An E.R. Kicks the Habit of Opioids for Pain
PATERSON, N.J. — Brenda Pitts sat stiffly in an emergency room cubicle, her face contorted by pain. An old shoulder injury was radiating fresh agony down to her elbow and up through her neck. She couldn’t turn her head. Her right arm had fallen slack.
Fast relief was a pill away — Percocet, an opioid painkiller — but Dr. Alexis LaPietra did not want to prescribe it. The drug, she explained to Mrs. Pitts, 75, might make her constipated and foggy, and could be addictive. Would Mrs. Pitts be willing to try something different?
Then the doctor massaged Mrs. Pitts’s neck, seeking the locus of a muscle spasm, apologizing as the patient groaned with raw, guttural ache and fear.
“Quick prick,” said Dr. LaPietra, giving Mrs. Pitts a trigger point injection of Marcaine, used as a numbing, non-opioid analgesic.
Within seconds, Mrs. Pitts blinked in surprise, her features relaxing, as if the doctor had sponged away her pain lines. She sat up, gingerly moving her head, then beamed and impulsively hugged the doctor, vigorously and with both arms.
Since Jan. 4, St. Joseph’s Regional Medical Center’s emergency department, one of the country’s busiest, has been using opioids only as a last resort. For patients with common types of acute pain — migraines, kidney stones,sciatica, fractures — doctors first try alternative regimens that include nonnarcotic infusions and injections, ultrasound guided nerve blocks, laughing gas, even “energy healing” and a wandering harpist.
Scattered E.R.s around the country have been working to reduce opioids as a first-line treatment, but St. Joe’s, as it is known locally, has taken the efforts to a new level.
“St. Joe’s is on the leading edge,” said Dr. Lewis S. Nelson, a professor of emergency medicine at New York University School of Medicine, who sat on a panel that recommended recent opioid guidelines for the Centers for Disease Control and Prevention. “But that involved a commitment to changing their entire culture.”
In doing so, St. Joe’s is taking on a challenge that is even more daunting than teaching new protocols to 79 doctors and 150 nurses. It must shake loose a longstanding conviction that opioids are the fastest, most surefire response to pain, an attitude held tightly not only by emergency department personnel, but by patients, too.
Pain is the chief reason nearly 75 percent of patients seek emergency treatment. The E.R. waiting rooms and corridors of St. Joe’s, where some 170,000 patients will be seen this year, are frequently pierced by high-pitched cries and anguished moans.
Such pain can be quickly subdued with opioids — Percocet and Vicodin pills; intravenous morphine and Dilaudid. Most doctors say those drugs can’t be altogether replaced. In extreme emergencies — a broken bonejutting through skin; a bad burn; an acute sickle cell crisis — opioids provide effective, immediate relief.
But it is what happens after patients leave the E.R. that public health experts believe has contributed to a crisis of addiction in the United States. At discharge, patients are often given opioid prescriptions. Since the medication has kept their pain at bay, they seek refills from their primary doctors. Though many never become dependent, others do. And so although emergency physicians write not quite 5 percent of opioid prescriptions, E.R.s have been identified as a starting point on a patient’s path to opioid and even heroin addiction.
“Because we are often the first doctors to provide the patient with opioids for acute pain, we have set in their minds that it’s the right treatment,” said Dr. Nelson.
Paterson, a densely packed, hard-bitten city of 146,000, is a heroin hub for a swarm of suburbs. On a recent weekday in the E.R., John Schiraldi, 25, a recovering heroin addict, was grateful that his merciless kidney stone pain was ebbing not because of intravenous morphine — a conventional E.R. protocol — but because of a regimen that included intravenous lidocaine, a non-opioid analgesic.
“At first I thought, ‘They must have given me opioids!’” said Mr. Schiraldi. “But I didn’t have that euphoric feeling or the heaviness in my chest. I was so glad they had an alternative.”
Mr. Schiraldi is a former emergency medical technician who got a Percocet prescription two years ago, after he strained his back lifting a patient. When he lost his job, he lost health insurance and couldn’t get refills. So he turned to another, cheaper opioid — heroin.
On the streets in Paterson, 30 milligrams of Percocet sell for about $25; a bag of heroin can be had for about $2. Two cubicles away from Mr. Schiraldi, doctors were trying to revive a man who had collapsed from a heroin overdose.
According to a 2013 federal study, nearly 1,150 people a day around the country went to emergency departments for treatment related to prescription opioids. The Centers for Disease Control and Prevention calculated that in 2014 there were 10,574 heroin overdose deaths and 14,838 for prescription opioids. Mindful of the exponential rise in opioid addiction at his hospital’s doorstep, Dr. Mark Rosenberg, St. Joe’s chairman of emergency medicine, began asking two years ago whether it was possible to treat many patients who arrive in the E.R. without opioids. He sent Dr. LaPietra on a fellowship year to study pain management at specialty departments at St. Joe’s and other hospitals. She trained the St. Joe’s staff. The ER’s pharmacy stocked the alternative medications. Dr. Rosenberg alerted departments throughout the hospital to sustain the opioid-avoidant philosophy when seeing E.R. patients for follow-up visits.So far the approach has proved effective. In five months, the hospital has reduced opioid use in the emergency department by 38 percent. St. Joe’s has treated about 500 acute pain patients with non-opioid protocols. About three-quarters of the efforts were successful.
