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One of the places many people are first prescribed opioids is a hospital emergency room. But in one of the busiest ERs in the U.S., doctors are relying less than they used to on oxycodone, Percocet, Vicodin and other opioids to ease patients' pain.
In an unusual program designed to help stem the opioid epidemic, the emergency department at St. Joseph's University Medical Center in Paterson, N.J., has been exploring alternative painkillers and methods. That strategy has led to a 58 percent drop in the ER's opioid prescriptions in the program's first year, according to numbers provided by St. Joseph's Healthcare System's chair of emergency medicine, Dr. Mark Rosenberg.
"There is a complete change in philosophy, a complete change in culture in the department," says Rosenberg, who launched the Alternatives to Opiates program in 2016 with Dr. Alexis LaPietra, the medical director of pain management in the emergency department.
Last year, the program was highlighted during a visit to the hospital by the chair of President Trump's commission to study the national opioid crisis, former New Jersey Gov. Chris Christie.
Patients are experiencing the shift in care for painful symptoms related to various diagnoses, including kidney stones, broken bones and muscle spasms.
It was a muscle spasm and a deep bruise from a subsequent fall that brought Jonathan Milton, a 43-year-old forklift driver from Jersey City, N.J., hobbling into St. Joseph's ER one morning in January.
A couple nights earlier, Milton was at home, lying on the floor and watching TV. He accidentally fell asleep on his left side. When he woke up the next morning, he could barely get up. From his left hip down to his leg, he says, the spasm left him feeling "like somebody just came into that room, just kicked me and kept moving." Later at work, when he tried to get up into the forklift, he fell.
"I was so much in pain — tears were coming out my eyes," he said as he waited in a hospital chair for more instructions from his doctors.
Milton has come into this ER in pain before.
"I did see from your visit you were here for that shoulder sprain," said LaPietra, after checking the hospital's records about Milton's 2011 visit. "You did get opioids. You got Percocet."
Back then, opioid painkillers were part of the emergency department's first line of offense against pain. Today, opioids are not banned, but LaPietra says sometimes the best way to reduce the pain from a muscle spasm, for example, is dry needling of a trigger point, not a pill.
"Because it's so contained, it's hard for that medication to actually get into the spasm," she explains, adding that the dry needle can break up the muscle tissue and mechanically stop the spasm and the pain — with no medication needed. The dry needling is followed with a small injection of a local anesthetic for the soreness caused by the needle.
The ER team at St. Joseph's employs a number of other pain-relieving strategies, too: using patches of lidocaine (a non-opioid painkiller); ultrasound to find nerves so they can inject numbing agents; laughing gas for patients to breathe in through a mask, and even a harpist to roam the halls to soothe patients, who are then often sent home with instructions to use ibuprofen, acetaminophen or a warm compress rather than opioids.
"We have to go back to times when things were a little more simple," LaPietra says. "Those easy, at-home techniques — good patient education, really — they help a lot with some of that pain that patients have to deal with when they go home."
But what may sound like common sense now — in light of the increased awareness of how addictive opioids can be — still requires a major culture shift among ER doctors who have prescribed these pills for years.
"It took a little bit of getting used to," says Dr. Ninad Shroff, an attending physician in St. Joseph's ER. "I've been doing this for about 20 years, so for me, it was a big change."
Two years into the alternatives-to-opioids program, however, Shroff says during some shifts in the ER, where he mainly treats bumps, bruises and other musculoskeletal injuries, he doesn't prescribe a single opioid. He still finds that "unbelievable," he says.
Rosenberg, who runs the ER, says doctors at other hospitals nearby are noticing the shift at St. Joseph's. He says he's been asked, "Why are all the drug users from your area coming to my emergency department?"
"It's because they're not going to get opioids at our emergency department unless they're absolutely needed," Rosenberg says.
One challenge his program has had to work through is the cost of using alternatives to opioids. A few times, doctors had to work with pharmacists to find more affordable alternatives to the alternatives. For example, instead of prescribing lidocaine patches for patients to put on at home, doctors have switched to lidocaine ointment or cream, which is often covered by insurers.
"The insurance companies don't embrace all the alternative treatments and instead would rather frequently have us prescribe opioids because they tend to be inexpensive and readily available," he says.
Other emergency departments have rolled out alternatives to opioids at a smaller scale. But the model that St. Joseph's has developed is now being copied at other facilities, including some in the UCHealth system in Colorado.
"A lot of people now are very sensitive to the opioid epidemic," says Dr. Thomas Brabson, chairman of emergency services at AtlantiCare Regional Medical Center in Atlantic City, N.J., where he launched a similar opioid-alternative program in 2016.
"The pleasant feeling of the opioids was something that people presumed was what the patients wanted, and that would help with your customer service scores," Brabson explains, adding that now more patients are asking physicians not to prescribe any opioids.
It's a change in expectations about the painkillers that you also hear from patients.
"Don't give me that," says Milton, the forklift driver with a muscle spasm. "I'd rather just keep dealing with the Motrin or the Advil."
For his shoulder sprain back in 2011, doctors at St. Joseph's gave Milton a dose of Percocet in the ER and more pills to take home. But during his recent visit, Dr. Jessica Lim put a patch of lidocaine on his left side and told him to take Motrin and Tylenol and to stretch at home.
"We were considering giving you a muscle relaxer," Lim explained to Milton, "and I know you don't like that feeling. So we're not going to give it to you. This is even more on you to do the work yourself at home, and I know a lot of patients don't like hearing that."
But Milton was OK with her advice — and glad to leave the ER with no opioids.