Bobby Redwood, MD, MPH, FACEP
The WACEP opioid task force has been very active in 2018, working with key stakeholders across Wisconsin to explore and develop opportunities to stem the tide of opioid-related morbidity and mortality in our state. One key initiative has been the development of the WACEP Alternatives to Opioids (ALTO) Pathways. The WACEP ALTO Pathways provide a roadmap for emergency physicians to treat a variety of acute pain syndromes using a multi-modal, receptor-based approach to analgesia. Using the ALTO approach, opioids are reserved as a rescue therapy with a goal of exposing fewer ED patients to this dangerous and addictive class of medications.
A State in Crisis
The opioid epidemic in Wisconsin is unprecedented in scale and scope. 20,590 Wisconsinites suffered from opioid use disorder in 2016 (triple the rate observed in 2005). 1,074 Wisconsinites died from an opioid overdose in 2016 (double the rate observed in 2005). Wisconsin led the nation in in ED opioid overdose visits between 2016-2017 with an increase of 109%. Nationwide, 42,249 Americans died of an opioid overdose in 2016 and the death rate from all opioids (including heroin) now exceeds the death rate from motor vehicle accidents. One of every 550 patients started on opioid therapy died of opioid-related causes a median of 2.6 years after the first opioid administration.
Your Last Blue Patient?
Do you work nights or weekends? If so, you have probably treated a patient presenting with an opioid overdose in the last month…or week…or day. I am writing this newsletter after my third night shift at a community emergency department and I have treated a patient with a life-threatening opioid overdose each of the past three shifts. All three survived, but one young woman suffered an anoxic brain injury and will spend the rest of her life in a long-term care facility. We cannot save all of our patients, but we can certainly take steps to prevent the next opioid overdose or at least ensure that Wisconsin emergency physicians are not exacerbating the epidemic.
A Plan to Save Lives and Curb an Epidemic
The ED is actually a minor source of opioid prescriptions (4% of all opioid prescriptions originate from the ED); however, initial exposure to opioids is common in the ED setting since patients routinely present in acute pain. In an effort to do our part, proactive emergency physicians have developed a four-fold strategy to address the opioid epidemic from the ED: (1) Reduce the amount of opioids used in the ED, (2) Reduce the amount of opioids prescribed from the ED, (3) Offer patients harm reduction interventions from the ED if appropriate (i.e. naloxone prescriptions), (4) Treat addicted/withdrawing patients and refer them to treatment.
A Duty to the Individual Patient
The WACEP ALTO pathways address the need to reduce opioid use and prescriptions in the ED, while respecting the need to provide analgesia to patients in acute pain. ALTO interventions are not one-size-fits-all and should always be administered with the individual patient’s risk profile in mind (age, allergies, weight, etc.)
Balancing Evidence-based Practice with the Urgency of this Historical Moment
ALTO interventions are based on the evidence that is available, but have not been as rigorously investigated to the extent that we, as emergency physicians, are accustomed to in our usual practice. At WACEP, we recognize the importance of this moment in history and have made a conscious decision to prioritize opioid harm reduction over the potential harm of using alternative therapies that (in some cases) have only a low level of evidence to support their efficacy. That being said, most of the ALTO interventions will be recognizable to seasoned physicians as common off-label practice (migraine cocktail, etc). WACEP members can expect multiple iterations of these pathways, updated as the evidence evolves.
Becoming an ALTO Physician Champion
Want to get involved? WACEP is here to help! As an individual physician, you can download the protocols, post them prominently in your physician-workspace, and start using the pathways (as long as there is not conflict with your established hospital protocols). Or better yet, why not change the culture of your entire ED and join the Midwest ALTO Project? The Midwest ALTO project will provide your hospital with a comprehensive ALTO toolkit that includes sample protocols, order sets, public realtions materials, and data abstraction tools to ensure that your ED’s ALTO care transformation has a successful launch. It is led by emergency physicians, nurses, and pharmacists, and coordinated through the Wisconsin Hospital Association. To join, have your quality department contact Shruthi Murali.