McMaster University

Michael G. DeGroote
National Pain Centre

Scope of Search

Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain

Cluster 5: Managing Opioid Misuse and Addiction in CNCP Patients

R23. Recommendation Statement

No. Recommendation Keyword
R23 Be prepared with an approach for dealing with patients who disagree with their opioid prescription or exhibit unacceptable behaviour (Grade C). Patient unacceptable behaviour
  • R23. Discussion

R23. Discussion

1. Patient Disagreement with the Opioid Prescription

Opioid prescribing is a common source of conflict between patients and physicians. Physicians can minimize conflicts through the following actions:

1. Use treatment agreements routinely.

2. Provide explanations for changes in prescribing, e.g.,

  • The prescribing is consistent with existing guidelines.
  • The change is intended to help, not penalize, the patients, e.g., it is meant to reduce the pain and improve mood, activity, and safety.

3. Book a longer appointment to allow for more time to provide education and explanations.

4. Arrange consultations: patients may accept a “team decision” more readily than an individual one.

5. Document verbal agreements and past discussions.

2. Patient Unacceptable Behaviour

Physicians are strongly advised to acquaint themselves with applicable legislation and their provincial regulatory body’s policies/guidelines regarding standards and termination of the physician-patient relationship. It is important to know the obligations to the patient, staff, and society if illegal patient activities are suspected.

2.1 Aberrant Drug-related Behaviours

Behaviours that stem from opioid addiction, such as aggressively demanding higher opioid doses or double-doctoring, often resolve when the physician ceases prescribing and refers the patient to addiction treatment. If the patient refuses to accept treatment referral and continues to demand opioids, the physician may consider discharging the patient from the practice.

2.2 Non-violent Offences

If a patient has committed a non-violent offence, such as altering a script, the physician is not obliged to contact the police. The physician should assess the patient for opioid addiction, and (in most instances) cease prescribing opioids and refer the patient for formal treatment.

2.3 Threatened or Actual Violence

The physician could contact the police if the patient has, for example:

  • threatened violence and there is perceived danger
  • committed violence against clinic staff and other patients, or
  • vandalized or stolen property.