Jessica S. Merlin, Janet Turan, Ivan Herbey, Andrew O. Westfall, Joanna L. Starrels,

1. Provider Documentation of Aberrant Drug-Related Behaviors(ADRBs) in Patients Referred to an HIV/Chronic Pain Clinic Jessica S. Merlin, Janet Turan, Ivan Herbey, Andrew O. Westfall, Joanna L. Starrels, Stefan G. Kertesz, Michael Saag, Christine Ritchie

2. Disclosures and Support • Career development award (PCOR K12 1K12HS021694-01) • Pilot grant support from the Center for Clinical and Translational Science (UL1 TR000165)

3. Introduction • Chronic Opioid Therapy (COT) is commonly prescribed for chronic pain • ADRBs refer to behaviors that potentially indicate opioid misuse/abuse • ADRBs are common in general and in HIV Chou R et al, J Pain 2009; 10(2): 131-46; Fishbain DA et al. Pain Med 2008; 9(4): 444-59.

4. Introduction • Implications of ADRBs are an emerging area of investigation • Systematic monitoring for ADRBs and identification of management protocols are important research priorities • How providers document ADRBs is unknown Meltzer EC et al, Pain Med 2012; 13(11):1436-43; Becker WC et al. J Gen Int Med 2013; 28(10):1364-7.

5. Objective • Describe how ADRBs are documented in provider notes from an HIV primary care clinic

6. Methods • Chart review study of patients in the HIV/chronic pain clinic, 2008-2011 • Textual data from interactions with any provider excerpted verbatim • Basic demographic and Patient Reported Outcome data collected

7. Methods: ADRB Definition • Focus on opioids at primary care visits • Pattern of early refills • Multiple calls/visits to request more opioids • Pattern of prescription problems • More than one opioid prescriber or using the ER to obtain prescriptions • Belligerent/angry/abusive behavior documented regarding opioid treatment, or • Any note that expresses provider concern about patient misuse or abuse of opioids Portenoy RK, J Pain Symptom Manage. 1996;11(4):203-17.

8. Analysis • Qualitative: • Content analysis, inductive • Matched with list of ADRBs • Second level of coding: language-based • Quantitative - comparison between patients with and without ADRBs: Fisher’s exact test and Wilxcoxon Rank-Sum

9. Table 1. Comparison Individuals in the HIV/chronic pain clinic with aberrant behaviors and the HIV/chronic pain clinic overall; *p<0.05

10. Table 1. Comparison Individuals in the HIV/chronic pain clinic with aberrant behaviors and the HIV/chronic pain clinic overall

11. Provider Language • Purely descriptive • Emotional (labeling, frustration, concern)

12. Purely descriptive • Devoid of labeling regarding intention, frustration, or concern; simply seeks to recount an interaction: • “States she is buying Lortab[hydrocodone/acetaminophen] 10mg from a friend ($5/pill). Mother states patient is actually selling these Lortabs to other people.”

13. Emotional • Labeling: language about a patient’s underlying intention or motivation re: opioid • “Said she left them [Lortab] on the bus and needs more. Has been dispensed 60 Lortab 10 in 2 weeks and claims to have none… [She] is obviously hoping to manipulate more narcotics from this clinic."

14. Emotional • Frustration: a feeling of insecurity or dissatisfaction related to unresolved problems with ADRBs • "Drug seeking behavior - NO NARCOTICS!” • “I called Ms. X back to verify that she had received the prescription for Lortab 5mg #20. She said she had the prescription but that Lortab 5mg ‘doesn’t work’ for her. I advised that she at least take them as directed. She might be surprised."

15. Emotional • Concern: acknowledging the presence of aberrant behaviors and expressing concern about the potential for negative implications or consequences • “There is a suspicion she was previously selling her narcotics in the past, so we will need to be careful if we decide to re-prescribe on a chronic basis."

16. Discussion • First qualitative analysis of ADRB documentation • Providers used many types of language – descriptive but also emotion-laden

17. Discussion • EMR is used to communicate between providers and is accessible by patients • ADRBs are subjective by nature; emotional language may cloud recognition of patterns of behavior Hanson JL et al. BMC Health Serv Res 2012;12:407.

18. Discussion • Begs the question: what constitutes safe, evidence-based care for individuals with ADRBs? • We propose that ADRBs should be documented factually, devoid of provider emotion • Further investigation into systematic documentation tools is needed

19. Limitations • Relied on chart review • Only provider’s view was captured • Unable to document outcome of ADRB • One site, did not perform provider-level analysis

20. Questions? • Thank you!

21. Supplemental Slides

22. Table 2. Types of ADRBs Identified in Content Analysis and Illustrative Quotes

24. Provider Responses • Setting conditions for opioid prescribing: willingness to prescribe opioids only if certain conditions are met • “Given he ran out early, no more Lortab today. Next prescription due on [date]. Only 55 pills at that time of Lortab 10. No refills further if does not meet with HIV doctors."

25. Provider Responses • Action oriented language: concrete, decisive, language to describe how they handled, or planned to handle, an ADRB • “He is out of the Lortab a bit over 2 weeks into the month. We discussed that this means he cannot get more until his next prescription is due.”