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The Stanford Opioid Management Model.
Prasad R, et al.
Journal: Practical Pain Management. 2014; 14(5):38-43. 15 references.
Reprint: Ravi Prasad, PhD, Director, Stanford Inpatient Pain Management Program, Stanford University School of Medicine, Stanford, California.
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Can we hear too much about opioid management? I don’t think so in the light of the current deadly overdose outbreak. Imagine yourself called about your patient who just died of an overdose. This article and others of its type ought to be at your (mental/physical) fingertips to demonstrate you have done due diligence in treating them. This article has good guidelines.
Class: Pharmacology: Opioids: The Stanford Opioid Management Model.
Any type of pharmacological treatment assumes there are obligations on the part of both the patient and provider, and it is important to clearly address the responsibilities and expectations at the onset of the treating relationship, especially when the controversial subject of opiate medications is involved. The purpose of the initial visit is to obtain a thorough evaluation to ascertain the most appropriate treatment course. A risk assessment tool for substance abuse should be administered if opioid prescribing will be part of the treatment plan, in addition to a thorough history and physical exam that includes information on the pain condition, past medical history, and psychiatric functioning.The system discussed in this paper consists of the Opioid Risk Tool (ORT), the Controlled Substance Utilization Review and Evaluation System (CURES), and urine drug screening (UDS). Patients deemed "Low Risk" on the ORT are considered to be at low risk for opioid abuse. Opioids may be initiated if clinically indicated but before prescribed the patient should sign documents that explain the risks of opioid therapy and parameters of treatment. Four areas are assessed to guide the continued use of opioids: 1) analgesia (does the patient obtain pain relief?); 2) activity (does opioid use improve activity levels/functioning?); 3) adverse effects (are there significant side effects?); and 4) aberrant behavior (with regard to opioid use, is the patient engaging in any inappropriate behavior?). UDS and CURES reports should be obtained on ensuing visits to monitor compliance. Deviations would result in re-categorization to "At Risk".With patients who are considered "At Risk" for opioid abuse, an evaluation by a pain psychologist should be obtained to identify the psychological factors that may be influencing the patient. An addiction medicine specialist should also be consulted. This will allow identification of the need for formal addiction treatment, or if the patient can be re-categorized as low risk. Patients remaining at risk should have an individualized treatment plan that addresses risk factors and is co-managed with their other providers. Reasons to consider discontinuing prescribing include (but are not limited to) aberrant behavior (unsanctioned overuse, concurrent substance use, etc.), lack of functional improvement, and medical complications (severe respiratory compromise, allergy, etc.).Opioid tapering can be done on either an outpatient or inpatient basis. Opioid doses can be converted to an equivalent methadone dose (if there are no contraindications to using methadone) with the total daily dose the first week being 50% to 80% of the opioid dose. The dose can then be tapered by 10% a week until 20% of the original dose remains with the remaining dose being tapered by 5% each week.Completing a taper in the inpatient setting allows for more rapid process. Currently, guidelines recommend managing chronic non-cancer pain with a biopsychosocial approach. This approach naturally results in the use of a multidisciplinary treatment plan to address the different factors that are part of the pain experience. Prior to or along with opioid weaning, psychiatric issues should be assessed and treated since untreated or undertreated psychiatric comorbidities can undermine the tapering process. Patients may strongly disagree with a plan to taper off opioid medications but education and expectation management may help. However, if addiction issues are present, referring the patient for formal chemical dependency treatment is essential.
At the time of initiation of a medical relationship, providers should review the treatment parameters (specifically discussing the role of opioids) and implement a multidisciplinary approach to care. This practice should be reinforced consistently across all visits to lessen the likelihood that the patient will become overly dependent on one mode of treatment.