With the prescription opioid crisis a growing concern across the country, providers are feeling the squeeze — caught between calls to limit prescribing powerful painkillers and patient complaints that treatment for pain is suboptimal. No one is feeling the heat more than frontline emergency providers who must contend daily with patients who present with fractures, injuries, and other instances of acute or chronic pain. How do physicians and nurses meet patient expectations for pain relief without exacerbating the opioid abuse problem?
One potential solution that is attracting considerable attention is the Alternatives to Opiates (ALTO) program developed by the St. Joseph’s Healthcare System in Paterson, NJ. While the program has only been formally in place in the ED at St. Joseph’s Regional Medical Center (SJRMC) since January, developers note that they have successfully treated more than 300 patients with non-opioid alternatives thus far, and other hospitals in New Jersey and around the country are eager to hear how they might implement a similar program.
Focus on Pain Receptor Sites
Mark Rosenberg, DO, MBA, FACEP, the chairman of emergency medicine and medical director for population health in the St. Joseph’s Healthcare System, said the road to the ALTO program began about two years ago when he first searched for a way to improve pain management in the ED while also moving the focus away from the use of opioid medications.
“I worked with New York Medical College [in Valhalla, NY] to develop an acute pain fellowship for emergency medicine, and my first fellow was Alexis LaPietra, DO,” Rosenberg explains, noting that LaPietra is now the medical director of pain management in the ED at SJRMC. “She took this pain fellowship and brought back the ALTO program.”
While the primary aim of the program is to use alternatives to opioids whenever possible, there is also another important underlying goal.
“Many patients who come to the ED with acute pain will go on to have chronic pain, so if we can stop the acute pain from becoming chronic, that would be helpful,” Rosenberg notes. “Also, if we don’t have to give opioids, then no one will get addicted to opioids.”
Rosenberg explains that the protocols that make up the ALTO program are focused on five key diagnoses that emergency providers see regularly:
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renal colic or kidney stones;
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lumbar radiculopathy or sciatica;
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acute headache, including migraine and cluster headaches;
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musculoskeletal pain, such as back pain and shoulder pain;
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extremity fractures and joint dislocations.
Under the ALTO program, instead of using opioids for these diagnoses, providers use a host of different therapies, but the focus of these therapies is very different, Rosenberg stresses.
“This is not just giving a different pain medication,” he says. “The pain medications are specifically chosen because of how they affect the pain receptor sites for each of the different pain syndromes.”
Rosenberg adds that it is not a matter of giving a patient acetaminophen instead of opioids.
“That is not how this works,” he explains. “All pain is mediated by receptors, so we are just addressing the receptor sites.”
Among the alternative therapies called for in the ALTO program are trigger point injections, nitrous oxide, and ultrasound-guided nerve blocks, to name a few. But are physicians receptive to using such therapies?
“Once [physicians] hear the protocols, they understand how it is really [about] receptor management, and when they hear our success rate, everyone is willing to jump on board,” Rosenberg says. “Physicians are well-meaning and don’t want to contribute to the opioid problem if they have another option.”
In many cases, the ALTO therapies actually work better than opioids, Rosenberg observes.
“We see this over and over again — more complete pain relief,” he says. “Rather than covering up the pain with an opioid, we are actually stopping the pain at the receptor site.”
Provide Education, Psychosocial Support
The ALTO program is not just about prescribing; it also focuses on providing psychosocial support and education to patients, Rosenberg notes.
“The majority of patients do not want to get dependent on opioids, and they would rather stay away from them. What they want is pain relief, and I can give them comparable or better pain relief without using opioids,” he says. “Patients are excited about this, and it is not experimental treatment. It is just using different treatments rather than going to opioids.”
For follow-up, the ALTO program reaches into outpatient centers that understand the approach.
“This is a comprehensive, multidisciplinary program that utilizes family medicine as part of our referral practice, and they know the patients in the ALTO protocol are trying to not use opioids,” Rosenberg says. In some of the more difficult cases, physical therapy and other non-opioid techniques may be used to help patients effectively manage their pain, he says.
