Opioid Reduction in the Emergency Department

Opioids have long been the go-to medication for pain because their ability to quickly alleviate pain.  Tragically, these medication which have helped those in excruciating pain are now reeking havoc on so many lives, due to their highly addictive properties and their potential for leading well-meaning folks down the path to heroin addiction.

Some emergency departments in the United States are working to reduce opioids as a first-line treatment such as St. Joseph’s Regional Medical Center’s emergency department in Paterson, NJ. In January of this year, the emergency department at St. Joe’s adopted an approach of using opioids only as a last resort.

Responding to the astonishing rise in opioid addiction, Dr. Mark Rosenberg, St. Joe’s chairman of emergency medicine, suggested the possibility of treating many ER patients without opioids.   These efforts appear to have paid off. The hospital reduced its opioid use in the ED by 38 percent in five months, administering non-opioid protocols to approximately 500 acute pain patients with about a 75% success rate during that time period.

According to Dr. Lewis Nelson, a professor of emergency medicine at New York University School of Medicine, patients have the impression that opioids are the right treatment for pain because ER doctors are often the first doctors treat acute pain with opioids.  However, opioids are not always the only effective treatment for pain.

For instance, instead of the typical regimen of Percocet, an opioid painkiller with possible side effects such as constipation and fogginess, but more importantly, addiction, doctors have, in some cases, been able to alleviate pain by administering a trigger point injection of Marcaine, a numbing, non-opioid analgesic.

There will be instances where pain medications such Vicodin and Percocet pills or intravenous morphine and Dilaudid cannot be effectively substituted, such as bad burns. However, the goal is to find a viable substitute when the opportunity is there.

When it comes to common instances of acute pain, such as migraines, kidney stones, or fractures, the ER doctors first try treating patients with alternative treatments including nonnarcotic injections, ultrasound guided nerve blocks, and nitrous oxide. They have even used “energy healing” and a wandering harpist.

The concern with treating pain with opioids lies in what happens after the patient is discharged from ER with a prescription for an opioid. Public health experts see the emergency rooms as a common starting point on a patient’s journey to opioid addiction and often subsequently heroin addiction.

A 2013 federal study found that almost 1,150 people a day nationwide went to emergency departments for treatment related to prescription opioids.   The CDC determined that there were 10,574 heroin overdose deaths and 14,838 for prescription opioids in 2014.

Patients who cannot get refills opioid prescriptions, for instance, for insurance reasons, have turned to the less expensive and more widely available opioid, heroin.  For example, 30 milligrams of Percocet can be bought on the streets in Paterson for about $25 whereas a bag of heroin sells for about $2.

Doctors and other health officials are not the only people who recognize the danger of using these medications to treat pain.  Patients who are in recovery from opioid addiction are grateful for alternative pain regimens such as intravenous lidocaine, a non-opioid analgesic instead of intravenous morphine, which will not put them at risk for relapse.

Unfortunately, there are patients whose pain will not respond to alternative treat alternative treatments and will eventually need opioids to curb pain.  At St. Joe’s, in those instances, some patients are given a limited prescription for opioids and a warning about the medications’ risks upon discharge. The staff then connects patients with therapists, pain management specialists, primary care physicians and psychiatrists who have bought into the program’s goals in order to help prevent acute pain from becoming chronic.

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