Dealing with Angry or Threatening Patients on Chronic Opioids

Patients on chronic opioid therapy may sometimes exhibit angry, aggressive, or threatening behavior. Such behaviors can arise for various reasons, including frustration over pain management, dissatisfaction with their treatment plan, or substance-related issues. Dealing with these behaviors requires a thoughtful, structured approach to maintain safety, preserve the therapeutic relationship, and address the underlying causes of aggression.

Below is an algorithm, derived from a Delphi study by a panel of experts, which outlines recommended actions, non-recommended actions, and considerations for clinicians when managing patients who exhibit aggressive or threatening behavior.

Key Principles for Managing Angry or Threatening Patients

  1. Prioritize Safety: The safety of the healthcare provider and staff should always be the top priority. If a patient’s behavior escalates, appropriate steps should be taken to de-escalate the situation, which may include involving security or law enforcement if necessary.
  2. Maintain Professionalism: Stay calm, composed, and professional during interactions with angry or threatening patients. Avoid reacting emotionally or defensively.
  3. Assess the Cause of Aggression: Understand that aggressive behavior may be linked to pain, frustration with treatment, or other underlying issues, such as anxiety, depression, or substance use disorder.
  4. Clear Communication: Effective communication is essential in de-escalating potentially volatile situations. Ensuring that the patient understands the reasons behind treatment decisions can help alleviate frustration.

Algorithm for Managing Angry or Threatening Patients on Opioids

Recommended Actions:

  1. Stay Calm and Professional:
    • Maintain a calm demeanor. Speak in a low, steady voice.
    • Avoid escalating the situation by staying defensive or argumentative.
  2. Listen Actively:
    • Allow the patient to express their concerns without interruption. Active listening can help defuse anger and provide insight into the root cause of the behavior.
    • Acknowledge the patient’s frustrations. Phrases like, “I understand that you’re upset, and I want to help you,” can be calming.
  3. De-escalate the Situation:
    • Use de-escalation techniques such as validating the patient’s emotions (“I can see you’re really upset, and I want to find a solution together”).
    • Encourage the patient to take a few deep breaths or take a break from the situation if needed.
  4. Set Clear Boundaries:
    • Clearly state that threatening or abusive behavior is unacceptable. Let the patient know the consequences if the behavior continues (e.g., leaving the appointment, involving security).
    • Be firm but respectful in communicating that the treatment cannot continue if the behavior does not improve.
  5. Offer Solutions and Alternatives:
    • If the patient is upset about their opioid regimen or pain management plan, work with them to explore alternative treatment options.
    • Offer other forms of pain management or provide resources for pain management support (e.g., physical therapy, mental health referrals, addiction counseling).
  6. Document the Interaction:
    • Document all interactions with the patient, particularly if they exhibit threatening or aggressive behavior. This documentation should include the patient’s behavior, your response, and any steps taken to address the situation.
  7. Involve a Colleague or Specialist:
    • If the situation cannot be resolved, consider involving a colleague or a mental health professional for further assistance.
    • Referral to a pain management or addiction specialist may be necessary if opioid misuse or dependence is suspected.

Not Recommended Actions:

  1. Engage in Escalatory Behavior:
    • Avoid responding with anger, sarcasm, or defensiveness. Engaging in a power struggle can escalate the situation and damage the therapeutic relationship.
  2. Discontinue Opioids Immediately:
    • Abruptly stopping opioids or terminating the doctor-patient relationship without proper communication may increase the risk of withdrawal, and the patient may become more frustrated or hostile.
    • Immediate opioid discontinuation should only be considered if there is clear evidence of misuse, diversion, or other safety concerns, and even then, it should be done in a carefully planned manner.
  3. Ignore the Behavior:
    • Ignoring aggressive or threatening behavior can be perceived as tacit approval and may worsen the situation.
    • Not addressing the behavior promptly can lead to further escalation and make it harder to regain control of the situation.
  4. Threaten Legal Action Immediately:
    • Although legal action may sometimes be warranted (e.g., when diversion or illegal activity is involved), threatening it immediately without understanding the full context can be confrontational and unproductive.

Considerations:

  1. Evaluate Underlying Factors:
    • Determine whether the aggression is related to issues such as pain, opioid misuse, or underlying psychological conditions. For example, withdrawal symptoms from opioids or untreated mental health disorders like anxiety or depression may contribute to irritability or aggression.
  2. Consider Referral to Mental Health Services:
    • If the aggressive behavior is linked to psychological factors, consider referring the patient to mental health professionals for further evaluation and treatment. Cognitive-behavioral therapy (CBT) or counseling may help patients develop coping mechanisms for managing pain and stress.
  3. Opioid Use Disorder (OUD) Screening:
    • If opioid misuse or addiction is suspected, use screening tools (such as the Opioid Risk Tool or SOAPP) to assess the patient’s risk for substance use disorder and consider referring them to a specialist for addiction treatment.
    • Consider discussing alternative treatments for pain management with the patient, including non-opioid medications or non-pharmacologic therapies.

Key Takeaways

  • The goal when managing angry or threatening patients is to maintain a calm, professional demeanor while focusing on understanding the cause of the behavior.
  • Safety is paramount, and escalating behavior should be addressed with de-escalation techniques and clear boundaries.
  • Aggression should be met with empathy and a willingness to find solutions, but discontinuation of opioid therapy should not be an immediate or reflexive response unless there is clear evidence of diversion or misuse.
  • In cases where non-compliance, opioid misuse, or mental health issues are contributing to the behavior, consider referrals to specialists and work with the patient to find alternative pain management strategies.

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.

By using these structured guidelines, healthcare providers can manage difficult patient interactions with compassion and professionalism, ensuring that patients receive the care and support they need while maintaining a safe and therapeutic environment.

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