An Opioid-Free ED

St. Joseph’s Regional Medical Center is first in country to implement an opiate-free protocol

Prescription pain killers do more than kill pain. When they are over-prescribed, they potentially lead to patient dependence, addiction, overdoses—and death. The problem has reached epidemic proportions in the United States. According to the CDC, each day in the U.S., 46 people die from an overdose of prescription painkillers—opioid or narcotic pain relievers, including drugs such as hydrocodone-acetaminophen, oxycodone, oxymorphone, and methadone.

Healthcare providers may take some blame in those figures, considering they “wrote 259 million prescriptions for painkillers in 2012 alone, enough for every American adult to have a bottle of pills,” according to the Centers of Disease Control and Prevention (CDC). The CDC suggests that healthcare providers increase their proactivity in containing the problem, including the following measures:

– Use prescription drug-monitoring programs to identify patients who might be misusing their prescription drugs, putting them at risk for overdose.
– Use effective treatments such as methadone or buprenorphine for patients with substance abuse problems.
– Discuss with patients the risks and benefits of pain treatment options, including ones that do not involve prescription painkillers.
– Follow best practices for responsible painkiller prescribing, including screening for substance abuse and mental health problems, avoiding combinations of prescription painkillers and sedatives unless there is a specific medical indication, and prescribing the lowest effective dose and only the quantity needed depending on the expected duration of pain.

Taking Action

Clinicians at St. Joseph’s Regional Medical Center, located in Paterson, N.J., have taken that call-to-arms seriously. The facility is the first in the nation to develop an “Alternatives to Opiates” (ALTO) program, described as “a highly successful, unique alternative approach to acute pain management without the use of opioids and the potential addictions associated with opioid use.”

The program caught traction in the hospital’s emergency department, where the chairman of emergency medicine, Mark Rosenberg, DO, MBA, FACEP, FACOEP-D, and the medical director of pain managemen,t Alexis LaPietra, DO, agreed to pursue a new way of doing things by adopting evidence-based pain management methods, some of which were already in use in other areas of the facility. One might call it an ultimate collaboration.

“I had heard a lecture from our anesthesiology colleagues, who were doing MRI-guided ultrasound nerve blocks and decreasing the amount of opiates they were giving surgical patients,” explained LaPietra. “I said to Dr. Rosenberg, ‘Could we do that?’ and he said, ‘Why not? Talk to anesthesia.’ Dr. Rosenberg and I, as well as hospital leadership, came to realize there was a lot we could learn from the different specialties within the hospital about pain management.”

It was decided that LaPietra would do a fellowship pertaining to pain management and share new insights with ED coworkers. But it didn’t stop there; as a continuation of collaborative spirit, buy-in and interest for the endeavor came from all sectors of the hospital, “. from the CEO to physical therapy, psychiatry, pharmacy, family medicine and more. Everyone is on board,” said LaPietra.

Pain Relief without Opioids

Armed with solid evidence for non-opioid pain management, the St. Joseph’s ED launched the ALTO program on January 4, 2016. Within the first month, 250 patients were treated with alternative protocols and did not receive opioids when previously they would have.

“It’s important to understand that not all pain is the same,” said Rosenberg. “So pain protocols are specific to address the specific pain receptors.”

ALTO utilizes targeted non-opioid medications, trigger point injections, nitrous oxide and ultrasound-guided nerve blocks to manage patient pain whenever possible. For example, kidney stone pain is now treated with intravenous lidocaine instead of opioids. LaPietra noted, “Evidence show intravenous lidocaine works well to decrease pain, increase function and proves more effective than morphine.”

Acute low-back pain is treated with a combination of oral and topical pain medications, as well as trigger-point injections. Extremity fractures are being treated with focused ultrasound-guided nerve blocks. And acute headache and migraine pain is treated based on an algorithm using a variety of progressive, non-opioid medications.

Asked if there is any “push back” from patients who believe opioids are necessary for true pain relief, LaPietra said it comes down to education. “We need to explain that alternatives are just as effective,” she said. “Most people are happy that they can leave the ED and not be inhibited from driving, not feel loopy, sedated, or nauseous. They are happy to have something effective and yet not feel drugged.”

Beyond the Hospital

In order for the in-hospital initiative to take meaningful hold, the team realized the effort needed to spread beyond hospital doors and out into the community. “We know that once patients are discharged, their care goes back to community doctors,” said LaPietra.

Serving as the hospital’s medical director for population health, Rosenberg reached out to primary care physicians to share understanding about the availability and utility of non-opioid pain relievers and the need to prescribe fewer opiates.

Rosenberg also determined that the ED is in a unique position to “capture” patients who come in from an overdose or an addiction, and recruit them right then and there into rehab. So he has partnered with drug and alcohol rehab centers in the community to make a seamless transition from emergency care to rehabilitative care.

The reaction to the effort at St. Joseph’s has been swift and widespread. “We’ve gotten a barrage of emails, support and interest. We are sharing our protocols with healthcare practitioners and facilities from all across the United States as well as internationally. We are hoping we can really help to change the culture,” said LaPietra.

Rosenberg reminded, “All pain starts with acute pain and all addiction starts with the first dose. Emergency medicine is responsible for 4% of the total opioid prescription pill count. Over the past five years, emergency medicine has decreased that pill count by 9%. In spite of that, we still have an opportunity to decrease the amount of opioids we prescribe and to better manage acute pain. We have a responsibility to try to prevent patients from getting addicted to opioids.”

The good news?

“It is not as hard as it seems to make a change,” said LaPietra. “If other EDs have any small interest in making a big change, this is the model that will do just that. It is powerful and can be a life-saving departmental change.”

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