Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study

Jessica S. Merlin, Sarah R. Young, Joanna L. Starrels, Soraya Azari, E. Jennifer Edelman, Jamie Pomeranz, Payel Roy, Shalini Saini, William C. Becker, Jane M. Liebschutz

Current guideline-recommended monitoring of patients prescribed long-term opioid therapy (LTOT) for chronic pain will likely result in increased identification of behaviors of concern for misuse and addiction, but there is a dearth of empiric evidence about how these behaviors should be managed. To establish expert consensus about treatment approaches for common and challenging concerning behaviors that arise among patients on LTOT. We used a Delphi approach, which allows for generation of consensus. Participants were clinical experts in chronic pain and opioid prescribing recruited from professional societies and other expert groups. The Delphi process was conducted online, and consisted of an initial brainstorming round to identify common and challenging behaviors, a second round to identify management strategies for each behavior, and two rounds to establish consensus and explore disagreement/uncertainty. Forty-two participants completed round 1, 22 completed round 2, 30 completed round 3, and 28 completed round 4. Half of round 1 participants were female (52%), and the majority were white (83%). Most (71%) were physicians, and most participants practiced in academic primary (40%) or specialty care (19%).The most frequently cited common and challenging behaviors were 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 use. Across behaviors, participants agreed that patient education and information gathering were important approaches. Participants also agreed that stopping opioids is not important initially, but if initial approaches do not work, tapering opioids and stopping opioids immediately may become important approaches. This study presents clinical expert consensus on how to manage concerning behaviors among patients on LTOT. Future research is needed to investigate how implementing these management strategies would impact patient outcomes, practice and policy.