1. 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

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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

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

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

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

12. 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

13. 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

14. Extremity Fracture Joint Dislocation
Ultrasound Guided Regional Anesthesia

15. Nitrous Oxide

16. 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 Ducasse 2013
Klomp Aboumarzouk 2011
Furuya Atassi 205

17. 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

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

19. 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

20. 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

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

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