Rosenberg acknowledges that some patients who have been on opioids before and want to receive opioids again for a variety of different pain relief reasons likely will not be satisfied with the ALTO approach. He adds that patients with dependency issues — especially those patients who have overdosed on oxycodone or heroin — will be referred to recovery programs.
While the aim of ALTO is to minimize the use of opioids, there is a major place for the powerful painkillers when they are, in fact, needed, Rosenberg stresses.
“We use opioids, but we try alternatives first,” he says. “The results have been phenomenal.”
Take More Time With Patients
The ALTO approach takes a bit more of a provider’s time to deliver for a variety of reasons, LaPietra acknowledges.
“Patients deserve to get a little bit more education than maybe we have classically given them,” she explains. “When we first prescribed something like a tablet of Percocet, we [would] say, ‘here you are getting a strong pain medication and you might get a little nauseous, and you might feel a craving for it, so be careful.’ [There was] very minimal instruction when they were getting one tablet.”
With the ALTO program, patient education is a high-priority task that applies not only to explaining the opiate alternatives that are available, but also to explaining the risks of opiates when they must be used.
“We do take a little bit more time than we did before, but that is a population health benefit overall,” she says. “It makes our patients feel involved in the conversation, and it helps them feel confident when we take the time to talk to them.”
LaPietra adds that the extra time with patients helps ease their anxieties, and probably also helps them feel better.
“They know that they are going to be treated and that we care about what is going on,” she says.
Also, some of the ALTO treatments, such as trigger point injections, take more time to deliver than prescribing a tablet, but they are also better medicine, LaPietra contends.
“It is a good investment. It is what medicine is about: involving the patient, caring for the patient, and taking some time with the patient,” she says.
On average, LaPietra estimates that the ALTO approach requires an extra one to two minutes — not enough of a change to adversely affect patient flow.
“In our 12-hour day, adding a minute or two to each patient shouldn’t inhibit our ability to discharge and see more patients,” she says. “The patients are very satisfied, so it is worth investing the time because they will leave the department feeling better about their experience.”
In fact, improved patient satisfaction has encouraged providers to spend extra time with patients because they get to see the positive patient response, LaPietra notes.
Rosenberg notes that the extra time providers spend with pain patients has not adversely affected the total amount of time patients spend in the ED.
“When I am looking at discharged patients, which most of [the ALTO] patients are, the cycle time after they have been seen by a physician has actually decreased,” he says. “On the global picture, I am not seeing any effect by implementing this pain management program on discharged patients.”
Consider Payer Response
How do program administrators know the program is working? Rosenberg observes that many of the patients receive immediate and complete relief from their pain. The approach has worked particularly well for patients who present with renal colic, he says. For instance, Rosenberg recalls one patient who had received hydromorphone, but achieved only partial pain relief.
“At that point we got a pain consult with our team and the decision was made to use the ALTO protocols. The patient got some IV lidocaine and had complete relief of his pain,” he explains.
Providers also are achieving good results from patients who present with severe back pain, many of whom are in such pain that they are unable to walk when they first arrive, Rosenberg says.
“We find the site of where the pain is coming from or where the trigger is,” he says. “That is where you have a focal area — a spasm of inflammation, whether it is in the neck or upper or lower back.”
Typically, these patients receive trigger point injections with lidocaine-type medications, and they feel much better very quickly, Rosenberg explains.
“We refer these patients into physical therapy or start them on physical therapy while they are still in the ED, and they are followed up with our family medicine program,” he explains. “We have not gotten any patients back in need of [repeat] trigger point injections. Most of the time the cycle is broken and patients are doing extremely well.”
The ALTO program is so new that it is not yet entirely clear how payers will view the treatments, Rosenberg notes.
“We have not had any issues,” he says. “We have been doing regional nerve blocks for a long time, so I would anticipate that these are billable procedures ... and that insurance companies would be paying for them.”
Decline Refill Requests for Opioid Prescriptions
Thus far, there is little evidence that the program has discouraged “doctor shopping” patients from presenting to the ED — at least not yet.
“The feedback I have gotten is that the patients are still coming, but they are asking questions and they are [mentioning] the program by name,” LaPietra says. “They are saying that they have some chronic pain or that they have come here before for a painful condition, and that they understand that we will not be giving them pain medication anymore.”
