Challenging Patient Behaviors or Concerns

Practices must establish program rules and policies that will inform patient expectations and guide staff responses to challenging behaviors. These include, but are not limited to, policies that address inappropriate patient-staff interactions, polysubstance use, recurrence of use, early refill requests, tampered urine screens, and diversion. The policies should be structured to support retention in treatment and recovery, while providing clear guidance on what staff should do if certain situations arise. Staff should be trained on these policies and given role play scenarios to help practice their responses.

North Star

Challenging patient behaviors are managed as best as they can be through systematically implemented policies that address such behaviors and the concerns they bring about in clinic staff. The policies are based on an understanding of the chronic relapsing nature of addictive disorders and encourage retention in treatment. Staff understand these policies and have been trained on how to implement them.

How Do You Do It?

Addiction is a disease that hijacks the brain and often leads people to engage in antisocial behaviors, such as lying, acting aggressively, or being disrespectful. This behavior does not mean that the patients are inherently bad people, but rather reflects the influence of an addictive disorder and the need for structure and support. Rather than quickly terminating treatment for these individuals, practices should aim to engage them in treatment and help provide the motivation to move them toward recovery.

The desire to help must, of course, be balanced with considerations for the safety of staff and other patients, as well as legal requirements. Practices need flexible, patient-centered procedures and action plans that detail how staff should respond to different situations. De-escalation techniques can be useful approaches when patients are upset and can help avoid intervention by security. These action plans should also clearly specify when assistance or intervention by security or police is immediately necessary.

Each practice should have a specified process for how to report and document incidents when they occur. This information should be reviewed on a regular basis to reassess whether additional measures or strategies need to be implemented for risk prevention.

Treatment agreements signed during intake should spell out the program’s expectations related to patient behavior. No single evidence-based model exists for such policies, but NIATx provides guidance and sample forms in a number of areas, including a patient consent form and medication-assisted treatment (MAT) expectations agreement. Given the nature of addictive disorders, it is unlikely that rules and expectations will be met in all cases.

Individuals with opioid use disorders may be using other substances while seeking treatment for their opioid use disorder. Polysubstance use with alcohol, tobacco, marijuana, stimulants, and other drugs is common. Each practice or organization developing a MAT program should have patient-centered strategies to address polysubstance use and recurrence of use.

Treatment strategies should reflect the nature of addictive disorders and hold engagement in treatment and recovery support as the ultimate goals. While medications may help their opioid use disorder, patients may need additional treatment modalities to successfully treat addiction to other substances and to support recovery.

Often, the opioid misuse poses the greatest immediate threat to the patient’s life because of the risk of death from overdose. Therefore, providers should embrace a harm reduction approach that recognizes that maintaining engagement in treatment is best for the patient. Patients should not be abruptly tapered off medications against their wishes or as a punishment for continued substance use.

However, providers should not ignore continued use of opioids or other substances or feel compelled to continue prescribing if they are uncomfortable doing so. Ongoing use typically indicates a patient’s need for a higher level of treatment intensity or recovery support. Providers should address the patient’s substance use during medication management visits, use motivational interviewing techniques and other brief counseling strategies to address the issue, and, if needed, support the patient’s transition to a higher level of care.

Learn more about Prevention and Response to Recurrence of Use of illicit and prescription opioids.

Signs of medication diversion may include patients reporting lost or stolen prescriptions or asking for medication refills early. If urine drug screen results indicate low or no levels of buprenorphine (or an unexpected level given the dosage prescribed), that may be a red flag. If a patient submits a urine sample the provider or other staff suspect has been tampered with, the program should have a protocol for how staff should respond.

For example, after asking the patient to submit another sample, the provider may talk to the patient about expectations regarding urine screens. Providers should emphasize that practice staff are there to help if the patient is struggling, but honesty is important to successful treatment.1 Programs may also choose to enact a policy in which repeated tampering may be reason to refer the patient to a higher level of care.

