EXECUTIVE SUMMARY

To combat the prescription opioid problem, St. Joseph’s Healthcare System in Paterson, NJ, has developed a new program that gives providers options they can use to effectively alleviate pain without resorting to highly addictive medication. Launched in January 2016 in the ED at St. Joseph’s Regional Medical Center (SJRMC), the Alternatives to Opioids (ALTO) program utilizes protocols that primarily target five common conditions: renal colic, sciatica, headaches, musculoskeletal pain, and extremity fractures. Administrators say they have successfully treated more than 300 patients under the new program, and they see ALTO as a model other hospitals can duplicate.

  • Among the alternative therapies called for in the ALTO program are trigger point injections, nitrous oxide, and ultrasound-guided nerve blocks.
  • ALTO medications are specifically chosen because of how they affect the pain receptor sites for each different pain syndrome.
  • While the primary goal of the program is to use alternatives to opioids whenever possible, another important underlying goal is to stop acute pain from becoming chronic.
  • While ALTO therapies typically take a bit longer to deliver than prescribing opioids, administrators note that this has not adversely affected patient flow in the ED.

ACEP Takes Issue With Pain Questions

The American College of Emergency Physicians (ACEP) urges the Department of Health and Human Services (HHS) to remove questions about pain from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), the survey HHS uses to assess patient satisfaction among discharged patients. In a letter to HHS Secretary Sylvia Burwell, ACEP President Jay Kaplan, MD, said the questions regarding pain have resulted in unintended consequences.

Specifically, Kaplan noted that in pursuit of higher patient satisfaction scores, providers may honor patient requests for powerful painkillers, even when such medications are unnecessary or even harmful.

“Any questions that provide an opportunity for patients to express dissatisfaction because they didn’t get the drugs they sought provide disincentives for physicians to prescribe non-opioid analgesics, which will negatively affect their scores,” Kaplan said.

The 32-item HCAHPS survey includes two questions about pain:

  • During this hospital stay, how often was your pain well-controlled?
  • During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

Beginning in 2016, less than satisfactory answers to these questions adversely affect hospital DRG payments, Kaplan explained. He also noted that similar questions are included in the third draft version of the Emergency Department Patient Experience of Care (EDPEC) survey, which has undergone pilot testing. After some earlier input from ACEP, those questions now read as follows:

  • During this ED visit did you have pain?
  • Did the doctors and nurses try to help reduce your pain?
  • Did you get medicine for pain?

Kaplan noted that similar questions have been a problem for years on other types of patient satisfaction surveys and that they are counterproductive to efforts to combat the opioid crisis.

“We are concerned that the current evaluation system may inappropriately penalize hospitals and physicians who, in the exercise of medical judgment, opt to limit opioid pain relievers to certain patients and instead reward those who prescribe opioids more frequently,” he said.

Kaplan concluded his letter by urging HHS to remove any questions regarding pain at least until there is a thorough examination of whether there is a connection between the pain questions and any inappropriate prescribing.

Mark Rosenberg, DO, MBA, FACEP, supports the ACEP missive, noting that emergency providers should not be judged specifically on patient satisfaction of their pain management.

“They should be judged on the care that they give their patients and how satisfied patients are with their care,” he says. “A significant number of patients who are dependent on opioids and come to the ED to doctor shop are also filling out those surveys, and they are not satisfied unless they get a prescription for opioids.”