JGIM LETTERS Response to Capsule Commentary on Merlin et al., Managing Concerning Behaviors in Patients Prescribed Opioids for Chronic Pain: A Delphi Study 1,2 1 3 Jessica S. Merlin, MD, PhD, MBA , Jane M. Liebschutz, MD, MPH , and Joanna L. Starrels, MD, MS on behalf of the Collaboration and Resources for Pain and Opioid Opinion Leaders (CARPOOL) investigator team 1 2 Center for Research on Healthcare, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Division 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 opioids for chronic pain was an area of expertise; for example, DOI: 10.1007/s11606-018-4402-1 they Bhave taught others, published, or are considered a re- © Society of General Internal Medicine 2018 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 r. Laws’ commentary on our manuscript BManaging well-regarded, scientifically accepted consensus approach and Concerning Behaviors in Patients Prescribed Opioids represents a level of evidence. for Chronic Pain: A Delphi Study^ misrepresents and misin- We agree that our findings should not replace clinical terprets both our study and the CDC Guideline for Prescribing judgement and need to be rigorously tested in primary care Opioids for Chronic Pain. settings. The findings provide a framework for future research The CDC Guideline recommendation about tapering opi- and for aiding front-line clinicians in navigating the clinical oids is based on the overall balance of risks vs. benefits. For uncertainty we face when operationalizing current guidelines some behaviors or events, the risk is so high that one occur- in patient care. 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 Financial Support Information: Dr. Merlin received support from care, cohorts up to 78% of patients on opioids have at least one the National Institute of Mental Health (K23MH104073[JSM]). such concerning behavior during treatment. Such behaviors Corresponding Author: Jessica S. Merlin, MD, PhD, MBA; Center for do not always represent a serious risk that immediately tips the Research on Healthcare, Division of General Internal balance. How to respond to behaviors that do not immediately MedicineUniversity of Pittsburgh School of Medicine, Pittsburgh, PA, tip the balance is not well addressed in the CDC Guideline due USA (e-mail: firstname.lastname@example.org). to a lack of empirical evidence. This is precisely why we turned to a rigorous Delphi process to harness expert clini- cians’ opinions. REFERENCES Notably, the Delphi participants rarely regarded tapering as 1. Merlin JS, Young SR, Starrels JL, Azari S, Edelman EJ, Pomeranz J, an important approach to the first occurrence of behaviors et al. Managing Concerning Behaviors in Patients Prescribed Opioids for addressed in the study. Rather, initial steps such as reviewing Chronic Pain: A Delphi Study. J Gen Intern Med. 2017. doi: https://doi. the opioid treatment agreement, providing non-opioid pain org/10.1007/s11606-017-4211-y 2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids treatments, and closer monitoring were favored. Experts en- for Chronic Pain - United States, 2016. MMWR Recomm Rep. dorsed tapering generally after more information was gath- 2016;65(1):1–49. ered, for example, when a pattern of behavior emerged; in our 3. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic opinion, this represents the tipping of the risk vs. benefit review and data synthesis. Pain. 2015;156(4):569–76. balance and is consistent with the CDC Guideline. 4. Merlin JS, Young SR, Azari S, Becker WC, Liebschutz JM, Pomeranz J, et al. Management of problematic behaviours among individuals on long- Laws questions our participants’ qualifications. We system- term opioid therapy: protocol for a Delphi study. BMJ Open. atically recruited from professional groups enriched with 2016;6(5):e011619. chronic pain management and opioid prescribing experts. 5. Campbell SM, Braspenning J, Hutchinson A, Marshall M. Research methods used in developing and applying quality indicators in primary Eligible participants were clinicians who self-reported that care. Qual Saf Health Care. 2002;11(4):358–64. Published online March 19, 2018
Journal of General Internal Medicine – Springer Journals
Published: Mar 19, 2018
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