Practices should create a diversion control plan that includes a series of policies and protocols to reduce diversion. These should cover the storage, dispensing, and prescribing of medications. The Substance Abuse and Mental Health Services Administration’s Treatment Improvement Protocol (TIP) 63: Medications for Opioid Use Disorder—Part 3: Pharmacotherapy for Opioid Use Disorder includes key elements of an office-based opioid treatment clinic diversion control plan (see Exhibit 3E.3) and a sample buprenorphine diversion control policy. NIATx also provides examples of policies and guidance related to diversion of buprenorphine, including a sample therapeutic agreement.

Practices should implement strategies that help prevent diversion of buprenorphine:

  • Policy on Refill Requests: Programs may enact a policy that prohibits or limits early refill requests and specifies the appropriate response or actions staff should take. While these requests may be a sign of diversion, it is also possible the patient has an unstable or unsafe living environment. After repeated reports of lost, stolen, or destroyed prescriptions, providers should consider whether the patient needs to be referred to a more structured treatment setting to help safeguard his or her medications.1
  • Supervised Dosing: Practices may require patients to take their medication in front of the prescribing physician. However, this policy may be impractical or a significant burden on both patient and provider in a primary or ambulatory care setting.
  • Pill/Film Counts: Providers may ask patients to bring in their unused medication. Checking the number of pills or films remaining against the original prescription may help identify diversion.
  • Regular, Observed, and Random Urine Drug Screens: Frequent, and ideally random, unannounced urine drug screens can help support adherence to buprenorphine as a qualitative check that a person has ingested the medication. Confirmation testing for buprenorphine should be considered due to the ease of altering unobserved urine. Levels of buprenorphine can be obtained but should not be used to determine adherence to the specified dose, as variation in levels can be caused by multiple factors. Individual trends in buprenorphine levels can be useful at times. Some practices may choose to implement a policy that requires all urine tests be observed by a same-sex staff member.
  • Prescription Drug Monitoring Program (PDMP) Checks: When providers are concerned about a risk of diversion or misuse of the medication, they should access the State’s PDMP to ensure their patient does not have prescription opioid or buprenorphine prescriptions from another provider.

If providers have evidence of patients diverting their medication, it is important they ask open-ended questions to understand the underlying reasons patients are misusing or diverting medication. For example, they may have a family member or significant other who cannot access or pay for treatment so they are sharing medication. Similarly, some patients may actually be diverting medication because the income helps them meet basic life needs. The TIP 63 expert panel recommends that “providers not discharge patients from treatment solely because of continued illicit opioid use if the benefits of treatment continue to outweigh the risks.”2

What Not To Do

  • Don’t kick a patient out of the program for poor behavior, unless it poses a distinct risk to the safety of staff and other patients. If he or she can no longer be seen at your practice, do your best to connect the patient with another source of treatment.
  • Don’t forget that challenging and difficult behaviors are often a normal part of the illness, even though they still need to be addressed safely in the clinic.
  • Don’t assume patients diverting their medication have no interest in getting better. Some patients diverting or misusing their medication may be sharing their medications with a family member or friend who does not have access to treatment or selling medications because financial problems are challenging their ability to secure stable housing, food, and other necessities.   
  • Don’t take it personally when patients behave in a way that seems disrespectful of the program or you. Recognize that you may be seeing the results of an addiction that has “taken over” their brain and that engagement in treatment and recovery may still be possible in time.

Resources

Reducing Risk of Misuse and Diversion (Type: PDF)

Describes strategies to help reduce the potential for misuse or diversion of medication for SUD treatment.

Type: PDF
Source: Addiction Technology Transfer Center Network
Harm Reduction Quickguide (Type: PDF)

Describes why providers should take a harm reduction approach and what strategies they may use with patients.

Type: PDF
Source: Association for Behavioral Healthcare

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References

  1. OBAT Policy and Procedure Manual. Boston, MA: Boston Medical Center; 2016.
  2. Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol 63: Medications for Opioid Use Disorder. Part 3: Pharmacotherapy for Opioid Use Disorder. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. Publication No. SMA18-5063PT3. https://store.samhsa.gov/system/files/sma18-5063pt3.pdf. Accessed May 21, 2019.