A pilot group of 10 EDs in Colorado has shown impressive reductions in opioid prescribing by encouraging the use of alternatives to opioids (ALTO) in the care of five key pain pathways. Between June and November 2017, the pilot sites reduced the use of opioids by 36% when compared to the same six-month period in 2016. The Colorado Hospital Association (CHA), which championed the initiative, is moving to expand the ALTO approach used in the pilot to other hospitals in the state.
- The pilot ED sites focused on alternative treatment options highlighted in the Opioid Prescribing and Treatment Guidelines unveiled by the Colorado chapter of the American College of Emergency Physicians in 2017.
- In-person training on ALTO techniques was provided to physicians, nurses, and pharmacists at each of the 10 pilot sites in advance of the pilot.
- The 10 pilot sites will assist CHA in expanding the ALTO approach to all the hospitals in the state.
- Also on tap is a new CHA initiative focused on the treatment of addiction in the state that will include a pilot where EDs will initiate medication-assisted treatment (MAT) before providing a warm handoff to MAT treatment providers in the community.
To the doubters who maintain that a large-scale reduction in opioid prescribing in the nation’s EDs is simply not realistic, check out what Colorado has accomplished. During a six-month period, a pilot group of 10 EDs set out to reduce the use of opioids by promoting alternative treatment approaches primarily focused on five common pain pathways: headaches, musculoskeletal pain, renal colic, chronic abdominal pain, and extremity fractures/joint dislocations.
The goal of the effort, which was led by the Colorado Hospital Association (CHA), was to see if the pilot EDs could reduce their use of opioids by 15% between June and November 2017. The participating EDs far surpassed these expectations, reducing opioid prescribing by 36% when compared to the same six-month period in 2016, a level of achievement that amounts to 35,000 fewer opioid doses delivered.
Further, investigators have found that there was virtually no statistical difference between patient satisfaction scores recorded before and during the pilot program, alleviating concerns that large numbers of patients would be aggrieved if they did not receive opioids for their pain. In fact, many providers experienced an opposite reaction: patients expressing relief that they would not require opioids, having heard about the well-publicized risks associated with these powerful drugs.
Now armed with a proven approach for reducing the use of opioids in the emergency setting, the CHA and its partners on the project are poised to extend the approach to all the hospitals in the state. However, pilot developers have compiled guidelines, clinical tools, and a roadmap to follow for other hospitals and communities that would like to follow suit. (See also in this issue: Shortages of injectable opioids causing adverse consequences for some physicians and patients.)
Begin With Guidelines
The impetus for the pilot stemmed, in part, from a survey CHA conducted in 2016, asking all its member hospitals what they were doing to address the opioid epidemic in Colorado, and what CHA could do to help. “It was clear that everybody was doing a little work here and there, but nobody was doing consistent, standardized work in the ED, explains Diane Rossi MacKay, RN, MSN, CPHQ, CHA’s clinical manager for quality improvement and patient safety.
In fact, survey participants indicated that the ED was their greatest concern regarding opioid safety, and more than 90% reported that they wanted to know how CHA could assist in this area. Consequently, CHA developed an Opioid Safety Steering Committee and forged partnerships with key stakeholders in the state, including the Colorado chapter of the American College of Emergency Physicians (ACEP), the Colorado Consortium for Prescription Drug Abuse Prevention, Telligen (the quality improvement organization for CMS in the region), and the Colorado chapter of the Emergency Nurses Association (ENA).
With these partners, CHA formed the Colorado Opioid Safety Collaborative to address opioid safety in Colorado’s EDs, and the pilot emerged as a key first step in addressing the opioid epidemic in the state.
