The ALTOSM Program Alexis M. LaPietra, DO Interim Chair, ACEP Pain Management Section Medical Director EM Pain Management St. Joseph’s Healthcare System Paterson, NJ The ALTOSM Program

Addiction What can we do in the ER? Acute Pain Alternatives Opiates Feel Better We see a huge population of patients for their first visit for acute painful conditions……. The main goal of all physicians in this current epidemic is to prevents addiction…. How was this typically done… we give opiates…. So lets now try and avoid them whenever possible in the hope that we decrease addiction Addiction

The ALTOSM Program “Alternatives To Opiates” St. Joseph’s Regional Medical Center, Paterson, NJ went live January 4, 2016 Multi-modal non-opioid approach to analgesia for specific conditions Not proposing an opiate free world I am proposing responsible prescribing with the understand that opiates are often no indicated

The ALTOSM Objectives The goal is to utilize non-opioid approaches as first line therapy, and educate our patients. Exhaust alternatives first Opioids will be used as a second line treatment or rescue medication Discuss realistic pain management goals without patients Discuss addiction potential and side effects with using opioids

Opioids are necessary…… ……but they are not the solution for all pain THINK before you prescribe USE alternatives whenever possible CARE about the patient , addiction is a disease Use your brain remember there is more to managing pain than giving opioids Think about what is causing their pain (inflammation- use an NSAID) Care about patients, because if you liberally prescribed opioids a percentage will go one to become dependent.

Targeted Treatment By identifying the generator of pain physicians can target treatment to that area Flooding the body with opioids only masks that pain to the brain, but does not actually address the underlying case

NMDA Receptor Antagonists Sodium Channel Blockers COX-1, 2, 3 inhibitors Nitrous Oxide GABA agonists/modulators We have so many different receptors we can target to eliminatre pain, why are we relying solely on the opioid receptpr Inflammatory Cytokine Inhibitors

Lidocaine and Ropivacaine Ketamine NSAIDs and Tylenol Lidocaine and Ropivacaine Benzodiazepines Neurontin Nitrous Oxide We can use all these different meidcaitons, we have lots of tools in our toolbox Corticosteroids

Extremity fracture/Dislocation ALTOSM Conditions Acute low back pain Lumbar radiculopathy Renal colic Migraine Extremity fracture/Dislocation

Acute Low Back Pain Alternatives NSAIDS Tylenol Topicals Lidoderm, Voltaren, Flector Trigger Point Injection Muscle Relaxants Use all of these to help with pain

Lumbar Radiculopathy Opioid Tolerant Patients NSAID + Tylenol Gabapentin Valium or Flexeril Ketamine infusion + drip Use all the alternatives but the important medication is ketamine

Renal Colic Toradol 30 mg IV Tylenol 1000 mg PO 1 L 0.9% normal saline Cardiac Lidocaine 1.5 mg/kg over 10 minutes Max 200 mg

Valproic Acid 500 mg in 50 mL over 20 minutes Migraine Algorithm Toradol 30 mg IV AND Reglan 10 mg IV Sumatriptan 6mg sc Trigger Point Inj Dexamethasone 4-8 mg IV AND Magnesium 1 g IV Valproic Acid 500 mg in 50 mL over 20 minutes <50% Relief If >50% relief If >50% relief Discharge Abstract presented at American Headache Society 2015

Extremity Fracture Joint Dislocation Ultrasound Guided Regional Anesthesia

Nitrous Oxide

Nitrous Oxide Evidence Laceration repair Lumbar puncture Peripheral or central access Incision & Drainage Foreign Body removal Burn/Wound Care It indicated for any and every painful condition All ages Can be used an analagesic for any painful procedure Herres 2015 Ducasse 2013 Klomp 2012 Aboumarzouk 2011 Furuya 2009 Atassi 205

ALTOSM Partnerships Departments Physical Therapy Family Medicine Psychiatry Chronic Pain Management The whole house of medicine needs to unite to make change and improve patient safety and care

Future ALTOSM Goals Suboxone in the ED Acupuncture in the ED Expansion to inpatient units

ALTOSM Partnerships St. Joseph’s Opioid Overdose Prevention and Naloxone Distribution Program Eva’s Village Peer Counselors Straight and Narrow Program WE cannot ignore the disease of addiction, we must work with out community partners to help patients suffering/ The SJRMC opioid OD prevention and naloxone distribution program holds community classes to educate family and friends of people with addiction and then gives out intranasal narcan to be kept in the house of car for quick administration is necessary. Eva’s village will send counselor to ER for every narcan resuscitation to try and capture that patient for recovery right from the ED S&N sends their patietns over to SJRMC because we utilizine non-opioid modalities for those who are recovery from opioid addiction

Education Emergency Medicine Residency Pain Management Curriculum Didactics + Hands on teaching Pain Management Rotation USRA and more Emergency Medicine Pain Management Fellowship, first of its kind Dr. Adelaide Viguri WE strive to sustain this program by educating our physicians and continuing to establish best practices for pain management

ALTOSM results First 3 months N= 1600 patients 47.6% reduction in opioids for acute low back pain, renal colic, and headache p= 0.0001 Pain scores pre-ALTO 8 1.9 Pain score post-ALTO 7.9 2.0 p=0.001

If you’d like to know more 1st ACEP Pain Management Section meeting Sunday October 16th at 5 pm Tradewinds B lapietra@sjhmc.org