The Stanford Opioid Management Model

First published on June 1, 2014

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…

Low-Risk Individuals

Patients who are categorized as “Low Risk” on the ORT, present a medication history that corresponds with the CURES [PDMP] 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…

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…

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…

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. 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…

Opioid Risk Tool (ORT) Assessment Instrument

Reprinted With Permission from Lynn Webster, MD

I took the test and scored in the “high risk” category.  In fact, I can’t imagine that too many pain patients would score in the low or moderate risk categories, as you (and your family) would have to be saints (or devout Mormons) to do so.  And if you have a large family, then you’ll have a higher risk for family members who have abused drugs or alcohol.

For instance, who doesn’t have a family member that has abused alcohol?  And if you’re an older pain patient, who hasn’t abused alcohol in their youth?  I know I did — not to the point of addiction, but I did some wild partying in my younger days.  Of course, I quit drinking (and partying) a very long time ago.  I can’t remember the last time I had any alcohol, including wine. Still, I’d be penalized for stuff that happened over 25 years ago.

And the test appears to discriminate against men, who get a higher score than women if they’ve ever abused alcohol and/or illegal drugs.  And if you’re a woman who’s been a victim of preadolescent sexual abuse, you get high marks used against you — but if you’re a man, you get no marks at all.

My high risk score just confirms that if I were to see a pain doctor, I would be denied any kind of treatment that included pain medication.  Of course, this test is self-reported by patients, so I could always lie on the questionnaire, as I’m sure many patients do.

11 thoughts on “The Stanford Opioid Management Model

  1. i occassionally have mild-moderate pain in my low back (DDD) and if i immediately treat it with vicodin , muscle relaxers and rest, it will resolve in a few days. i can ask my pcp each month for a refill of 2 pills per day for a month anytime i need it. but if i were to be ‘graded’ on my mental health, the fact that i was raped as a teen only, then i would still be on the border for moderate-high risk patient to receive opiate based treatment. that is completely ridiculous. i have never used this or any other med to get high. i have never abused the number of pills per day, nor per refill. i always drop urine that show low to no use of the opiate. with any other doctor who uses this ORT Test, i would never see a pain pill again. and i am the kind of patient that should be seen as responsible with opiate treatment, except for the fact i was teen raped, and have psychiatric issues. how are those related to my pain and the need to treat it?

    Liked by 1 person

    • Allegedly, these kinds of things show you’re at a high risk for drug addiction. Even though I scored at a really high risk, here I sit, without any medications at all, and I’m not shooting heroin in my veins. In fact, I’ve never done that. But my 30-year history as a pain patient says I’m a drug addict.

      This test is so general that it would show just about anyone is at risk for addiction. Pretty soon, these tests will ask if you’re addicted to cigarettes or caffeine, then no one will be allowed any pain meds. And this is only one of the tests they use — there are many others.

      If your urine test doesn’t show any level of the pain med you’ve been prescribed, then the doctor may think you’re selling or hoarding your meds. More strikes against you, which will likely cause the doctor to stop prescribing or abandon you. And drug tests are notoriously unreliable, so there’s that problem too.

      If you’ve been seeing your doctor for awhile and he/she trusts you, then you shouldn’t have any problems. But if you have to switch doctors for any reason, like if your doctor retires, moves, or is no longer taking Medicare/Medicaid patients, then you might have a problem getting pain meds. Especially if you ask for them specifically. And a new doctor might think your mental health issues are being under-treated or mistreated, so you have a problem there too.

      Basically, it’s discrimination against a whole lot of different people, you and me included.

      Liked by 1 person

  2. Man, am I glad I don’t live over there! The ONLY pain meds, apart from Imigran for migraines, that I can tolerate are the opiate family, in my case oxycontin, Oramorph and dihydrocodeine. They’d probably lock me up! Everything else literally makes me projectile volmit, increases pain levels and makes me feel even more ill than usual.

    Liked by 1 person

  3. I notice that nowhere is the life-destroying impact of chronic pain even mentioned! They,really don’t seem to care about pain levels AT ALL.

    Oh jeez, here I go again… I hope anger doesn’t disqualify me from getting opioids, yet I’m sure it would if I admitted it to a doctor. My recommendation is sad: lie, lie, lie.

    This is a matter of life and death, so if you have to break your moral code to get opioids, so be it. Once you’re getting them, I think the other criteria (like checking your adherence) would work out OK.

    Liked by 1 person

    • Until your pain doctor decides you’re suffering from untreated depression or anxiety. Or your urine test results are inaccurate. Or the PDMP is incorrect or the database is down and can’t be accessed. Or the DEA raids your pain doctor’s office. Or…

      Liked by 1 person

    • Don’t wait for them to put a rat in a cage on your face. Just tell them you love Big Brother and anything else they want to hear and don’t admit to anything than can and will be used against you in a court of non-law. Your doctor is judge, jury, executioner and court-stenographer and if at any point he decides he doesn’t like you or you may be a threat to him he can sentence you to torture by medical deprivation. You owe him nothing for being a part of this system. The only morality is surviving this system. Don’t be ashamed if you have to submit to its rules to survive, and don’t be ashamed for breaking those rules to survive.

      Liked by 2 people

  4. Charitably, I’d say this is patient profiling. More realistically, I’d say it’s totalitarianism. The idea that you can predict the behavior of an individual based on membership in some sub group or culture is the essence of bigotry. But the idea that individuals must be continuously monitored so that any perceived misbehavior no matter how slight can be punished with torture is the essence of totalitarianism.

    Having served as an abuse object in the US military as well as under the US medical industrial complex, I would rather live in a military dictatorship any day than in a society run by doctors. I can’t think of anything I experienced in the military that was as restrictive, controlling and so intolerant to the imperfection of human nature as the “Stanford model” which is really just the model being created everywhere by so-called “pain specialists.” It was developed for the coercion and exploitation of people with pain with absolutist control that brooks no error or noncompliance. Military discipline has nothing on medical despotism. At 450,000 victims a year doctors even manage to kill more people than the US military,

    There is no more reactionary, fascistic group in our society than the medical profession. Don’t believe me? Read medical blogs and see how they talk about patients. Self-superior eggheads with the crusader’s certainty that only they have the final solution to the misbehavior of their moral and intellectual inferiors.

    Liked by 1 person

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