Managing Non-Adherence to Opioid Treatment Plans

Non-adherence to opioid treatment plans can manifest in various ways, including patients taking opioids for symptoms other than pain or missing scheduled appointments with their prescriber. These behaviors may indicate potential misuse, diversion, or other underlying issues. It’s important to address these concerns through structured and careful approaches, rather than immediately discontinuing opioid therapy. Below are the recommended strategies based on a Delphi consensus study conducted by a panel of experts.

Key Principles for Addressing Non-Adherence

  1. Do Not Discontinue Opioid Therapy Immediately:
    • Immediate discontinuation of opioid therapy is not recommended as the first course of action. The goal should be to understand the root causes of the non-adherence and implement appropriate interventions while maintaining the therapeutic relationship.
  2. Individualized Approach:
    • Each patient’s situation should be evaluated individually, taking into account their medical history, behavior, and any contributing factors such as mental health issues, substance use, or social circumstances.

1. When a Patient is Taking Opioids for Symptoms Other than Pain

This situation may indicate misuse or dependence. It is essential to explore the reasons behind the use of opioids for purposes other than managing pain, such as anxiety, insomnia, or self-medication for psychological distress.

Recommended Actions:

  • Evaluate the Underlying Cause: Assess the patient’s reasons for using opioids outside of prescribed parameters. Common reasons include anxiety, depression, or other mood disorders. Understanding the motivation will help guide the treatment plan.
    • Consider Psychological or Psychiatric Evaluation: Refer the patient to a mental health professional to assess for underlying conditions such as anxiety, depression, or opioid use disorder (OUD).
    • Review the Pain Treatment Plan: Reevaluate the adequacy of the pain management plan. Consider adjusting the regimen, switching to alternative pain management strategies (non-opioid options, physical therapy, etc.), or providing adjunctive treatments for co-occurring conditions.
    • Increase Monitoring: Increase the frequency of urine drug screens, pill counts, or checks of the Prescription Drug Monitoring Program (PDMP) to ensure compliance with the prescribed therapy.

Not Recommended Actions:

  • Stop Opioid Therapy Immediately: While non-adherence should be addressed, abrupt discontinuation of opioids can lead to withdrawal symptoms, increased pain, or potential escalation to illicit drug use. Stopping opioids without addressing the underlying causes may harm the patient.
  • Ignore the Issue: Ignoring the patient’s use of opioids for non-pain symptoms could worsen the situation, potentially leading to misuse or overdose.

Consider:

  • Referral to Addiction Services: If misuse or dependence is suspected, it may be appropriate to refer the patient for addiction treatment or to a specialized pain management clinic.
  • Educational Intervention: Provide education about the risks of opioid misuse and the importance of using opioids only as prescribed.
  • Non-Opioid Alternatives: In cases where psychological distress is contributing to opioid use, consider adjunct therapies like cognitive behavioral therapy (CBT), mindfulness, or medications that treat anxiety or depression.

2. When a Patient Misses Appointments with the Opioid Prescriber

Missed appointments can be a red flag indicating issues with treatment adherence, non-compliance, or even an attempt to avoid monitoring or screening. It’s essential to approach this situation with care, as there could be many reasons behind missed appointments.

Recommended Actions:

  • Contact the Patient: Reach out to the patient to discuss the missed appointment. A personal call or letter can help assess the situation and determine if there is a legitimate reason for the missed visit (e.g., transportation issues, work conflicts, health problems).
  • Reevaluate the Treatment Plan: If missed appointments are frequent, reassess the current treatment plan. Consider whether the patient feels that their pain is inadequately managed or if there are other barriers to treatment compliance.
    • Review the Patient’s History: Check the patient’s history of appointments, PDMP records, and any concerns regarding missed doses or unsanctioned use.
    • Clarify the Expectations: Make it clear that adherence to the treatment plan, including regular appointments, is essential for continued opioid therapy. Reinforce the importance of regular visits to monitor for misuse or diversion and to assess treatment efficacy.

Not Recommended Actions:

  • Ignore the Missed Appointment: Allowing missed appointments without addressing the cause may reinforce non-adherence and potentially indicate larger issues with treatment compliance or patient behavior.
  • Discontinue Opioids Immediately: Stopping opioids abruptly due to missed appointments can increase the risk of withdrawal symptoms, patient dissatisfaction, and escalation of pain or substance use.

Consider:

  • Offer Flexible Appointment Scheduling: If the patient has difficulties attending appointments due to logistical reasons (e.g., transportation, work schedule), consider offering telemedicine appointments or more flexible scheduling options.
  • Substitute with Non-Opioid Pain Management: If non-adherence continues and there are concerns about opioid misuse, consider transitioning the patient to non-opioid pain management strategies, including physical therapy, alternative medications, or behavioral health interventions.
  • Referral to a Pain or Addiction Specialist: If missed appointments are a sign of opioid misuse, or the patient is not following the prescribed treatment plan, referral to a pain specialist or addiction services may be necessary.

Summary of Actions for Both Scenarios

In both cases—whether the patient is taking opioids for symptoms other than pain or missing appointments—the approach should be:

  1. Assess the Cause: Understand the underlying reason for the non-adherence, whether it’s related to the pain treatment plan, psychological distress, or potential misuse.
  2. Increase Monitoring: Use more frequent urine drug screens, pill counts, and PDMP checks to ensure the patient is adhering to the prescribed opioid regimen.
  3. Collaborative Decision-Making: Work with the patient to explore solutions, such as adjusting the pain management plan, providing additional support services, or referring them to addiction or pain specialists.
  4. Educate the Patient: Educate the patient about the risks of opioid misuse and the importance of following the prescribed regimen to avoid adverse effects.

Sources:

  • 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 Int Med, 2018 Feb;33(2):166-176.
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