Challenging Patient Behaviors and Concerns

Negative stigma about patients with OUD and SUD paints them as particularly challenging to deal with. However, challenging behaviors are relatively rare and can occur among the general patient population as well. Challenging behaviors do not mean patients with OUD are inherently bad people—they reflect the influence of an addictive disorder and highlight the need for structure and support. Rather than quickly terminating treatment for these individuals, aim to increase their engagement in treatment and help them find the motivation to move toward recovery.

Do not abruptly taper patients from medication for OUD against their wishes or as a punishment for continued substance use.² If their OUD and other issues are too much for your practice, transfer them to a higher level of care using a warm or soft handoff.

Balance the desire to support patients with the need to ensure the safety of staff and other patients, and to comply with legal requirements. Establish flexible, person-centered procedures for how staff are expected to respond to different situations. When patients are upset, de-escalation techniques can help prevent the need for security involvement. In the procedures, clearly define the circumstances under which intervention by security or police is appropriate.

Develop a process for reporting and documenting incidents and review this information regularly to reassess whether additional measures or strategies need to be implemented for risk prevention.

Treatment agreements signed during intake should spell out the programs expectations related to patient behavior. Given the nature of addictive disorders, it is important to recognize that rules and expectations may not be met in all cases.

Individuals with OUD may use other substances alongside opioids, even while seeking or participating in OUD treatment. Intentional and unintentional use of other substances along with opioids is common—particularly combinations of opioids with xylazine, methamphetamine, or alcohol. Polysubstance use is not a catchall category and is a nonspecific term as different drug combinations lead to different symptoms and treatments.³

Similarly, patients receiving medication for OUD may continue to use non-prescribed opioids, which may indicate a need for an increased dose, more intensive treatment, or additional recovery supports. Address the patients substance use during medication management visits. Motivational interviewing techniques and other brief counseling strategies can help you address the issue.

If your patient continues to use substances, do not discontinue their OUD medication or treatment. Often, the opioid misuse poses the greatest immediate threat to the patients life because of the risk of death from overdose. Therefore, maintaining engagement in treatment is best for the patient.

While medications can address OUD, patients may need additional treatment services to successfully treat their addiction to other substances and to support recovery. If needed, support the patients transition to a more intensive or higher level of care.

See the Prevent and Respond to Recurrence of Use section to learn more.

Signs of medication diversion may include patients reporting lost or stolen prescriptions, urine drug screens with no buprenorphine, consistent refusal to leave a urine drug sample or requesting early refills. While these signs may raise concerns, they may also signal that the patients current buprenorphine dose is inadequate-- especially considering the increasing presence of fentanyl in the drug supply. Emphasize to patients that practice staff are there to help if they are struggling, and that honesty is key to a successful treatment plan.²⁵

Develop a diversion control plan with clear policies and protocols for storing, dispensing, and prescribing medications. Be aware of any local and state legal and reporting requirements related to diversion. Include strategies to help prevent buprenorphine diversion, such as:

• Policy on Refill Requests: Consider implementing a policy for how to manage early refill requests that includes discussing the request with the patient. Repeated reports of lost, stolen, or destroyed prescriptions may signal a variety of situations such as:⁵⁷
  • Diversion for personal gain;
  • Diversion to someone who needs the medication but is unable to access or afford it legally. This may be an opportunity to engage that person in MOUD treatment;
  • The patient is using more than the prescribed dose because their dose may be too low to control cravings;
  • An unsafe or unstable living environment; or
  • The need for a more structured treatment setting to help safeguard his or her medications.²⁵
• Supervised Dosing: Requiring patients to take their medication in front of the prescribing provider can reduce diversion. However, this approach may be burdensome or impractical in primary care or other ambulatory care settings, for both patients and providers.
• Switch to LAI Buprenorphine: Injectable formulations of buprenorphine can eliminate the risk of diversion.
• Pill/Film Counts: Ask patients to bring their remaining medication to appointments. Comparing the quantity on hand to the original prescription can help identify potential diversion.
• Locking Boxes. Patients who report one or more lost or stolen doses can be required to store their medication in a locked box, similar to a cashbox.
• Drug Screens: Determine whether you will conduct drug screens to monitor adherence and if so, how often (e.g., each visit, random selection of visits, call them to test at a random time outside of visits). Note that some payers have specific drug screening requirements. To ensure validity:
  • Confirm the identity and integrity of urine samples (e.g., temperature checks, confirmation testing, or same-sex observation). If a patient is on the buprenorphine/naloxone combination product, an irregular ratio of naloxone to buprenorphine in the urine sample can indicate tampering.
  • Consider saliva drug testing, which is easier to observe in-person or via telehealth.
  • Note: While buprenorphine levels cannot confirm adherence to a specific dose, tracking individual trends may offer insights.

Prescription Drug Monitoring Program (PDMP) Checks: Every time you prescribe buprenorphine (i.e., at each visit), check your states PDMP to see whether the patient has a prescription for buprenorphine or other opioid from another provider. This is required by most states. PDMPs are statewide electronic databases that collect and monitor controlled substance prescribing and dispensing data, submitted by prescribers and pharmacies.

PDMP checks can help identify patterns of misuse, such as "doctor shopping" or overlapping prescriptions. Full participation by prescribers is essential when treating OUD with medications like buprenorphine. Note that PDMPs vary by state in terms of oversight, which drug schedules are included, and who can access the information. For more details, visit your states PDMP Training and Technical Assistance Center.

If you identify potential diversion, use open-ended questions to understand the underlying reasons patients are misusing or diverting medication. For instance, they may be sharing it with a loved one who lacks access to treatment or selling it to meet basic needs like food or housing.