Problematic Behavior: Difficult Conversations, Part II

This is the second article in a series of eight articles by Ilene Robeck, M.D. regarding difficult conversations a primary care provider may have when dealing with patients with chronic pain. This series is meant to be a guide for primary care providers facing these situations. 

  • Difficult situation #2: A patient’s behavior becomes increasingly irritable, anxious, and labile. 

Advice: There are many reasons that a patient’s behavior can become problematic. Keep in mind that problematic behavior that can be seen in the office is frequently following a period of time in which this behavior has been apparent at home, as the medical office may be the last place that the patient exhibits deteriorating function. Many patients can function during a 15-minute office visit only to deteriorate upon returning home and at work.

Family members may be a good source of information about how the patient is doing. If there are concerns about behavior, I ask to speak to a family member either on the phone, or at the time of the next visit. I make sure that the patient has signed the proper HIPAA forms before they leave the office. If the patient refuses to let you speak to a family member, then this in itself is information that can help guide some of your future decisions. Sometimes a family member will call the office unsolicited concerning a patient. While it is a violation of confidentiality to confirm that you are seeing a particular patient or to discuss medical information, it is possible to have a clinical person talk to the family member and state that they cannot confirm that the patient is seeing a particular physician or enrolled in the clinic, but can get the information that the family member wants to pass on, in case that patient is ever seen in the future. This information can sometimes be life-saving, not only for the patient but the family as well.

Problematic behavior is frequently related to undiagnosed substance use disorder and is related to substances that the patient has taken prior to coming into the office or can also be related to acute or subacute withdrawal. If the patient is going through withdrawal, you may not get a positive drug screen for substances like alcohol that are only present in a urine drug screen for a few hours after ingestion. Also, there is now a subset of drugs that are synthetic marijuana that will not be picked up in a urine drug screen that have been reported to be associated with psychotic and dangerous behavior.

Another common cause of inappropriate behavior is an underlying mental health disorder such as bipolar disorder, personality disorder or schizophrenia, among others. Most primary care providers are not set up to handle a patient with mental health functioning that is deteriorating enough to be evident at an office visit. They should make sure that prior to treating patients with opiate therapy, they have some option for psychiatric support should it become necessary. In some situations, the behavior is actually purposeful and manipulative in an attempt to harass the physician into increasing a narcotic dose. Escalating an opiate dose in response to inappropriate behavior is fraught with difficulty. If increasing pain is a concern, alternatives to opiates should be sought until there is a better definition of what the problem is.

It is always easier to deal with demands for increased opiates with a non-opiate approach if there has been a previous opiate agreement signed in which belligerent behavior is listed as a possible reason for tapering and discontinuing opiates. Behavior that impacts other patients and the feeling of safety of providers in an office cannot be tolerated and needs to be handled professionally, but firmly. Patients with behavioral problems are frequently at high risk of an opiate-related adverse event due to their underlying substance abuse and/or mental health disorders. Opiates should be tapered and discontinued in patients with inability to function in an office setting, but more importantly is the need to make sure that the behavior is not related to underlying medical problems, psychiatric problems and/or substance abuse disorder that should be properly diagnosed and treated.