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Chapter 5

Alternatives to Opioids (ALTO)

Don Stader, MD and Rob Orman, MD
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We're now in an era of hyper-awareness to the detrimental effects of opioids. But more than saying, "These meds are a problem," how do we apply that awareness to clinical practice and still provide analgesia. Don Stader, champion of the Colorado Alternatives to Opioids (ALTO) project, gives his clinical approach.

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scott w. -

Great piece. Curious if Dr. Stadler uses ALTO therapy for sickle cell and cancer patients. Thanks.

Rob O., MD -

Hey Scott,
Here are two replies. The first from Don Stader and the second Reuben Strayer...

Don Stader:
I'd say while I may use opioids more readily on these patients - I would never "just use opioids". In patients who are opioid dependent / tolerant I really like using Ketamine. I also use a lot of different agents depending on type of pain / contraindications: NSAIDS, IV Lido, Gabapentin, APAP - just to name a few that I'd likely consider along with an opioid / ketamine.

Reuben Strayer:
No quick answers. assess the patient to determine if they have opioid addiction. If they do, they need to be treated for addiction, see this slideset (

Otherwise, assess how much the patient is being harmed by opioids; if they don't use opioids regularly, you can treat them with whatever you think will work best, in the same way you would treat anyone with acute pain. I use a lot of haldol/droperidol and ketamine in this group.

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2.25 AMA PRA Category 1 Credits™ certified by Hippo Education (2020)