The nursing staff report they spend a lot of time bedside with these patients, educating them about what ALTO really is, and pointing out that they will receive treatment for their pain; however, nurses also stress patients will undergo a risk assessment, and that providers will try to be appropriate and responsible in what they prescribe, LaPietra explains.
“For some of these patients who have chronic pain and longstanding prescriptions from their physicians, we are able to look them up in our prescription database, and if they have a history of opioid prescriptions from their physicians, that is good and it leads me to believe that they are receiving good care in the community,” LaPietra says. “But we will not refill those chronic pain medications. That is a part of ALTO that we have tried to push our physicians to educate our patients about.”
Emergency providers will take care of an acute pain episode in the ED, and they will turn to opioid alternatives first, but patients must understand that emergency providers will not be refilling any high-milligram prescriptions for pain medications, and that is for patient safety, LaPietra stresses.
“If patients are on a lot of strong opiates that have side-effects, then they need to be followed up regularly with the physician who did the extensive evaluation before giving out those kinds of medications,” she says. “We don’t have that kind of time with our patients.”
LaPietra agrees these types of patients might eventually seek treatment elsewhere, but she is also hopeful that with some education and understanding of the risks, patients will follow up with a primary care practitioner.
“That is the most appropriate place to go rather than utilizing the ED for prescription refills,” she says.
Make the Required Investments
Clinicians and administrators interested in establishing a program similar to ALTO in their own hospitals must allow time for providers to learn the new protocols and become comfortable with the approach, LaPietra notes. This required four to five months of intense training in the ED at SJRMC, but it is a very large department with 50 to 60 attending physicians, 24 residents, a few mid-level providers, and more than 100 nurses, she explains.
However, the hardest work, and what takes the longest amount of time to accomplish, is involving other departments, LaPietra says.
“In the ED, you are a closed unit, so word travels quickly and the dissemination of information can happen pretty easily,” she explains. “But when you are talking about getting the support of other departments, that calls for meetings, and then after the meetings there is reflection, and then discussion with colleagues.”
Engaging other departments requires effort and resources, but it is worth the investment, LaPietra stresses. “If the hospital system wants to adopt this protocol, the ED is the heart and soul of it, but really the benefit of this program is in the community where there will be a strong downstream effect,” she says.
Further, LaPietra states that clinicians from many different disciplines have been receptive to the ALTO approach.
“Everyone is very aware of what is going on right now with prescription opiates, and what I am finding is that everyone is trying to do a little better,” she says. “[The other departments at SJRMC] were very open to adopting something that we already had for them.”
Implementation does not necessarily have to take a full year, but administrators should appreciate the amount of outreach and training that must take place, LaPietra stresses.
“The long-term effects of all this investment are going to be huge,” she says. “This is going to continue to improve patient lives and patient safety.”
Be Proactive
Both LaPietra and Rosenberg say they are happy to share their protocols and research, and they are willing to collaborate with others interested in implementing an ALTO-type program.
“If we are the only ones doing this, then it is not helping everybody,” LaPietra explains. “We want to be a model. We want to show people what we are doing and how we have made it successful ... so that we can start a paradigm shift away from only using opiates and [having providers realize] that there is a lot more out there.”
LaPietra adds that the ALTO program is about reform and the recognition that things need to change.
“Not only do we need to make change in terms of available treatment for people who have an addiction, but we also need to promote a proactive approach to prevent people from getting hooked on prescription opiates, which are really a gateway drug into heroin,” she says.
Also, by taking a proactive approach to the problem, there is no need for the government to issue more regulations, LaPietra observes.
“We don’t need the government to limit our opiate prescribing. We want to be able to prescribe these medications. They are very important, especially for end-of-life pain,” she says. “We are already regulating ourselves by [implementing] an innovative, proactive program that can contribute to dampening this epidemic.”
SOURCES
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Alexis LaPietra, DO, Medical Director, Pain Management, Emergency Department, St. Joseph’s Regional Medical Center, Paterson, NJ. Email: [email protected].
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Mark Rosenberg, DO, MBA, FACEP, Chairman, Emergency Medicine; Medical Director, Population Health, St. Joseph’s Healthcare System, Paterson, NJ. Email: [email protected].
