Journal of General Internal Medicine

, Volume 33, Issue 2, pp 166–176 | Cite as

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
Original Research



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.

Main Measures

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.

Key Results

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.



The authors wish to acknowledge the following study participants, who completed all four Delphi rounds and have given permission for us to publish their names (alphabetically):

Osvaldo Acosta-Rodriguez

J. Mark Bailey

Geetanjali Chander

Phoebe Cushman

Mark Eisenberg

Janette Elliott

Joseph Frank

Shannon Gully

Jared Klein

Erin Krebs

Marc LaRochelle

Hilary Moshe.

Daniel Pomerantz

Ilene Robeck

Daniel Tobin


Three authors were supported by NIH career development awards awarded by the National Institute of Mental Health (K23MH104073 [JSM]) and the National Institute on Drug Abuse (K23DA027719 [JLS] and K12DA033312 [EJE]).

Compliance with Ethical Standards

Conflict of Interest

JLS receives research support from the Opioid Post-Marketing Requirements Consortium, via subcontract with the Clinical Directors Network. The remaining authors declare that they have no conflict of interest.

Supplementary material

11606_2017_4211_MOESM1_ESM.pdf (331 kb)
ESM 1 (PDF 330 kb)


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Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Jessica S. Merlin
    • 1
    • 2
  • Sarah R. Young
    • 1
    • 3
  • Joanna L. Starrels
    • 4
  • Soraya Azari
    • 5
  • E. Jennifer Edelman
    • 6
  • Jamie Pomeranz
    • 7
  • Payel Roy
    • 8
  • Shalini Saini
    • 9
  • William C. Becker
    • 6
    • 10
  • Jane M. Liebschutz
    • 8
  1. 1.Division of Infectious DiseasesUniversity of Alabama at BirminghamBirminghamUSA
  2. 2.Division of Gerontology, Geriatrics, and Palliative CareUniversity of Alabama at BirminghamBirminghamUSA
  3. 3.Department of Social Work, College of Community and Public AffairsBinghamton UniversityBinghamtonUSA
  4. 4.Division of General Internal MedicineAlbert Einstein College of Medicine and Montefiore Medical CenterBronxUSA
  5. 5.Division of General Internal Medicine, San Francisco General HospitalUniversity of California San FranciscoSan FranciscoUSA
  6. 6.Department of Internal MedicineYale University School of MedicineNew HavenUSA
  7. 7.Department of Occupational TherapyUniversity of FloridaGainesvilleUSA
  8. 8.Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical CenterBoston University School of MedicineBostonUSA
  9. 9.Department of Medicine, Information TechnologyUniversity of Alabama at BirminghamBirminghamUSA
  10. 10.VA Connecticut Healthcare SystemWest HavenUSA

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