Fortuitously, the Colorado chapter of ACEP was already working on the issue, unveiling Opioid Prescribing and Treatment Guidelines that focus on four key areas: limiting opioid use in the ED, using alternatives to opioids (ALTO) when treating pain, reducing harm in the ED, and treating opioid addiction. Notably, the ALTO approaches highlighted in the guidelines borrow heavily from techniques pioneered in the ED at St. Joseph’s University Medical Center (SJUMC) in Paterson, NJ, which launched the country’s first ALTO program in January 2016. “Most of the pathways that we use have been trialed and mastered [at SJUMC],” explains Don Stader, MD, FACEP, the associate medical director in the ED at Swedish Medical Center in Englewood, CO, and the physician educator for the pilot. “We are their proof of concept. Where they did it in an academic, level I trauma center, we took this and said ‘let’s see if we can put this into practice in all types of EDs.’”
Indeed, in selecting hospitals to participate in the pilot, CHA wanted to make sure that the list represented diversity. “We wanted to cover the entire state of Colorado to the best of our ability,” MacKay observes. “One of the reasons for that is we wanted to make sure that the [results] from the pilot could be transferrable across all types of hospitals with all kinds of patients.”
For example, while Swedish Medical Center is a level I trauma center, two of the other participating facilities — UCHealth Greeley Emergency and Surgery Center in Greeley and UCHealth Harmony Campus in Fort Collins — are freestanding EDs. Facilities in rural areas, such as Gunnison Valley Health in Gunnison Valley and Sedgwick County Health Center in Julesburg, were also among the 10 sites selected for the pilot.
Secure Higher-level Commitment
Bringing all the clinicians in 10 separate EDs up to speed on the ALTO techniques highlighted in the Opioid Prescribing and Treatment Guidelines was a big challenge, involving a series of on-site training sessions at each ED. “From a nursing perspective, what we did was develop PowerPoint presentations, communications scripts, and role playing,” MacKay notes. “We presented to the nurses on how you talk to patients and family members who are perhaps used to receiving an opioid when they come in with migraine headaches or kidney stones.”
On the nursing side, the trainers were from the ENA, so emergency nurses were talking and training with emergency nurses. Similarly, pharmacists provided training to pharmacists, and Stader delivered the training to physicians and advanced practice providers.
Administrative leaders at all the pilot sites had to first commit in writing to supporting the effort, a step that proved pivotal in securing buy-in from the clinical staff members, many of whom expressed concerns about the potential impact of ALTO techniques on patient satisfaction. Knowing that upper management was not only behind the effort, but also expected providers to change their prescribing practices, proved motivating, Stader observes.
However, Stader notes that most emergency providers were receptive to receiving guidance on steps they could take to address the opioid epidemic. “Many of the clinicians were very eager for education, and very eager for a way to do things differently,” he says. “How we got them to a point where they were ready to implement ALTO [approaches] was through several different mechanisms.”
First, the clinicians all had a chance to review the treatment guidelines, which provided background information on how they could use opioid alternatives for muscle pain or renal colic and other painful conditions. “The most important thing by far, however, was the in-person training, and we didn’t only train the physicians and advanced service providers, we also trained the nurses — often at the same time,” Stader notes. “I think that multidisciplinary training often times helps to break down barriers when it comes down to a clinician ordering a medicine ... so we got all the different practitioners speaking the same language and thinking the same steps when it came to different types of pain.”
During the in-person training sessions, Stader reviewed each of the ALTO medicines and what the patient indications were for each drug, and also some of the new procedures he was encouraging practitioners to use such as trigger-point injections.
“I was able to tell them what my practice was, and they were able to raise their hands and ask questions about medicines they may not have used before or any concerns they had,” he says.
For example, many clinicians were worried that IV lidocaine — one of the ALTO medicines that Stader has found to be effective in the treatment of renal colic — was dangerous. “When I reassured them that we were giving less than half of the toxic dose, that eased their worries,” Stader notes.
Specifically, when a patient presents with renal colic, Stader often will provide a dose of Toradol (ketorolac tromethamine), followed by a long infusion of IV lidocaine. “I have usually been able to give my patients excellent relief, and the nice thing is we encourage the safe use of Toradol,” he says. “We used to blast everyone with 30 milligrams of Toradol, which is actually three times more than what you need. If you actually lower the dose, you are still able to get the same pain relief, but it gives you the ability to re-dose the same way you would with morphine.”
