Alternatives to opioid protocols in Colorado emergency departments reduce opioid use without changing reported pain

Abstract

Objective: The objective of this study was to determine whether instituting an alternative to opioids (ALTO) protocol significantly reduced opioid use in emergency departments (EDs). The secondary objective was to determine whether patient-reported pain and satisfaction were affected. Methods: Electronic health records for 10 EDs in Colorado were retrospectively examined for the 6 months before the intervention and for the same 6 months the following year after the intervention, which consisted of systemic and educational initiatives in line with the Colorado American College of Emergency Physicians 2017 Opioid Prescribing and Treatment Guidelines. Results: Of the total preintervention and postintervention unique patient visits, 47.2% received 1 of the drugs of interest, an opioid or ALTO, while in the ED. In aggregate, the EDs decreased opioid usage, measured in morphine equivalent units per 1000 ED visits, by 37.4% (95% confidence interval, 33.6%-76.2%; P < 0.0001) after the intervention. Statistically significant decreases were seen in every type of opioid. Statistically significant increases in ALTO usage were also noted across all study hospitals. There were no significant changes observed in Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores before and after the intervention in the hospitals with Hospital Consumer Assessment of Healthcare Providers and Systems data (preintervention mean, 3.74; postintervention mean, 3.74; P = 0.637), and there was a small but statistically significant improvement in pain scores (preintervention mean, 3.62; postintervention mean, 3.66; P = 0.002). In a subgroup analysis of patients presenting with chief complaints of long bone fractures and malignant neoplasms, there were no significant reductions in opioid use. Conclusions: This study demonstrated the feasibility and effectiveness of implementing ALTO protocols to reduce opioid use in the ED setting without an overall reduction in patient perception of pain or satisfaction with care.

Emergency Department Alternatives to Opioids: Adapting and Implementing Proven Therapies in Practice

“…The ED-ALTO programs initiated within other institutions in the United States have focused on medication-based changes to the treatment of pain [7][8][9][10][11]. Given that most of the medications were not novel with respect to ED care prior to this intervention, we did not anticipate a large increase in ED-ALTO medication use, yet our results do show a small overall increase in medication utilization.…”

“…ED-ALTO therapies included the use of alternative medications and procedures to treat pain. A specific order set containing various medication choices based on a previous publication [8] was added to our hospital formularies under an "ALTO Study ED Pain Management" label within the EHR. This order set is categorized by types and areas of pain complaints, namely, headache/migraine, musculoskeletal, renal, abdominal, and extremity fracture/joint dislocation.…”

“…Innovative programs that encourage the use of non-narcotic medications and procedures to treat pain in the ED have recently been evaluated [7][8][9][10][11]. These programs, collectively known as Emergency-Department Alternatives to Opioids (ED-ALTO) programs, have shown initial promise with respect to reductions in opioid use [7,8], effective pain control, and patient satisfaction [7][8][9]. The early ED-ALTO programs primarily focused on the adoption of non-narcotic pharmacologic therapies to treat pain [7][8][9].…”

“…These programs, collectively known as Emergency-Department Alternatives to Opioids (ED-ALTO) programs, have shown initial promise with respect to reductions in opioid use [7,8], effective pain control, and patient satisfaction [7][8][9]. The early ED-ALTO programs primarily focused on the adoption of non-narcotic pharmacologic therapies to treat pain [7][8][9]. However, the additional adoption of proven procedures from other medical specialties to treat pain in the complaints.…”