opioid pharmacologic therapies, non-opioid non-pharmacologic therapies) • Discuss or assess for a substance use disorder • Individualize my response to the patient’s behavior Now imagine that you have implemented all of these strategies. Please consider the following cases: |
Case 1. You assess the patient. You determine that a pattern of concerning behavior HAS NOT been present, and there is NO CLEAR BASIS for a diagnosis of opioid use disorder. Given this information: | Utilize pill counts | C | 5 |
| Make a referral to addiction treatment | C | 2 | ||
| Make a referral to a pain specialist | C | 6 | ||
| Deny early refill, even on first ask | C | 6 | ||
| Taper opioids | C | 4 | ||
| Case 2. You assess the patient. You determine that a pattern of concerning behavior HAS been present but there is NO CLEAR BASIS for a diagnosis of opioid use disorder. Given this information: | Utilize pill counts | C | 6 | |
| Make a referral to addiction treatment | C | 5 | ||
| Make a referral to a pain specialist | C | 6 | ||
| Deny early refill, even on first ask | C | 8 | ||
| Taper opioids | C | 5 | ||
| Case 3. You assess the patient. You determine that a pattern of concerning behavior HAS been present, and YOU STRONGLY SUSPECT a diagnosis of opioid use disorder. Given this information: | Utilize pill counts | C | 7 | |
| Make a referral to addiction treatment | C | 9 | ||
| Make a referral to a pain specialist | C | 7 | ||
| Deny early refill, even on first ask | C | 9 | ||
| Taper opioids | C | 7 | ||
| Behavior 4: Asking for increase in opioid dose (e.g., demanding, repeatedly asking, or asking in the absence of a clinical change in pain) You are seeing a patient in clinic with the following behavior: Asking for increase in opioid dose (e.g., demanding or repeatedly asking). In the previous round, participants agreed that the following management strategies are an important response to this behavior: • Discuss or refer for non-opioid therapies (e.g., non-opioid pharmacologic therapies, non-opioid non-pharmacologic therapies) • Make a referral to a pain specialist Now imagine that you have implemented all of the above strategies. Please consider the following cases: |
Case 1. The patient is on a dose of opioids equivalent to less than 50 mg of morphine per day. | Increase dose if reasonable (including time-limited trial of dose increase) | C | 5 |
| Case 2: The patient is on a dose of opioids equivalent to 50–100 mg of morphine per day. | Increase dose if reasonable (including time-limited trial of dose increase) | C | 4.5 | |
| Case 3. The patient is on a dose of opioids equivalent to greater than 100 mg of morphine per day. | Increase dose if reasonable (including time-limited trial of dose increase) | C | 2 | |
| Behavior 5 (now divided into two behaviors): Verbally aggressive behavior where there is no concern for provider or staff safety (e.g., outbursts of anger, rude or demanding behavior towards providers or staff) | N/A | Listen to patient’s concerns | C | 8 |
| Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | C | 8 | ||
| Ask for third party to be present (e.g., clinic manager, nurse, social worker) | C | 7 | ||
| Call security | C | 5 | ||
| Taper opioids | C | 5 | ||
| Stop opioids immediately (no additional prescriptions) | C | 2.5 | ||
| Let patient know that their behavior will not be tolerated | C | 9 | ||
| Discharge patient from the practice | C | 2.5 | ||
| Behavior 5 (now divided into two behaviors): Aggressive behavior where there is concern for provider or staff safety (e.g., threats towards staff) | N/A | Listen to patient’s concerns | C | 6.5 |
| Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) | C | 9 | ||
| Ask for third party to be present (e.g., clinic manager, nurse, social worker) | C | 9 | ||
| Call security | C | 9 | ||
| Taper opioids | C | 8 | ||
| Stop opioids immediately (no additional prescriptions) | C | 8 | ||
| Let patient know that their behavior will not be tolerated | C | 9 | ||
| Discharge patient from the practice | C | 6.5 | ||
| Behavior 6: Substance use—cocaine Cocaine use with urine drug screen repeatedly negative for prescribed opioids |
N/A | Stop therapy immediately | C | 8.5 |
| Behavior 6: Substance use—alcohol You are seeing a patient in clinic with the following behavior: Alcohol use. In the previous round, participants agreed that the following management strategies are an important response to this behavior: • Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) • Discuss or assess for a substance use disorder • Refer for addiction treatment or related services • Review opioid treatment agreement with the patient • Order urine toxicology tests more frequently Now imagine that you have implemented all of these strategies. Please consider the following cases: |
Case 1. You assess the patient. You determine that a pattern of at risk alcohol use HAS NOT been present, and there is NO CLEAR BASIS for a diagnosis of alcohol use disorder. Given this information: | Taper opioids | C | 3 |
| Stop opioid therapy immediately (no additional prescriptions) | C | 2 | ||
| Case 2. You assess the patient. You determine that a pattern of at risk alcohol use HAS been present, but there is NO CLEAR BASIS for a diagnosis of alcohol use disorder. Given this information: | Taper opioids | C | 6 | |
| Stop opioid therapy immediately (no additional prescriptions) | C | 3 | ||
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | C | 2.5 | ||