Mrs. Pitts, the patient whose neck and arm pain was alleviated by a trigger-point injection, went home with non-opioid patches. She told E.R. staff in a follow-up call that she didn’t need further medication.
The other 25 percent eventually needed opioids to curb pain, most of them patients with sciatica, kidney stones or migraines so devastating that they resisted a non-opioid headache protocol developed by the Cleveland Clinic. Upon discharge, some of them were given a limited prescription for opioids. E.R. staff not only warns these patients about the medications’ risks, but, to help prevent acute pain from becoming chronic, connects them with hospital physical therapists, pain management specialists, psychiatrists and primary care physicians who have committed to sticking to the program’s goals.
The E.R. staff is beginning to embrace the non-opioid options. “I’m thrilled,” said Allison Walker, a nurse. “I’d hate to be the first to give Percocet to a teenager who dislocated his knee at hockey practice. And then he comes back a year later, addicted to opioids? I don’t want that on my conscience.”
One patient in the pediatric E.R. recently was a 17-year-old high school varsity baseball player, who had been treated with intravenous opioids at another E.R. for a lower-back compression fracture. Physicians sent him home with tapentadol, a strong opioid.
Throughout the week, the teenager was roiled by side effects, including constipation and panic attacks. His pain did not abate. An orthopedist sent him to St. Joe’s, where he arrived sleep-deprived, thrashing and incoherent.
St. Joe’s pediatricians used a non-opioid protocol including a nasal spray of ketamine, a powerful drug which, in low doses, has analgesic and sedative properties. Within 30 minutes the patient was smiling, quiet and, without flinching, able to be transferred to a gurney for scans.
While changing medical culture has been difficult, changing patient attitudes about opioids may be more so.
“One patient might come in with short-lived pain like an ankle sprain and say, ‘I think I need some Percocet,’” said Dr. LaPietra. “And others who are dependent on opioids come in demanding and abusive. And meanwhile, you’ve got someone in the next room having a stroke! It can seem easier just to give them their prescription. They get through your armor and affect morale.”
Dr. Sergey M. Motov, an emergency medicine physician at Maimonides Medical Center in Brooklyn and a leading proponent of opioid reduction, said that for new approaches to succeed, “we need to talk with patients, acknowledge their pain, their suffering, but ask them: ‘What if we can manage it without opioids?’”
St. Joe’s doctors and nurses are learning to reframe discussions, to educate patients that complete eradication of pain may be either not realistic, or achieved at too high a price.
One treatment that gets swift patient buy-in is nitrous oxide, which the E.R. staff introduces with its better-known name: laughing gas. It is short-acting, mildly sedating, noninvasive and has countless applications in the ER Children hold masks to their faces, grinning while having a major abscess drained; teens, while having a dislocated joint popped back into place; older patients while being “disimpacted” — treated for severe constipation.
The dynamics of pain are complex and also highly individual. Pain’s components are biological, but also psychological. The other day, Edie Elkan wandered the halls of the geriatric E.R., softly plucking a six-pound “therapy harp” anchored at her waist. Patients would beckon her into their cubicles, listening fixedly as she sifted through her vast repertoire of classical and contemporary songs, of lullabies and Latin pop, her tranquil notes threading through the atonal squawks and beeps of a raucous emergency department.
St. Joe’s is even cautiously trying therapies not typically taught in medical school. A nurse practitioner is studying acupuncture for pain. And another nurse, Lauren Khalifeh, the hospital’s holistic coordinator, does a treatment called “pranic healing.”
One afternoon, Mrs. Khalifeh visited a brittle-thin older patient whose sciatica was so inflamed she could not rise from her chair. On a scale of one to 10, the woman, doubled over, said her pain was a 10.
Mrs. Khalifeh pulled up a chair. “I am going to sweep the energy,” she told the patient. She opened a bottle of saline water. “The salt will destroy the negative energy.”
Dr. LaPietra, hard-wired with scientific skepticism, observed from a corner.
The patient closed her eyes, placing hands on lap, palms up. Mrs. Khalifeh leaned intently toward her, sculpting the air in figure eights. She stirred and swirled the space, and then passed her hands over each other. Then she hovered a palm near the patient’s heart.
“Let’s do a check-in,”said Mrs. Khalifeh.
The patient slowly stood. She walked over to Dr. LaPietra, who watched, open-mouthed.
“Much better,” the patient said. “Now it’s a five.”
Mrs. Khalifeh continued for two more minutes. “It’s a three,” said the patient wonderingly, doing deep knee-bends in her leather pants.
The entire process took about six minutes.
Dr. LaPietra’s eyes glistened with tears.
Afterward, in the hallway, the doctor struggled to understand what she had witnessed. “I saw a patient with anxiety and stress who couldn’t control her pain,” she said, carefully. “And then someone spoke soothingly, and led her into deep breathing.
“So much of pain is tied up with fear,” Dr. LaPietra continued. “We can do more than we think, if we can just take the time to sit with patients and let them know we’re present for them.”
Then she smiled and shrugged. “And when we can get it right, why not, especially if we don’t have to use opioids?”
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