Stader stresses that the ALTO approach he favors does not mean opioid-free.
“It means that we have so many more tools that we can reach into and treat that patient in front of us with further consideration of the underlying risk factors and underlying health,” he says. “It really changes pain control back into a science.”
For instance, Stader notes that there are psychological, social, and biological components to pain, all of which contribute to how a patient expresses his or her pain, or ranks his or her pain if given a scale of one to 10. Such factors can be important when determining the best treatment strategy.
“When I walk into a room, and the patient is just hysterical with pain — be there a really painful stimuli or something that you wouldn’t objectively think is that painful — I ask myself whether this person has a psychological driver of pain,” he says. “If the answer is yes, I may start with a small dose of Haldol, a non-addictive sedative, for that patient.”
Stader notes that he has seen patients with all different types of pain report significant relief just from the calming effect on the psychological component of their pain. Early in the training sessions, one of the provider groups wanted to know how to tell patients that they would not be receiving a narcotic for their pain, and Stader responded with a list of how he often approaches the issue:
- First, Stader asks patients if they will be driving home. If they are, then he communicates that he will give them something that will not knock them out.
- Another strategy is to communicate to the patient that you are going to give them a medicine that will control their pain but not make them drowsy. “That is something that most patients are going to respond positively to,” Stader advises.
- For patients who insist that they need something stronger than the ALTO medication, Stader tells them the medicines he is prescribing should be strong enough to control their pain, but if they do not control the pain effectively, then a traditional opioid still is an option.
- When patients are skeptical, Stader elevates the drug decision over his head by saying it is hospital policy or ED policy to use a non-opioid medication first. That typically removes conflict from the physician-patient interaction.
- For patients who are just in the ED to get their hands on narcotics, and who are not open to receiving help for an addiction, Stader will draw the line and say he is not comfortable prescribing a narcotic medication. These patients most likely will leave the ED at this point.
It is important to note that while some patients may express concerns about not receiving an opioid, there also are many patients who are relieved to hear that they will not be receiving narcotic medications. “That is a population that has been growing over the last few years,” Stader observes. “You have this population that reads newspapers, is hyper-educated, and sees the danger of opioids because it has been written about so much, and they actually come in fearing an opioid. Sometimes, I have to convince them that an opioid is actually the right drug for them.”
Identify Champions, Share Data
During the ALTO training sessions, practitioners received a start date and a directive to go out and integrate the new medicines and procedures into use. “How they put this kind of information into their practice varied from physician to physician, but they were able to take all of that data and all of the new tools and apply them to their practices with a lot of success,” Stader says.
Every site had a physician champion with whom Stader would communicate. Often, this would be the medical director of the ED. The pilot sites also could communicate with each other through email on a listserv. “When there was a challenge, someone would put it on the email, and the hospitals would talk and communicate with each other,” Mackay notes.
Not every physician was enthusiastic about taking steps to change their practice in line with the ALTO approach. In fact, even after all the ALTO education, Stader found that some physicians at his own hospital, Swedish Medical Center, still were prescribing four times as many opioids as the other providers. “What we did with that data is we showed it to the clinicians who were, in our minds, over-prescribing opioids, and we pointed out that they were the largest prescribers of opioids in the group,” he explains. Stader then used the data-sharing interaction as an opportunity to find out what concerns the providers had about ALTO, and what was holding them back from making improvements in this area. “We actually worked with our top three prescribers and got their prescribing down as well,” he says.
This practice of sharing data and using the information to motivate change can be a particularly effective strategy with physicians, Stader observes. “It is part of what we encourage our hospitals to do because it is such a good way to get people, who might be a little more resistant up front, to actually take steps to change their practice,” he says. “When you are being graded against your peers and [the data] show that you are falling short — that’s really powerful motivation.”
