Table 1 Core opioid reassessment clinic (ORC) treatment strategies in three cases

64-year-old with severe COPD, PTSD and degenerative joint disease of the lumbar spine, chronic pain and long-term, high-dose opioid therapy. Diagnosed with mild opioid use disorder (OUD) in ORC

Prior to OUD diagnosis: offered lower dose full-agonist opioid versus switch to buprenorphine/naloxone (BUP/NX)

After OUD diagnosis: offered switch to BUP/NX maintenance or taper off

When BUP/NX was deemed unsafe, it was discontinued and non-opioid pain treatment was continued

Health psychology met with patient at each ORC visit to establish functional goals and monitor progress

Pulmonary rehabilitation engaged patient in upper body and breathing exercises

Treatment of significant PTSD symptoms. When a co-occurring condition is significantly contributing to pain, we make engagement in treatment of the condition part of the opioid treatment agreement

65-year-old with history of low back pain, cervical and lumbar surgeries, spinal cord stimulator placement and high-dose opioid therapy. No opioid misuse present. Assessed as having low efficacy, high-dose opioid therapy

Initially offered options: (1) taper down/off current opioid; (2) rotate to another full agonist, at a lower equivalent dose; (3) switch to BUP/NX for off-label treatment of pain. (Patient chose option 3)

When BUP/NX was maximized without benefit, patient was offered a choice to taper off or switch to low dose full agonist opioid. He chose the latter option and is continued at a moderate opioid dose

Health psychology met with patient at each ORC visit for engagement in cognitive-behavioral therapy for pain

Non-opioid medications were prescribed for neuropathic component of pain

Patient had no significant pain-impacting co-occurring conditions

56-year-old with alcohol use disorder and bilateral hip pain due to severe osteoarthritis treated with morphine. Exhibited opioid misuse and experienced a return to alcohol use

Initially, expectations regarding safe opioid use were made explicit; morphine was continued and closely monitored

Following return to alcohol use, morphine was tapered off. Tramadol was continued as long as safe use is demonstrated

Orthopedics was engaged to develop a plan for hip replacement

Health Psychology met with patient at each ORC visit for engagement in cognitive-behavioral therapy for pain

Non-opioid medications were prescribed to treat inflammation

Addiction treatment was a requirement for ongoing opioid therapy. Breathalyzers were obtained at each visit along with urine drug testing. We collaborated closely with addiction treaters to ensure their ability to reinforce the pain care plan