| Case 3. You assess the patient. You determine that a pattern of at risk alcohol use HAS been present, and YOU STRONGLY SUSPECT a diagnosis of alcohol use disorder. Given this information: | Taper opioids | C | 8 | |
| Stop opioid therapy immediately (no additional prescriptions) | D | N/A | ||
| Behavior 6: Substance use—methamphetamine You are seeing a patient in clinic with the following behavior: Methamphetamine use. In the previous round, participants agreed that the following management strategies are an important response to this behavior: • Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) • Discuss or assess for a substance use disorder • Refer for addiction treatment or related services • Review opioid treatment agreement with the patient • Order urine toxicology tests more frequently Now imagine that you have implemented all of the above strategies. Please consider the following cases: |
Case 1. You assess the patient. You determine that a pattern of repeated methamphetamine use HAS NOT been present, and there is NO CLEAR BASIS for a diagnosis of methamphetamine use disorder. Given this information: | Taper opioids | C | 5 |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | C | 3.5 | ||
| Stop opioid therapy | C | 3.5 | ||
| Case 2. You assess the patient. You determine that a pattern of repeated methamphetamine use HAS been present, but there is NO CLEAR BASIS for a diagnosis of methamphetamine use disorder. Given this information: | Taper opioids | C | 7.5 | |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | C | 5 | ||
| Stop opioid therapy immediately (no additional prescriptions) | C | 5 | ||
| Case 3. You assess the patient. You determine that a pattern of repeated methamphetamine use HAS been present, and YOU STRONGLY SUSPECT a diagnosis of methamphetamine use disorder. Given this information: | Taper opioids | C | 8 | |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | D | N/A | ||
| Stop opioid therapy immediately (no additional prescriptions) | C | 6 | ||
| Behavior 6: Substance use—cocaine You are seeing a patient in clinic with the following behavior: Cocaine use. In the previous round, participants agreed that the following management strategies are an important response to this behavior: • Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) • Discuss or assess for a substance use disorder • Refer for addiction treatment or related services • Review opioid treatment agreement with the patient • Order urine toxicology tests more frequently Now imagine that you have implemented all of the above strategies. Please consider the following cases: |
Case 1. You assess the patient. You determine that a pattern of repeated cocaine use HAS NOT been present, and there is NO CLEAR BASIS for a diagnosis of cocaine use disorder. Given this information: Please rate the importance of the following management strategy: | Taper opioids | C | 4.5 |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | C | 2.5 | ||
| Stop opioid therapy | C | 3 | ||
| Case 2. You assess the patient. You determine that a pattern of repeated cocaine use HAS been present but there is NO CLEAR BASIS for a diagnosis of cocaine use disorder. Given this information: | Taper opioids | C | 7 | |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | C | 5 | ||
| Stop opioid therapy | C | 5 | ||
| Case 3. You assess the patient. You determine that a pattern of repeated cocaine use HAS been present, and YOU STRONGLY SUSPECT a diagnosis of cocaine use disorder. Given this information: | Taper opioids | C | 8 | |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | D | N/A | ||
| Stop opioid therapy | C | 6 | ||
| Behavior 6: Substance use—benzodiazepine You are seeing a patient in clinic with the following behavior: Benzodiazepine use (illicit use or non-medical use of prescription benzodiazepine). In the previous round, participants agreed that the following management strategies are an important response to this behavior: • Determine whether a pattern of behavior has been present (e.g., by talking to the patient or reviewing records) • Discuss or assess for a substance use disorder • Refer for addiction treatment or related services • Review opioid treatment agreement with the patient • Order urine toxicology tests more frequently Now imagine that you have implemented all of the above strategies. Please consider the following cases: |
Case 1. You assess the patient. You determine that a pattern of repeated benzodiazepine use HAS NOT been present, and there is NO CLEAR BASIS for a diagnosis of benzodiazepine use disorder. Given this information: | Taper opioids | C | 5 |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | C | 2 | ||
| Stop opioid therapy | C | 2.5 | ||
| Case 2. You assess the patient. You determine that a pattern of repeated benzodiazepine use HAS been present, but there is NO CLEAR BASIS for a diagnosis of benzodiazepine use disorder. Given this information: | Taper opioids | C | 7 | |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | C | 2 | ||
| Stop opioid therapy | C | 4 | ||
| Case 3. You assess the patient. You determine that a pattern of repeated benzodiazepine use HAS been present, and YOU STRONGLY SUSPECT a diagnosis of benzodiazepine use disorder. Given this information: | Taper opioids | C | 8 | |
| Switch patient to buprenorphine/naloxone if you have a waiver to prescribe this medication, or refer patient to someone who does | D | N/A | ||
| Stop opioid therapy | D | N/A |