Appendix V: Beyond UDT: Other Red Flags for Harm

While UDT is one marker of risk, there are numerous other indicators suggesting that a patient is being harmed, or is at risk of harm, from opioid medications…

While urine drug testing is one of the most objective markers of risk, there are other factors that need to be considered when weighing the risks and benefits. Chapter 9 covers how to act in the clinical context based on the overall balance, with a focus on UDT results. This section will focus on how other observations may contribute to a patient’s risk assessment.

It is important to note that not all aberrant behaviours indicate opioid misuse. Some patients may demonstrate aberrant behaviours such as drug hoarding or escalating doses without permission due to other reasons such as inadequate pain control. If pain is adequately treated, these behaviours may subside. It is important to consider alternative explanations for these behaviours within the patient’s context.1

Commonly observed drug-related aberrant behaviours

  • More likely predictive of abuse
  • Probably less likely predictive of abuse:
  • Selling prescription medications or *prescription forgery1
  • *Stealing or “borrowing” medications from others (ie. family and friends) 1
  • Injecting oral formulations (or biting or crushing oral formulations2)
  • Obtaining opioids from nonmedical sources (i.e. purchasing street drugs)
  • Concurrent abuse of alcohol or illicit drugs
  • Multiple dose escalations or other noncompliance with therapy despite warnings
  • *Multiple episodes of prescription “losses”1
  • Repeatedly seeking medications from other clinicians or emergency departments (ie. double doctoring) without informing prescribers or after warnings to stop
  • Signs of deterioration in function (ie. work, family, socially)
  • Resistance to therapy changes despite clear evidence of side effects (adverse physical or psychological)1
  • Aggressive complaining about the need for more medication
  • Drug hoarding during periods of decreased pain
  • Requesting specific medications
  • Openly acquiring similar medications from other physicians
  • Dose escalations or other noncompliance on 1-2 occasions
  • Unapproved use of the medication to treat other symptoms
  • Reporting psychic effects not intended by the prescriber
  • Resistance to a change in therapy associated with “tolerable” adverse effects, with expressions of anxiety related to return of severe symptoms
  • * Those identified as more predictive of opioid misuse by Kaye et al.(2017)1
    Lists adapted from Portenoy (1996).3 Behaviours were divided based on investigators’ beliefs on predictive ability.


Case 1

Your patient has been escalating their dose twice now and you have other soft concerns for harm. You don’t think you have enough to justify tapering and stopping at this point, but you are worried and want to put an end to this pattern of dose escalation. What options do you have?

The real concern here seems to be the pattern of dose escalation. This could be from inadequately treated pain, or alternatively from opioid abuse/misuse. One thing we have found helpful in these particular scenarios is to use the Brief Pain Inventory as a means of measuring the patient’s pain and functional impairment (if dose is escalating then typically both scores will be high). If you escalate the dose and then 2 months later the patient comes back wanting another increase, you may apply the BPI again - if the score is the same or worse then naturally it looks like opioids aren’t helping. Most of us at the MFHT don’t use the BPI otherwise, but once an early habit of dose escalation has been started it’s helpful to have this as a means of pointing that out- by the patient’s own reports - opioids don’t seem to be helping and therefore further escalations are not justified. If your clinical Gestalt dictates that a further dose increase is reasonable, then certainly consider moving the person up the risk ladder as these dose escalations are soft concerns for harm and likely tilt your risk/benefit balance.


Chapter Pearls

  • Be aware of drug-related aberrant behaviours but keep in mind that not all behaviours are indicating drug misuse/abuse and consider alternative explanations within the patients current context.


  1. Kaye AD, Jones MR, Kaye AM, et al. Prescription Opioid Abuse in Chronic Pain: An Updated Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse (Part 2). Pain Physician. 2017;20(2S):S111-S133.
  2. Centre for Effective Practice. Opioid Tapering Template. February 2018. Accessed August 14, 2019.
  3. Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage. 1996;11(4):203-217.

Once red flag behaviours have been identified, the next step is having a discussion with your patient. For guidance on those difficult discussions see the next appendix, VI: Difficult Discussions with Patients..