Dealing with Negative or Disruptive Behaviors of Opioid Dependent Patients

Some health providers particularly those who work in primary care are concerned that substance dependent patients will disrupt their practice or cause trouble in the office. However, this is largely a myth related to the stigma of addiction and stereotypes about substance-dependent patients.

Patients in buprenorphine treatment are usually stable, compliant, and not disruptive to other patients in a general medical setting. They typically look just like the patient sitting in the next chair, and there is no reason to expect them to be "troublemakers".

However, it is still important to set ground rules and expectations with patients who are entering into buprenorphine treatment.

Inform patients about rules and expectations regarding the following:

  • Office rules/protocols
  • Procedures for prescriptions
  • Urine testing protocols
  • Patient responsibilities in treatment
  • Consequences for noncompliance/problematic behaviors (tapering and stopping the treatment could be included as an option)
Related Resources: 

Setting Rules and Expectations

Description: 
Discusses the importance of setting guidelines for patients in an office-based buprenorphine program and gives examples of the types of procedures and protocol that should be set and agreed upon prior to beginning treatment.
Setting Rules and Expectations

Perhaps the most obvious thing that the provider and patient need to address is the functioning of the office-based buprenorphine program. Things to discuss include cancelled appointments, how to contact the provider after office hours, payment of fees, and prescription procedures. Also, be sure to discuss things of particular interest to the patient, such as confidentiality and urine testing.

Furthermore, the patient and the provider need to discuss things that will certainly affect the course of treatment. Such topics include proper adherence to induction and maintenance protocols, disclosure of nonprescriptive psychoactive substances, other prescriptions, and problematic behaviors and their consequences. As always, providers should ensure that they have complete knowledge of all drugs their patient is currently using.

The following is a list of examples of specific rules on which you and your patient can agree, broken down by topic. Appropriate consequences should accompany each rule.

 

Office Protocol
  • The patient will call at least X hours before a scheduled appointment to say that he or she is unable to attend.

  • The patient will make satisfactory arrangements with the treating provider to pay for all services.

Prescription Procedures
  • The patient must visit the office for the first X days of treatment to receive buprenorphine doses. If the provider determines acceptable progress, a prescription may be written.

  • Lost prescriptions will not be rewritten.

Urine Testing
  • The patient will disclose to the provider all opioid or other drug use.

  • The patient agrees to random urinalysis when requested by the provider.

Patient Responsibilities
  • The patient will not alter his or her own buprenorphine dose.

  • The patient will make a concerted effort to learn about community support and/or self-help groups and meetings.