title: Management of problematic behaviours among individuals on long-term opioid therapy: protocol for a Delphi study.
abstract: Given the sharp rise in opioid prescribing and heightened recognition of opioid addiction and overdose, opioid safety has become a priority. Clinical guidelines on long-term opioid therapy (LTOT) for chronic pain consistently recommend routine monitoring and screening for problematic behaviours. Yet, there is no consensus definition regarding what constitutes a problematic behaviour, and recommendations for appropriate management to inform front-line providers, researchers and policymakers are lacking. This creates a barrier to effective guideline implementation. Thus, our objective is to present the protocol for a Delphi study designed to: (1) elicit expert opinion to identify the most important problematic behaviours seen in clinical practice and (2) develop consensus on how these behaviours should be managed in the context of routine clinical care.
  
  
  
  We will include clinical experts, defined as individuals who provide direct patient care to adults with chronic pain who are on LTOT in an ambulatory setting, and for whom opioid prescribing for chronic non-malignant pain is an area of expertise. The Delphi study will be conducted online in 4 consecutive rounds. Participants will be asked to list problematic behaviours and identify which behaviours are most common and challenging. They will then describe how they would manage the most frequently occurring common and challenging behaviours, rating the importance of each management strategy. Qualitative analysis will be used to categorise behaviours and management strategies, and consensus will be based on a definition established a priori.
  
  
  
  This study has been approved by the Institutional Review Board (IRB) of the University of Alabama at Birmingham (UAB). This study will generate Delphi-based expert consensus on the management of problematic behaviours that arise in individuals on LTOT, which we will publish and disseminate to appropriate professional societies. Ultimately, our findings will provide guidance to front-line providers, researchers and policymakers.
authors.affiliation: Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Jessica S
authors.initials: JS
authors.lastname: Merlin
authors.affiliation: Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Sarah R
authors.initials: SR
authors.lastname: Young
authors.affiliation: Division of General Internal Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA.
authors.forename: Soraya
authors.initials: S
authors.lastname: Azari
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA VA Connecticut Healthcare System, West Haven, Connecticut, USA.
authors.forename: William C
authors.initials: WC
authors.lastname: Becker
authors.affiliation: Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Clinical Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.
authors.forename: Jane M
authors.initials: JM
authors.lastname: Liebschutz
authors.affiliation: Department of Occupational Therapy, University of Florida, Gainesville, Florida, USA.
authors.forename: Jamie
authors.initials: J
authors.lastname: Pomeranz
authors.affiliation: Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Clinical Addiction, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA.
authors.forename: Payel
authors.initials: P
authors.lastname: Roy
authors.affiliation: Department of Medicine, Information Technology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Shalini
authors.initials: S
authors.lastname: Saini
authors.affiliation: Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
authors.forename: Joanna L
authors.initials: JL
authors.lastname: Starrels
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
authors.forename: E Jennifer
authors.initials: EJ
authors.lastname: Edelman
mesh_terms: D000701:Analgesics, Opioid / Q000009:adverse effects* / Q000627:therapeutic use; D059350:Chronic Pain / Q000188:drug therapy / Q000523:psychology*; D002985:Clinical Protocols; D032921:Consensus; D003697:Delphi Technique; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D007175:Impulsive Behavior; D007266:Inhibition, Psychological; D008297:Male; D009293:Opioid-Related Disorders / Q000188:drug therapy / Q000523:psychology* / Q000534:rehabilitation; D014481:United States; D014754:Violence
chemical_list: D000701:Analgesics, Opioid
keywords: analgesics; chronic pain; delphi; opioid