In February of this year, the Centers for Disease Control and Prevention (CDC) issued new voluntary guidelines for prescribing physicians to limit the use of opioids. The CDC recommends that prescription painkillers not be a first-choice for treatment of common ailments such as back pain and arthritis. Late last year, President Obama announced federal, state and local efforts to increase prescriber training on opioid use, and improve access to addiction treatment.

The Stanford Pain Management Center has multiple programs in place that mirror these national efforts to improve the safety of opioids.

"There is no question that opioids can be a gateway to heroin use," said Sean Mackey, MD, PhD, chief of the Division of Pain Medicine and the Redlich Professor of Anesthesiology, Perioperative and Pain Medicine, Neurosciences and Neurology. “But these same prescriptions provide critical pain relief from ailments ranging from bone fractures to surgery to cancer.”

According to an Institute of Medicine report, Relieving Pain in America, 100 million Americans suffer from pain, more than diabetes, heart disease and cancer combined. For a number of these individuals, responsible use of opioids substantially reduces their suffering and improves their quality of life, without adverse addiction issues.

"As a pain medicine physician, I know that for chronic pain, opioids are rarely a first line agent," said Mackey. At the Stanford Pain Management Center, there are more than 200 medications used to treat pain, 20 of which are opioids. Pain medicine specialists work together with psychologists, physical therapists and complementary medical providers to relieve chronic pain with a multi-modal approach that goes well beyond prescribing opioids. Treatment plans for patients with chronic pain look at both the psychological and physical components of pain.

Treating pain is complex. Rather than just a symptom of another condition, chronic pain has become a disease in its own right, said Mackey. Over time, the pain caused by an injury or illness changes the nervous, immune and inflammatory systems. It morphs from a symptom into the disease of chronic pain that persists even when the initial injury has healed.

But most patients are treated for pain, not by specialists like Mackey, but by internists, surgeons and clinicians in hospitals and clinics following an acute illness or injury. What is being done to help these physicians prescribe opioids more safely?

Enhancing prescriber training
Last November, the Stanford Pain Management Center in conjunction with the American Academy of Pain Medicine developed the very first free, massive open online course related to safe opioid prescribing, Safe Opioid Prescribing and Risk Evaluation and Mitigation Strategies (REMS). Taught by pain medicine specialists, this free CME course aims to improve providers’ knowledge, competence and performance in prescribing opioids in the treatment of chronic pain. The course focuses on how to assess and recognize the psychological factors that increase the risk for opioid abuse and diversion, and how to develop treatment plans and interventions to decrease the risk for unintentional misuse, abuse and addiction to opioid analgesics.

Pain medicine physicians are also embedded at Stanford hospital and increasingly in Stanford and UHA primary care clinics to consult with clinicians on how to manage pain for their patients.

Identifying at risk patients and providing optimal care
At the heart of the prescription opioid issue is the ability to identify patients who are at risk for addiction. "We know there is a percentage of people who are vulnerable to the addictive properties of these medications," said Mackey. "While we don’t have a genetic or blood marker that’s clear yet, there are other markers that point to an increased propensity to addiction.” These include early adverse child event, a history of post-traumatic stress disorder, history of depression or anxiety, a history of substance abuse in the family or a prior history of substance abuse on the patient’s own end. Getting this information from patients requires time and significant questioning, which is often difficult for physicians with busy practices.

Stanford has created an open source learning healthcare system (LHS) to capture large amounts of data on patients’ physical, psychological and social health, making this information more accessible to prescribing physicians. The Collaborative Health Outcomes Information Registry (CHOIR) is a computer-based platform that integrates into clinics and their workflow to help clinicians optimally treat chronic pain and other medical conditions more effectively. CHOIR is much faster and more efficient than previous pen-and-paper patient surveys through the use of computer adaptive testing. As an LHS, CHOIR is also helping to risk stratify and identify people who are going to run into problems with persistent opioid use.

CHOIR has been adopted by other Stanford Medicine clinics, other clinics nationally, and now contains data from over 20,000 people.