Capsule Commentary on Merlin et al., Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study
Merlin et al.1 used a Delphi approach involving health care providers who have some interest or expertise in pain management. The process elicited what they call consensus on appropriate responses to “concerning behaviors” by patients receiving long-term opioid therapy (LTOT) for chronic pain. The rationale is that the CDC guidelines on prescribing opioids for long-term pain, promulgated in 2016,2 are insufficiently specific in this regard.
The CDC guidelines are based on gathering evidence, evaluating its quality, and incorporating expert and stakeholder opinion for interpretation. They find no evidence supporting the effectiveness of opioid therapy for chronic pain, and substantial evidence for harm, including increased risk for opioid abuse or dependence, overdose3 including death,4 and other risks. Ninety-six percent of patients taking opioids for chronic pain have been found to experience side effects.5 Given this unfavorable risk–benefit profile, the guidelines call for frequent reassessment of the balance of benefits and risks for all patients receiving LTOT.
The Delphi process elicited intuitions, not evidence. Indeed, participants were specifically asked to respond in “real time” without doing any “homework.” The definition of consensus tolerated a threshold of disagreement. The “concerning behaviors” of missing appointments and “aggressive behavior” are not specifically mentioned in the CDC guidelines. However, most “concerning behaviors” are adverse events, warning signs for adverse events, and signs of opioid use disorder. The guidelines call for dosage reduction or discontinuation in these circumstances [p. 25]. They are also clear that discontinuation should be by tapering. Merlin et al. conclude that “Tapering or stopping opioids were never considered as a first step, but rather as something to contemplate depending on how the patient responded to other initial steps.” It is not clear that this conclusion is consistent with the CDC guidelines. This study informs us on what a convenience sample of providers would do in certain circumstances, but should not be taken as evidence or guidance for appropriate clinical decision making. Remember that it was the general opinion for more than a decade that LTOT for chronic pain was generally safe and effective.
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Conflict of Interest
The author has no conflict of interest with this material.
- 1.Merlin JS, Young SR, Starrels JL, Azari S, Edelman EJ, Pomeranz J, Roy P, Saini S, Becker WC, Liebschutz JM. Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi study. J Gen Intern Med. https://doi.org/10.1007/s11606-017-4211-y.
- 3.Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 2014;30(7):557–64. https://doi.org/10.1097/AJP.0000000000000021.PubMedPubMedCentralGoogle Scholar