Managing Unsanctioned Dose Increases in Opioid Therapy

Addressing unsanctioned dose increases—whether a patient uses more opioids than prescribed or asks for an increase in their opioid dose—requires a structured approach to ensure patient safety, effective pain management, and minimize the risk of opioid misuse or addiction. These approaches are based on a Delphi consensus study conducted by experts in the field, which outlines evidence-based actions to take when these situations arise.

Key Principles for Addressing Unsanctioned Dose Increases

  1. Stopping Opioid Therapy is NOT the First Step:
    • Both experts and guidelines agree that immediate discontinuation of opioid therapy is not the first action when a patient exceeds the prescribed dose or asks for an increase. The focus should be on understanding the root cause of the behavior and addressing it through appropriate clinical intervention.
  2. Individualized Approach:
    • Each case should be evaluated individually, considering the patient’s medical history, the reason for the dose increase, and their overall clinical situation.

Algorithm for Managing Unsanctioned Dose Increases

1. When a Patient Uses More Opioids than Prescribed

Recommended Actions:

  • Assess the Cause: Investigate why the patient is using more opioids. Is it due to pain levels, a misunderstanding of the prescribed dosage, or psychological issues (e.g., anxiety or dependence)?
    • Evaluate Pain Control: Ensure the prescribed opioid regimen is adequate for pain management. If the pain is not being managed appropriately, a change in the treatment plan may be needed.
    • Review Other Medication Use: Check for concurrent use of other medications or substances that may affect opioid metabolism or increase pain perception (e.g., benzodiazepines, alcohol, illicit drugs).
    • Conduct a Urine Drug Test (UDT): Use UDT to verify the use of prescribed opioids and check for non-prescribed substances.
    • Implement Monitoring: Increase the frequency of urine drug screens, pill counts, or Prescription Drug Monitoring Program (PDMP) checks to ensure adherence to prescribed therapy.

Not Recommended Actions:

  • Discontinue Opioids Immediately: Abruptly stopping opioid therapy without understanding the reason for the unsanctioned dose increase may cause significant withdrawal symptoms and harm to the patient. It also risks disrupting the therapeutic relationship.

Consider:

  • Offer Education on Proper Medication Use: Reinforce the importance of adhering to the prescribed dose and explain the risks of taking extra medication, including the potential for addiction or overdose.
  • Referral to Addiction Services: If misuse or addiction is suspected, a referral to a substance use treatment provider should be considered.
  • Adjust the Treatment Plan: If the patient’s pain is not being managed adequately, consider adjusting the pain management plan by exploring non-opioid options or considering a lower dose opioid.

2. When a Patient Requests an Increase in Opioid Dose

Recommended Actions:

  • Explore Reasons for the Request: Discuss the patient’s pain levels, their perception of the current opioid regimen, and any other factors that may contribute to the request. Some common reasons include inadequate pain control, fear of pain recurrence, or psychological dependence.
    • Assess Functional Status: Evaluate whether the increased dose is improving the patient’s quality of life and functionality. Higher doses are not always the answer if the patient’s function and quality of life are not improving.
    • Review PDMP and Urine Drug Testing: Check for any inconsistencies between what the patient reports and what is documented in the PDMP or UDT results.
    • Consult with a Pain Specialist: If the dose increase request is based on inadequate pain control, a pain management specialist may help assess and refine the pain treatment regimen.

Not Recommended Actions:

  • Grant the Dose Increase Without Evaluation: Simply increasing the dose without a thorough assessment could lead to misuse, dependence, and harm.
  • Ignore the Request: Dismissing the patient’s concerns without discussion may harm the therapeutic relationship and lead to non-compliance or even risk the patient seeking opioids elsewhere.

Consider:

  • Offer Non-Opioid Pain Management Options: Consider adjunct therapies like physical therapy, cognitive behavioral therapy (CBT), acupuncture, or other pain management techniques.
  • Psychological Evaluation: If the patient demonstrates signs of opioid misuse or dependence, consider referring them for psychological evaluation or addiction treatment.
  • Tapering or Switching Medications: In some cases, it may be appropriate to consider tapering the opioid or switching to a different medication or combination of therapies to improve pain management and reduce risk.

Summary of Actions for Both Scenarios

Both scenarios—whether the patient is using more opioids than prescribed or requesting a higher dose—require a careful and measured approach. The focus should be on:

  1. Thorough assessment to understand the underlying reasons behind the behavior.
  2. Close monitoring of the patient’s opioid use through PDMP checks, urine drug testing, and pill counts.
  3. Collaborative decision-making with the patient to adjust their treatment plan as necessary, including considering non-opioid options.
  4. Referral to addiction services if there are concerns about misuse, dependence, or psychological factors influencing opioid use.

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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