Managing Red Flag Behaviors for Opioid Use in Patients with Chronic Pain

With Jessica S. Merlin, MD, MBA

A panel of clinical experts sought consensus on best practices for addressing red flag behaviors in patients who are on long-term opioid therapy (LTOT),¹ and shared their findings in the Journal of General Internal Medicine. Using the Delphi method, the panel completed four rounds of surveys about handling concerning behaviors. The process yielded areas of agreement and hesitation in both identifying and addressing behaviors of concern for patients who are receiving LTOT for chronic pain.

Managing concerning behaviors in LTOT patients is among the most difficult challenges facing pain practitioners, said Jessica S. Merlin, MD, MBA, visiting associate professor of medicine at University of Pittsburgh School of Medicine in Pennsylvania. Dr. Merlin, who directs a chronic pain clinic embedded within an HIV patient-centered medical home at the University of Pittsburgh, was lead author of the study while at the University of Alabama at Birmingham.

She and her co-authors initiated the study because they see so many divergent clinical practices in the real world·¹

First-Line Pain Treatment Challenges

“One of the reasons I was so excited to do this study is that I do a lot of speaking nationally to groups of primary care providers about chronic pain management,” Dr. Merlin told Practical Pain Management, “I talk about pain strategies and the appropriateness of opioids and how to monitor and all these types of things, and really what they want to know is, but when there's a problem, when I have a patient who has one of the opioid addictive behaviors, or when I have a patient who won't show up for their appointments, or a patient who has a urine positive for cocaine, or a patient who has a pattern of prescription problems, or whatever it is, what do I do?"

Practice environments differ significantly, from individual providers to members of group practices with varying approaches. “Oftentimes what we see happening in the real world is that a patient, for example, has a urine screen positive for cocaine, then their opioids are stopped. Or a patient is told, "Our practice is not prescribing opioids anymore,” said Dr. Merlin. By contrast, the Delphi panel experts were more apt to respond with intermediate steps before possibly weaning the patient off opioids.

The Delphi process, used to forecast the responses from the questionnaires, was conducted with a panel comprising members of the American Academy of Pain Medicine, the Society of General Internal Medicine, and the Department of Veterans Affairs.¹ All panel members were currently delivering patient care in an ambulatory setting to adults under treatment for chronic pain and have expertise in prescribing on LTOT opioids to manage chronic pain conditions.

The responses to the questionnaires resulted in a set of management strategies that experts likely would advocate for, said Dr. Merlin, “yet, maybe a little bit different than what frontline providers may actually be doing.”

Experts advocate Ground Rules for Opioid Prescribing

The most commonly seen challenges for pain practitioners were patients who:¹

• Request early refills on their opioid prescription

• Run out of medication early

• Appear to be over-using (have an over-reliance on) their opioids

The panel consensus for managing challenging patients was to give any patients exhibiting any of these concerning behaviors an immediate urine toxicology test with regularly schedule repeat testing, shorter-interval prescriptions, and denied early refills.

Practitioners may consider referring these types of patients for non-opioid therapies or to institute monitoring for overuse with techniques such as pill counts. If a pattern of concerning behavior persists practitioners are urged to discuss addiction treatment options with the patient.¹

Another common challenge for pain practitioners is identifying patients who may be suffering from anxiety, depression, or insomnia and may be relying on their opioids to manage these concomitant conditions, not just as prescribed for their pain.²˒³A more in-depth discussion of the co-morbid conditions has been presented in the ongoing mental health series in the Practical Pain Management.

When presented with this situation, panel members agreed that their first approach was usually to consider redirecting patients to non-opioid therapies.¹ Depending on the patients’ needs and receptiveness, practitioners may opt to refer the patient to a psychologist, psychiatrist, a sleep specialist, or an addiction treatment program.

Responding to Common Red Flag Behaviors

A particular red flag was raised regarding patients who consistently or frequently missed appointments. Panel members said they generally attempt to confirm the reasons behind any pattern of absence, explain that appointments are required before a prescription will be renewed, and then offer the patient at least one final chance to correct their behavior.¹ When patients fail to comply with these requirements, the only realistic option would be to taper them off their long-acting opioid treatment.

Other commonly concerning behaviors include patients who:¹

• Demand increased doses (without corresponding pain)

• Behave aggressively, using an angry, rude, or threatening manner

• Signs of substance abuse, such as to alcohol, methamphetamines, cocaine, benzodiazepines, or heroin

There was general agreement among panel members that stopping opioids cold would not be their first response to any of the red flag behaviors. Instead, they favored a systematic, patient-centered process that included information-gathering, more frequent monitoring, a concerted effort at patient education, and a pointed review of the opioid treatment agreement.¹

“Only then, once all that additional information has been gathered, and those additional things have been done to help support the patient, only then did management strategies like tapering and stopping opioids come into play,” said Dr. Merlin, “It must be approached as a much more nuanced process.”

Directed Referrals Offer Value to Patient and Practitioner

The authors noted a dearth of support for more problematic cases, especially in cases of substance abuse, in which non-opioid and complementary therapies may be appropriate and efficacious options for referral.¹

“We still need specialists to care for patients who are too challenging to manage, particularly in the primary care setting,” said Dr. Merlin. For example, “In a lot of practice environments, it can be really important but challenging [for patients] to find an addiction specialist.”

“Cognitive Behavioral Therapy (CBT) and chronic pain management programs are really some of the most efficacious and lowest risk interventions for chronic pain,” Dr. Merlin said. These programs generally include mindfulness, coping skills, and other therapeutic components.

Growing research also presents promise for the benefits of pain relief with physical therapy and acupuncture.⁴˒⁵ “So there are lots of other modalities that practitioners may direct patients to for their pain,” beyond LTOT, she said.

“The way our healthcare payment system, in general, is set up is such that it's really easy to write a prescription for an opioid or another medication,” said Dr. Merlin. “That's something that we get reimbursed for and that patients generally have access to, but these other things may not be paid for, or there may not be somebody [accessible] who does cognitive behavioral therapy for example, let alone CBT for chronic pain.”

Dr. Merlin noted that locations vary in available resources. For example, when she practiced in Alabama, “we almost couldn't get access to acupuncture at all. It's very expensive when you do have access to it, and most insurance doesn't cover it.”

In her ideal scenario, all treatment modalities would be integrated seamlessly "so the physician and the physical therapist, psychologist, etc. all approach the patient together and know what the other is doing. But these types of environments are not really reimbursed by insurance and some people don't have access to that and it's a real shame.”

Turning the Delphi Findings into Tested Best Practices

While the Delphi method yielded insights into how pain management experts currently approach opioid prescribing challenges, the research into behaviors that drive pain treatment really has just begun, said Dr. Merlin, “These are consensus approaches, but they're not rules.”

The next step would be to test the consensus strategies in primary care settings, according to Dr. Merlin.

“For example, if primary care providers do employ these strategies, it would be beneficial to know how easy were they to implement? In the absence of an addiction specialist or lack of availability of non-opioid therapies, such as CBT, how easy is it, how feasible is it for providers to incorporate these [clinical best practices]? And what impact might they have on things like pain control?” said Dr. Merlin, “Ultimately, that is really going to be an important next step for us.”

Funding for the study was support by career development awards from the National Institute of Mental Health and the National Institute on Drug Abuse received research support from the Opioid Post-Marketing Requirements Consortium but no other authors had any conflicts of interest to disclose.