Project developers encountered numerous other challenges over the course of the pilot, too. For instance, one initial obstacle that every hospital faced was getting access to drugs that have not been used traditionally, such as small doses of ketamine and IV lidocaine. Such an approval typically goes through a hospital’s dangerous drugs committee, Stader explains. In many cases, it took multiple communications and reassurances that the ALTO approaches were safe.
Similarly, there were challenges at some hospitals regarding the use of nerve blocks — procedures that basically involve infusing lidocaine or another nerve-blocking agent around the nerve in an affected area of the body to block the transmission of pain to the brain. “Nerve blocks are procedures that some departments of anesthesia say that only an anesthesiologist can do, and some of these [requirements] are in hospital bylaws,” Stader notes. “Sometimes, you have to change those [bylaws].” It also took time to fine tune a process for collecting and reporting data from hospitals that use a variety of different IT systems. “We did have challenges with data collection, but the great news about that is those kinks have been worked out, so when we bring new hospitals on board, we will be able to spend less time on that issue,” MacKay stresses. “That’s why we do a pilot, and we do it in a small population. Because we are looking to find what works, what doesn’t work, and what we need to do differently to make things better.”
Build on Early Success
Now that the pilot is complete, CHA is preparing to launch a much larger effort aimed at getting all the EDs in Colorado to adopt ALTO techniques. “We are currently shoring up and improving the tools we have on hand now because that is what performance improvement is all about,” Mackay observes. “We are looking to start in the southern part of the state, and we will be rolling this out on a larger scale.”
The 10 pilot hospitals will be able to help the other hospitals come on board, shortening the implementation time significantly, MacKay says. Further, she notes that CHA will continue to collect data from the hospitals to ensure that the reductions in opioid prescribing are sustained.
“The participants have told us that this has changed their clinical practices permanently,” she says. “It does take time, but in six months it has changed their practices.”
While CHA is rolling out the ALTO approach statewide, the organization soon will begin working on another focus of the treatment guidelines: the treatment of addiction. Specifically, CHA is readying a pilot that will use the screening, brief intervention, and referral to treatment (SBIRT) model to initiate medication-assisted treatment (MAT) in the ED, and then provide patients with a warm handoff either to a primary care provider (PCP) or a trained MAT provider in the community who can continue to provide MAT.
“Expanding access to treatment is what we are doing here,” MacKay notes. “We are chipping away [at the opioid epidemic]. We started in one area with the ALTO pilot, and now we are expanding to MAT. It is exciting work, and we are looking at saving lives.”
Acting as an opioid consultant for CHA, Stader will take a leading role in the MAT pilot, training the clinicians and explaining how MAT will be integrated into the ED. Stader anticipates there will be some pushback, but says he is armed with data and examples.
“There is really compelling evidence that we help people [with addictions] when we actually initiate [treatment] and are then able to transition them to a MAT provider,” he explains. “I try to bring people who are in recovery from their addictions so clinicians can actually see people who are on Suboxone and are functioning who were in the throes of addiction.”
While there has been some resistance from the emergency medicine community to getting involved with the treatment of addiction, Stader maintains that initiating MAT in the ED is something that the community needs.
“We deal with a lot more dangerous situations than putting someone on Suboxone, which is a pretty easy process,” he observes. “We have to have an eagerness to look at solutions, and this is one of the solutions that we can provide.”
Editor’s Note: To access more information about the Colorado Opioid Safety Pilot, a pre-launch checklist for ED-based ALTO initiatives, and the Colorado ACEP 2017 Opioid Prescribing and Treatment Guidelines, visit the Colorado Hospital Association website at:
- Diane Rossi MacKay, RN, MSN, CPHQ, Clinical Manager, Quality Improvement and Patient Safety, Colorado Hospital Association, Greenwood Village, CO. Email: email@example.com.
- Don Stader, MD, FACEP, Associate Medical Director, Emergency Department, Swedish Medical Center, Englewood, CO. Email: firstname.lastname@example.org.