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Emergentology: The Opioid-Lite Emergency Department

Walker, Graham MD

doi: 10.1097/01.EEM.0000511098.82775.57
Emergentology

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at http://bit.ly/EMN-Emergentology.

If you're an emergency physician and you crawled out from under your rock at least once in the past nine months, you've probably heard of Alexis M. LaPietra, DO, and her mystical “opiate-free ED.” She and her emergency department at St. Joseph's Regional Medical Center in Paterson, NJ, have been featured in The Guardian and on MSNBC, CNN, Fox News, and the NBC Nightly News for trying to make a dent in emergency medicine's dependence on opioids for pain relief.

Please, dear reader, unroll your eyes. Dr. LaPietra will be the first to tell you that her ED still uses opiates on a daily basis. “No ER can or should function without opiates. I'm a huge fan of opiates,” she said, but she said EPs can provide excellent pain control in a number of cases without them.

I'd read about her department in the New York Times quite skeptically, but I was still interested. Which one of us wouldn't love to dole out fewer opioids if there were a reasonable and effective alternative? I spent an hour talking with her about her innovative ALTO (Alternatives to Opiates) program, but first, a bit of backstory.

Paterson, NJ, is in an interesting spot geographically. It has wealthy suburbs to the north, Newark to the south, farmland to the west, and New York City to the east. And sadly (but not surprisingly), St. Joseph's ED has seen the effects of opiates from all directions on the map. “People often drive into the community to get pills or heroin,” she told me. “There are women dressed in very expensive clothes with an expensive handbag overdosing, and in the next stretcher there is inner-city homeless with pinpoint pupils as well. Opiate dependence and addiction affect every race, age, and community, and we see them all here at St. Joseph's,” said Dr. LaPietra, the medical director of emergency medicine pain management and the director of the emergency medicine pain management fellowship at St. Joseph's Healthcare System and the chair of ACEP's pain management section.

When she was graduating from her residency in 2014, she was trying to answer that question we all faced: What now? Become an attending? Do a fellowship? She tells me she liked the idea of an ultrasound fellowship so she could master regional nerve blocks. She ended up talking with the regional anesthesia experts at her hospital and realized regional anesthesia was doing “a ton of stuff ... with a ton of crossover that we don't know about.” With the support of her innovative, forward-thinking department chair Mark Rosenberg, DO, her pain management fellowship was born.

Dr. LaPietra said she spent a year talking to everyone in her hospital who dealt with pain; it helped that her hospital is incredibly collegial and that the departments have good relationships and work together. She met with the regional anesthesia experts, by neurology, physical medicine and rehabilitation, orthopedics, pain management, and even palliative care, taking their knowledge and adapting it to the emergency department. Toward the end of her fellowship year, Dr. Rosenberg asked her what she was going to do with all of her knowledge? Opiate reduction was the obvious answer for her.

“Maybe we can try to prevent [opiate addiction] by having fewer people prescribed opiates. Some opiate prescribing in the ED might be inappropriate, or some might be quantity-related,” she said, noting that having unused opiates around the house can be a disaster for patients and their children. Dr. LaPietra wants to address both ends of the spectrum — treating more conditions without opiates at all and treating some conditions with fewer opiates, especially upon discharge. In case you're wondering, the maximum number of Percocet she'll write for from the ED is 12, usually fewer.

A few examples of her ALTO protocols appear in the table. Next month, I will interview Dr. LaPietra in a Q&A about when she still uses opiates, dealing with drug seekers, trigger point injections, and more.

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ALTO Clinical Applications

Renal Colic

1. Toradol 30 mg IV

2. Cardiac lidocaine 1.5 mg/kg IV in 100 mL NS over 10 minutes (MAX 200 mg)

a. Patient should be on a cardiac monitor.

3. Acetaminophen 975 mg PO

4. 1 L NS bolus

Musculoskeletal Pain (sprains, strains, or opiate-naïve lower back pain)

1. Acetaminophen 975 mg PO

2. Motrin 600 mg PO or Toradol 30 mg IV/IM

3. Muscle relaxant (choose one of the following)

a. Flexeril 5 mg PO (patients >65 years old or <70 kg or concerns for somnolence)

b. Flexeril 10 mg PO (patients >70 kg)

c. Valium 5 mg PO

4. Lidoderm patch to most painful area, MAX 3 patches. Instruct patient to remove after 12 hours.

5. Gabapentin (neuropathic component of pain)

a. 300 mg PO (patients >65 years old or <70 kg or concerns for somnolence/naïve to med)

b. 600 mg PO (patients >70 kg or not naïve to med)

6. Trigger point injection with 1-2 mL of Marcaine 0.5% or lidocaine 1%

Acute on Chronic Radicular LBP (opiate tolerant)

1. Acetaminophen 975 mg PO

2. Motrin 600 mg PO or Toradol 30 mg IV/IM

3. Muscle relaxant (choose one of the following)

a. Flexeril 5 mg PO (patients >65 years old or <70 kg or concerns for somnolence)

b. Flexeril 10 mg PO (patients >70 kg)

c. Valium 5 mg PO

4. Gabapentin (neuropathic component of pain)

a. 300 mg PO

5. Dexamethasone 8 mg IV

6. Lidoderm patch to most painful area, MAX 3 patches. Instruct patient to remove after 12 hours.

7. Trigger point injection with Marcaine 0.5% or lidocaine 1% 1-2 mL

8. Ketamine 0.3 mg/kg over 10 minutes

a. Ketamine 0.1 mg/kg/hour

Used with permission. Copyright ©2015 St. Joseph's Healthcare System. All Rights Reserved. This table and the references that went into creating it are available at http://bit.ly/ALTOprotocols.

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