Response to Capsule Commentary on Merlin et al., Managing
Concerning Behaviors in Patients Prescribed Opioids for Chronic
Pain: A Delphi Study
Jessica S. Merlin, MD, PhD, MBA
, Jane M. Liebschutz, MD, MPH
, and Joanna L. Starrels, MD, MS
behalf of the Collaboration and Resources for Pain and Opioid Opinion Leaders (CARPOOL)
Center for Research on Healthcare, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA;
of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA;
Division of General Internal Medicine, Albert Einstein College
of Medicine and Montefiore Medical Center, Bronx, NY, USA.
J Gen Intern Med 33(6):783
© Society of General Internal Medicine 2018
r. Laws’ commentary on our manuscript BManaging
Concerning Behaviors in Patients Prescribed Opioids
for Chronic Pain: A Delphi Study^
misrepresents and misin-
terprets both our study and the CDC Guideline for Prescribing
Opioids for Chronic Pain.
The CDC Guideline recommendation about tapering opi-
oids is based on the overall balance of risks vs. benefits. For
some behaviors or events, the risk is so high that one occur-
rence tips the balance (e.g., a nonfatal overdose event). How-
ever, a much more common scenario is a behavior such as
missed visits or running out of medications early; in primary
care, cohorts up to 78% of patients on opioids have at least one
such concerning behavior during treatment.
do not always represent a serious risk that immediately tips the
balance. How to respond to behaviors that do not immediately
tip the balance is not well addressed in the CDC Guideline due
to a lack of empirical evidence. This is precisely why we
turned to a rigorous Delphi process to harness expert clini-
Notably, the Delphi participants rarely regarded tapering as
an important approach to the first occurrence of behaviors
addressed in the study. Rather, initial steps such as reviewing
the opioid treatment agreement, providing non-opioid pain
treatments, and closer monitoring were favored. Experts en-
dorsed tapering generally after more information was gath-
ered, for example, when a pattern of behavior emerged; in our
opinion, this represents the tipping of the risk vs. benefit
balance and is consistent with the CDC Guideline.
Laws questions our participants’ qualifications. We system-
atically recruited from professional groups enriched with
chronic pain management and opioid prescribing experts.
Eligible participants were clinicians who self-reported that
opioids for chronic pain was an area of expertise; for example,
they Bhave taught others, published, or are considered a re-
source for other clinicians on this topic.^
The commentary also questions the rigor of the Delphi
approach. Our findings were based on expert providers’ col-
lective experiences, not Bintuitions.^ The Delphi method is a
well-regarded, scientifically accepted consensus approach and
represents a level of evidence.
We agree that our findings should not replace clinical
judgement and need to be rigorously tested in primary care
settings. The findings provide a framework for future research
and for aiding front-line clinicians in navigating the clinical
uncertainty we face when operationalizing current guidelines
in patient care.
Financial Support Information: Dr. Merlin received support from
the National Institute of Mental Health (K23MH104073[JSM]).
Corresponding Author: Jessica S. Merlin, MD, PhD, MBA; Center for
Research on Healthcare, Division of General Internal
MedicineUniversity of Pittsburgh School of Medicine, Pittsburgh, PA,
USA (e-mail: firstname.lastname@example.org).
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Published online March 19, 2018