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11 Articles in Volume 14, Issue #5
DEA and Doctors Working Together
Working With Law Enforcement and DEA
Demystifying CRPS: What Clinicians Need to Know
Glial Cell Activation and Neuroinflammation: How They Cause Centralized Pain
History of Pain: The Treatment of Pain
Spirituality Assessments and Interventions In Pain Medicine
The Stanford Opioid Management Model
We Need More “Tolerance” in Medical Pain Management
Treating Rebound or Chronic Daily Headaches
Buprenorphine With Naloxone for Chronic Pain
More on Nitrous Oxide and Meperidine in Pain Care

The Stanford Opioid Management Model

It is important to clearly address patient/physician responsibilities and expectations at the onset of establishing a treating relationship, particularly when opiate medications is involved.

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.

 

 

Low-Risk Individuals

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.

At-Risk Individuals

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.

Aberrant Behavior

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

tcomes. UDS performed at random intervals should be used to assess for the presence of such substances. In the event of a positive screening result, confirmatory analysis is recommended to reduce the likelihood of a false-positive adversely impacting care.5 When available, prescription drug monitoring program reports should be obtained regularly to ensure that controlled medication prescribing and acquisition are consistent with the established treatment plan.

Lack of Functional Improvement

One of the hallmark differences between acute and chronic pain is the fact that the latter lacks a definitive cure; thus, treatment approaches focus on management of the condition. It can be tempting to focus solely on pain palliation when prescribing medication, but optimal pain management treatment should encompass a wider range of factors, including functional status and emotional well-being.6 Use of activity diaries (documents in which patients track daily activity), monitoring of work absenteeism due to pain, and obtaining corroborating information from family members may facilitate assessment of functioning. A lack of functional improvement despite opioid therapy may suggest a lack of opioid responsiveness and would warrant re-evaluation of the treatment plan.

Medical Complications

There are many situations in which chronic opioid therapy may be inappropriate or harmful. Examples include severe respiratory compromise, allergy to opioids, concomitant administration of drugs capable of causing severe drug interactions, use of methadone (Dolophine, others) when a patient’s QTc interval is >500 milliseconds, a history of opioids that were discontinued due to intolerance, severe adverse effects, lack of efficacy, acute psychiatric diagnoses or uncontrolled suicide risk, and the presence of a substance use disorder that is not in remission and for which the patient is not in treatment. Patients unwilling, or who lack the ability, to comply with treatment plan also may be unsuitable for chronic opioid therapy.7

Patients taking concomitant benzodiazepines or antidepressants and opioids appear to be at an elevated risk for morbidity and mortality. Of pharmaceutical overdose deaths, opioids are associated with 75.2%, benzodiazepines 29.2% and antidepressants 17.6%.8 The combination of opioids and benzodiazepine further increase the risk of death.

Successful Opioid Tapering

Tapering Process

Opioid tapering can occur on an outpatient or inpatient basis. The optimal setting will vary depending on the patient’s situation. If there are no contraindications to the use of methadone, current opioid doses should be converted to an equivalent methadone dose. The total daily dose for the first week typically will be 50% to 80% of the original opioid dose, and it is administered at either twice-daily or thrice-daily intervals. This dose can be tapered by 10% each week until 20% of the original dose remains. Then, the remaining dose can be tapered by 5% per week.9

Completing a taper in an inpatient setting allows for more rapid process. The methadone equivalent dose is calculated, and the initial dose of methadone may be approximately 20% of the original dose. Dosing should be adjusted daily to avoid significant withdrawal symptoms.

Blinded pain cocktails often are useful in this setting. In such scenarios, patients receive the same volume of liquid medication at each administration, but the dose may vary. Patients are informed of the contents of the cocktail but are blinded to the specific dose of the medications. This process helps decrease anxiety that may accompany and impede an open-label taper. The blinded pain cocktail typically will include methadone liquid, a blinding agent (eg, baclofen or gabapentin [Neurontin, Gralise, Horizant, others]), and clonidine (Catapres, others). As the dose of methadone is tapered, the blinding agent remains constant and provides the patient an experience of continued medication administration. Clonidine is used to address symptoms of opioid withdrawal.

In most scenarios, patients can be tapered off methadone within 7 to 10 days in an inpatient setting. Patients on very high doses of opioids can be tapered rapidly to lower levels of methadone on an inpatient basis and can complete the taper over a period of weeks as an outpatient.

Inpatients who experience mild or moderate opioid withdrawal are treated symptomatically. Patients with tachycardia and anxiety may receive additional doses of clonidine or a transdermal patch of clonidine. Nausea is treated with ondansetron (Zofran, others), which also may assist in addressing opiate withdrawal symptoms. Severe opiate withdrawal symptoms may be treated with additional opioids (eg, a low-dose short-acting agent). If an opioid rescue secondary to withdrawal is implemented, this may indicate the need to decrease the rate of the methadone taper.

The above is meant to serve as a general approach to tapering; ultimately, these schedules should be tailored to meet each patient’s unique clinical scenario.

During opioid taper, patients may experience increased pain symptoms and demonstrate increased pain behaviors. Unlike with severe withdrawal, these symptoms are managed with non-opioid interventions, including adjuvant medication and behavioral tools (discussed in next section).

Incorporation of Multidisciplinary Treatment

Current guidelines recommend a biopsychosocial approach to managing chronic non-cancer pain.6 Such an approach inherently results in the use of multidisciplinary treatment approaches to address the different factors that contribute to the pain experience. Studies have consistently demonstrated the benefits of multidisciplinary care in the management of chronic pain conditions.10 Cognitive-behavioral treatment approaches, in particular, have shown to decrease work absenteeism, pain levels, health care utilization, and costs, while concurrently improving quality of life and general health.11-13 Use of multidisciplinary treatment programs specifically in the context of facilitating tapering of opioids has shown improvement in pain severity, catastrophizing, and functioning, and these gains persisted over time.14,15 Patients use the behavioral strategies and techniques that are taught in such programs to help manage any increases in pain that they may experience as part of the tapering process.

Addressing Comorbidities

Psychiatric issues should be assessed and treated prior to or along with opioid weaning because the presence of untreated or undertreated psychiatric comorbidities can undermine the tapering process. Providers also should be aware of the possibility that the opioid medications are masking underlying psychiatric distress. In such circumstances, acute emotional destabilization is likely to occur. Initiating the opioid wean only after establishing formal mental health treatment will facilitate the treatment of such symptoms in a timely fashion.

The presence of chemical dependency issues also should be addressed prior to initiating the tapering process. If opioid addiction is deemed to be a primary problem, completing the taper in a formal substance abuse treatment program will allow the patient to receive formal addiction treatment and subsequently minimize the risk of relapse.

Obstacles to Success

Patients may strongly disagree with a treatment plan that consists of weaning off opioid medication, particularly if this is the primary tool that they have used to manage their pain or if addiction issues are present. In latter such situations, referring the patient for formal chemical dependency treatment is essential. Patients’ receptiveness to this process will vary depending on their readiness for change. In the case of patients with high medication dependence but no frank addiction or abuse issues, education and expectation management may help shape their responsiveness.

At the time that a medical relationship is initiated, providers should review the parameters of treatment (specifically addressing the role of opioids) and implement a multidisciplinary approach to care. The practice philosophy should be reinforced consistently across visits to minimize the likelihood that patients become overly dependent on one mode of treatment.

Last updated on: May 12, 2017
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