Moving Toward an (Almost) Opioid-Free Emergency Department
One emergency department in New Jersey has taken the lead in fighting the opioid epidemic. St. Joseph’s Regional Medical Center in Paterson, New Jersey, launched the Alternatives to Opiates (ALTO) program in January 2016 to drastically cut the use of opioids in the ED without sacrificing pain relief. Since the program was reported in The New York Times,1 the department has received more than 100 inquiries from EDs across the country and abroad.
“EDs are on the front lines of addiction,” said Andrew Kolodny, MD, executive director and cofounder of Physicians for Responsible Opioid Prescribing. People who overdose are brought to the ED to receive rescue medications, people who are addicted go to the ED to obtain more opioids, and perhaps most importantly, often the ED physicians are the first people to hand an opioid prescription to a patient, noted Dr. Kolodny.
“Emergency departments are responsible for a large number of first prescriptions of opioids, but only responsible for 4.7% of the total opioid prescriptions in the country,” said Mark Rosenberg, DO, chairman of emergency medicine at St. Joe’s, as the hospital is referred to locally. “When patients follow up with their physician, that physician frequently gives them a [new] prescription [for] a large maintenance dose,” said Dr. Rosenberg.
Pain in the ED
Pain remains the most common reason why a person visits an emergency department.2 Concerns over the undertreatment of pain3 and the linking of pay to patient satisfaction and timely pain control4 may have led to the significant increase in opioid prescription from EDs during the last decade.5 A review by Poon and Greenwood-Ericksen noted that “the high-volume, high-stress work environment of the ED” may lead a clinician to send a patient home with a short supply of opioids—despite his or her clinical judgment that the risks may outweigh the benefits.6
In response to the rise in opioid prescriptions (and overdose deaths), the Centers for Disease Control and Prevention issued recommendations for opioid prescribing, known as the “Guidelines for Opioids for Chronic Pain,” on March 15, 2016.7 In the guidelines, the agency specifically addresses the issue of opioid prescribing for acute pain. The guidelines state: “Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed.”
If the ED could avoid prescribing that first dose of opioids, Dr. Rosenberg posited, the patient would not be exposed to a highly addictive medication. According to Dr. Kolodny, a handful of EDs across the country are addressing this concern. In fact, the American College of Emergency Physicians (ACEP) has created opioid prescribing guidelines for ambulatory and ED visits.8
All the recent federal and medical guidelines contain the same elements: avoid prescribing long-acting opioids, limit prescriptions to a 3-day supply, routinely use prescription drug monitoring programs, and do not replace lost, stolen, or destroyed prescriptions.6
Comprehensive Acute Pain Program
In addition to adopting the new guidelines, Dr. Rosenberg wanted to do something comprehensive. “As a physician, I’m trained and went into medicine because I wanted to stop pain and relieve suffering,” said Dr. Rosenberg. “Now we’re adding that we need to try this without using opioids [as the first line of treatment].”
The first step was to create an acute pain fellowship through St. Joe’s and New York Medical College, in Valhalla, New York. The team identified centers in New Jersey and New York that would provide specific training in alternatives to opioids for pain management. Though there are numerous pain management programs, most deal with chronic pain, not acute pain, the kind of pain that ED physicians treat. Alexis LaPietra, DO, medical director of emergency department pain management at St. Joe’s, was the first to go through the fellowship. She conducted evidence-based reviews that identified established acute pain protocols and learned to use them in the ED.
These alternatives include a combination of nonopiate medications delivered intravenously, through nerve blocks, intranasally, and orally, as well as the use of nitrous oxide to deal with severely acute pain. Many of these treatments, such as nerve blocks, are not typically performed in the ED, partly because of a lack of training. The hospital has also turned to complementary therapies, such as massage; and, a Pranic healer, who uses energy fields.
Drs. LaPietra and Rosenberg created the protocols, which focus on 5 conditions that commonly present to the ED: kidney stones, lumbar radiculopathy, acute headache and migraine, musculoskeletal pain, and extremity fracture or joint dislocation (see Table 1). For patients with kidney stones, the protocol calls for intravenous lidocaine. “It gives patients tremendous amount of relief because it’s secreted in urine and anesthetizes and blocks nerves through a sodium channel blockade,” said Dr. Rosenberg. He believes it also helps patients pass the stones more quickly. "About 75% of patients get complete pain relief with IV lidocaine," he said.
All of the ED physicians and staff were trained in how to use the opioid alternatives described in Table 1. But the approach has spread beyond these 5 diagnoses. “The entire culture has changed at St. Joseph’s. Rather than the easy response of taking out the opioids from your medical bag, we’re trying to think of an alternative,” he said.
Many people still need opioids, particularly cancer patients or those with chronic pain syndromes related to trauma or fibromyalgia, but the goal for these patients is to use the lowest dose possible and help them maintain function and an active lifestyle.