A new study published in the Journal of General Internal Medicine, reported that expert consensus about treatment approaches should be implemented to manage challenging and concerning behaviours such as using more opioid medication than prescribed or concomitant alcohol or drug use

Dr Jessica S. Merlin, the investigator said: “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.”

The guidelines provide recommendations for monitoring patients with chronic pain on long-term opioid therapy, such as frequent visits and urine drug screening. However, provide little guidance on how to actually address concerning behaviours.

Clinical experts from across the country completed each of four rounds of the online study. In the first round, experts identified six common challenging and concerning behaviours.

Missing appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, demanding for an increase in opioid dose, behaving aggressively toward provider or staff, using alcohol and other substances (cocaine, methamphetamine, benzodiazepines and heroin) were the behaviours.

In second round, the experts identified the management strategies that would use for each of the behaviours. Strategies that were consistent across behaviours included assessing risk and safety concerns, identifying pain symptoms, discussing the pros and cons of the behaviour with the patient and providing patient education.

In the third round, thirty experts were presented with the behaviours and corresponding management strategies. Twenty eight experts 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. The 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 was also 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 behaviours outside of additional substance use.

The study provides guidance to manage behaviours in patients who are receiving opioids for the treatment of chronic pain. Further studies are required to determine how the recommendations could be implemented in clinical practice and to understand the effect on patient outcomes, Dr Merlin concluded.