The Stanford Opioid Management Model
It is not uncommon for patients to present to their first pain clinic appointment with the expectation that they will receive opioid medications to treat their non-
cancer pain. Some of these patients are interested in starting opioids; others are taking opioids and are in need of a provider to continue the prescriptions. Providing any type of pharmacologic treatment assumes obligations on the part of the patient and provider. It is important to clearly address these responsibilities and expectations at the onset of establishing a treating relationship, particularly when the increasingly controversial subject of opiate medications is involved.
Risk Identification and Stratification
Patients should be notified prior to their visit that medications will not be prescribed during their first appointment. The purpose of the initial evaluation is to obtain a thorough history and physical examination to ascertain the most appropriate treatment course. The history should include information relevant to the pain condition, past medical history, and psychiatric functioning. A risk assessment tool for substance abuse should be administered in the event that opioid prescribing will be a part of the treatment plan. A number of tools are available to assist with risk assessment; a screening system should be chosen carefully to ensure that it is the best fit for a particular clinical setting. The system proposed in this paper is comprised of the Opioid Risk Tool (ORT),1 the Controlled Substance Utilization Review and Evaluation System (CURES),2 and urine drug screening (UDS) (Table). The Stanford University model for risk stratification is outlined in the Figure.
Patients who are categorized as “Low Risk” on the ORT, present a medication history that corresponds with the CURES report, have a UDS result that is consistent with their prescribed medications, and do not have untreated or undertreated mental health issues are considered at low risk for opioid abuse. Prescribing of opioids may be initiated if it is clinically indicated. Before opioids are prescribed, the patient should sign written documents that explain the risks of opioid therapy and the parameters of treatment. The American Academy of Pain Medicine has 2 such templates available: the Consent for Chronic Opioid Therapy describes the risks of chronic opioid use, including physical dependence and addiction; and the Agreement on Control Substances Therapy for Chronic Pain Treatment details the expectations of the patient who receives opioid therapy.3
UDS and CURES reports should be obtained at subsequent visits to ensure compliance. Continued use of opioids should be guided by assessing the following 4 areas:
- Analgesia: Does the patient derive pain relief?
- Activity: Does use of opioids improve activity levels/functioning?
- Adverse effects: Are there significant medication side effects?
- Aberrant behavior: Is the patient engaging in any inappropriate behavior with regard to opioid medication use?
Consistent UDS results, CURES reports, and appropriate responses in the above areas suggest a lack of contraindications for continued opioid use. However, any deviations in the above parameters would result in the patient being recategorized as being “At Risk” and would prompt a switch to the pathway described in the next section.
Patients are considered “At Risk” for opioid abuse due to any combination of the following:
- Moderate- or high-risk result on the ORT
- Medication history that does not correspond to the CURES report
- UDS result that is inconsistent with prescribed medications
- Untreated or undertreated mental health issues.
An evaluation by a pain psychologist should be obtained for all at-risk patients to identify the nature and extent to which psychological factors may be influencing the patient’s predicament. An additional consultation with an addiction medicine specialist should be obtained for patients at moderate or high risk based on the ORT, incongruent CURES, or inconsistent UDS results.
Upon completion of the additional evaluations, the information should be integrated to identify whether the patient should be recategorized as low risk or if an active substance abuse disorder is present that necessitates formal addiction treatment. Patients who remain at risk should have an individualized treatment plan that addresses the risk factors and should be co-managed with their other providers. Opioid prescribing may take place provided that all aspects of the individualized treatment plan are being followed in addition to the parameters outlined in the previous section.
Reasons to Consider Opioid Cessation
It is critical for prescribing providers to actively monitor patients to ensure that use of opioid therapy remains appropriate. The parameters surrounding the number and type(s) of infractions that would result in medication discontinuation should be specified clearly in the agreement. Once the threshold for discontinuation has been reached, providers should initiate a taper. Contraindications for continued prescribing include (but are not limited to) aberrant behavior, lack of functional improvement, and medical complications.
Unsanctioned medication overuse. Research has shown that patients who are prescribed higher levels of opioids have an increased risk of overdose.4 Patients may report taking more medication than prescribed secondary to poor pain control, resulting in early refills or acquiring medications from other sources. Such situations may arise due to medication tolerance, failure to incorporate non-pharmacologic approaches in treatment (eg, psychological and behavioral tools), or development of acute on chronic pain. Alternatively, overuse also may be the result of the patient using opioids for non-medical purposes.
Just as the reasons for unsanctioned escalation vary greatly, so do the ways that it should be clinically managed. A patient’s failure to notify a prescriber of a perceived need for dose modification precludes the provider from assessing the situation and making appropriate care recommendations. Moreover, independent dose escalations can have deleterious direct and indirect effects, including the development of addiction issues.
Diversion. Providers should have zero tolerance for any form of medication distribution by patients (eg, sharing, selling). A UDS result that shows no evidence of opioids in the system may be indicative of possible diversion, but, by itself, it is not conclusive evidence of such behavior.
Concurrent substance use. Use of illicit substances or medications not sanctioned by the prescribing provider can place a patient at high risk for negative ou