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 Pitts, 75, might make her constipated and foggy, and could be addictive. Would Pitts be willing to try something different?
Then the doctor massaged Pitts’s neck, seeking the locus of a muscle spasm, apologizing as the patient groaned with raw, guttural ache and fear.
“Quick prick,” LaPietra said, giving Pitts an injection of Marcaine, used as a numbing, non-opioid analgesic.
Within seconds, 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 harpist.
Scattered ERs 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 ER 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 replaced altogether. In extreme emergencies – a broken bone jutting through skin, a bad burn, an acute sickle cell crisis – opioids provide effective, immediate relief.
But it is what happens after patients leave the ER 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, ERs 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,” Nelson said.
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 ER patients without opioids. He sent 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 pharmacy stocked alternative medications. Rosenberg alerted departments throughout the hospital to sustain the opioid-avoidant philosophy when seeing ER 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. Pitts, whose neck and arm pain was alleviated by a trigger-point injection, went home with non-opioid patches. She told ER staff members in a follow-up call that she didn’t need further medication.
The rest 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 limited prescriptions for opioids. ER staff members not only warn these patients about the 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 ER 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.”
A recent patient in the pediatric ER was a 17-year-old high school varsity baseball player who had been treated with intravenous opioids at another ER 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,’” LaPietra said. “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 New York 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 unrealistic, or achieved at too high a price.
One treatment that gets swift patient buy-in is nitrous oxide, which the ER staff introduces with its better-known name: laughing gas. It is short-acting, mildly sedating and 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.
“So much of pain is tied up with fear,” LaPietra said. “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?”