Treating Pain Without Opiates: The ALTO Program

November 2018 - Vol.15 No. 11 - Page #32
Category: Drug Verification Products
Q&A with Steven F. Nerenberg, PharmD 
and Radhika Pisupati, PharmD, BCPS

Pharmacy Purchasing & Products: What are the goals of St. Joseph’s Health’s Alternatives to Opiates (ALTO) program?

Steven F. Nerenberg, PharmD, and Radhika Pisupati, PharmD, BCPS: Reducing reliance on opioids for pain relief is a common goal for health systems across the US. The ALTO program began in St. Joseph’s University Medical Center emergency department (ED) and then expanded to the St. Joseph’s Wayne, New Jersey, Medical Center. The program is a unique, multimodal, non-opioid approach to analgesia for specific medical conditions, including renal colic, acute musculoskeletal pain, migraine, extremity dislocation or fracture, and acute or chronic radicular lower back pain. Due to the complex nature of pain, a multimodal approach to treatment—using synergistic combinations of medications that act on different target sites—may provide superior pain relief, with a lower incidence of adverse effects, compared to use of opioids alone.

The main goal of the ALTO program is to use a non-opioid medication as first-line treatment for pain, specifically in conditions for which data suggests non-opioid medications are superior or equally efficacious to opioids in treating pain. For example, many patients who suffer from chronic pain that is treated with opioids present to the ED for acute flare-ups. Having a treatment algorithm in place for these patients using trigger point injections and alternative medications, such as topical lidocaine and ketamine, helps reduce pain in this population. If the non-opioid medication does not significantly reduce the patient’s pain, opioids may be given as a second-line or rescue medication. The comprehensive approach at St. Joseph’s Health involves administration of multiple medications that target a variety of non-opiate pain receptors, including inhaled nitrous oxide, ultrasound-guided regional anesthesia, and trigger point injections.

  • Nitrous Oxide. The role of nitrous oxide in the ED is to assist with procedural pain with or without the use of local anesthetic injections. If there will be a finite amount of pain during a procedure—for example, joint reduction, central venous access, lumbar puncture, incision and drainage, laceration repair, and burn or wound care—nitrous oxide is used as the sole analgesic.
  • Ultrasound-Guided Regional Anesthesia. Ultrasound-guided regional anesthesia is used primarily for fracture pain. If a patient has a fracture associated with significant pain, a nerve block is performed in lieu of opioids, for additional pain relief.
  • Trigger Point Injections. Trigger point injections are performed when the physician identifies a focal area of hyperirritable muscle spasm that with palpation is fully reproducible. The physician injects a small amount of local anesthetic into the area of discomfort. The value of this intervention is treating the source of pain instead of masking pain with opioids.

For certain conditions, evidence supports the efficacy of alternative medications to treat pain; however other conditions still require opioids, especially when treated in the ED. As such, it is not realistic to completely eliminate use of opioids. Identifying patient populations that require opioids is an essential step to preventing unnecessary opioid prescribing. Opioids are not restricted in the ED; the treating physician has discretion on which analgesic methods to use. Evidence-based, best practice order sets were built into the EHR to assist physicians in ordering alternative medications (see a sample ALTO order set in the FIGURE).

Click here to view a larger version of this Figure

PP&P: What education and training is provided to staff and patients?

Nerenberg and Pisupati: Extensive staff education and training are essential to successfully implement an opioid alternative program. For example, ultrasound-guided regional anesthesia and trigger point injections are specialized, minimally invasive, local anesthetic injections that provide targeted pain relief of musculoskeletal pain secondary to muscle spasms. These procedures require specific training to perform. In order to implement these services, a physician trained in these procedures must be involved to help train and educate other physicians. In addition, education on the appropriate use of nitrous oxide must be provided to physicians and nurses. Pharmacists can play a key role in educating staff on utilizing alternative medications through the use of in-service presentations and quick reference handouts. To ensure safe, effective use of these methods, physician, nursing, and pharmacy education is critical to convey the potential benefits and risks.

Patient education is a key component of the ALTO program, as patients must have a clear understanding of the addiction potential of opioid medications and the potential benefits of non-opioid medications. ALTO targets medical conditions for which opioids are frequently prescribed but for which data show opioids to be largely ineffective in managing pain; some of these conditions include renal colic, migraine, and acute musculoskeletal pain. Administering multiple medications with varying mechanisms of action that target non-opioid receptors provides a synergistic effect to ultimately decrease pain without the use of opioids. As a result, ALTO takes advantage of common medications used in the hospital setting that might not traditionally be considered to treat pain. Because patients often expect opioid treatment and may feel cautious in taking a different approach to treating pain, education regarding the goals and benefits of non-opioid options must be provided in order to gain patient buy-in.

Patients must also be educated to ensure they set realistic pain management goals and to manage their expectations for pain relief. Patients often expect medications to completely eliminate their pain; however, the goals of medication therapy are to make them comfortable and their pain tolerable.

PP&P: What is the role of the pharmacist in a multidisciplinary opioid stewardship program?

Nerenberg and Pisupati: As medication experts, pharmacists have a responsibility to help ensure proper opioid use and reduce the risk of opioid addiction. Pharmacists can make a meaningful impact in several ways:

  • Promote Alternatives to Opioids. Pharmacists should collaborate with providers to develop protocols that promote alternatives to opioids and to establish programs that support addiction recovery.
  • Ensure Opioids Are Used Appropriately. Pharmacists can play an integral role in ensuring that when opioids are used in their organizations, they are used properly and in compliance with federal and state regulations.
  • Take an Active Role in Diversion-Prevention Efforts. Several high-profile hospitals have been at the center of diversion cases in recent years. This is not surprising, as diversion can and does occur in facilities of all types and sizes. Health care workers, including pharmacists, pharmacy directors, technicians, and nurses, have been implicated in drug diversion schemes. Pharmacists must take a proactive role in implementing programs that detect and prevent diversion of controlled substances. Diversion-prevention efforts may include implementing surveillance technology programs; taking part in diversion-detection rounds; developing policies and procedures (P&Ps) surrounding use, wasting, and returns of controlled substances; and performing controlled substance audits.

The pharmacy department should work closely with physician and nursing leadership in acute care areas to properly manage opioids. Institutions that have established pain management services can look to implement an opioid stewardship program. These programs can take an interdisciplinary approach to working with the pain management services and other departments to help identify target populations, integrate evidence-based alternative medications, and develop a plan to educate staff and successfully implement the program in the respective areas.

PP&P: What is St. Joseph’s strategy for ensuring the future of the ALTO initiative?

Nerenberg and Pisupati: Ongoing staff education and frequent reminders of the ALTO program’s multimodal approach to analgesia help ensure the long-term success of the program. Moreover, consistent pharmacy support is essential to continued success.

  • Provide Robust Management and Monitoring. Pharmacy staff should collaborate with providers to monitor the program, including review of any adverse events from use of ALTO agents and opioids, medication errors, and overall opioid use. With the increased use of intravenous lidocaine, pharmacists must ensure that all areas have lipid rescue protocols readily available in case of unintended adverse events.
  • Maintain Proper Stocking Levels for ALTO Medications. Pharmacy should remain continually abreast of the alternative medications that are stocked in the acute care area to ensure there is a sufficient quantity. If a sufficient quantity of medications is not maintained or available with a short turnaround time, physicians may default to medications that are readily available, such as opioids.
  • Ensure Consistent Naming. Pharmacists must work with nurses and providers to ensure that ALTO agents are named appropriately and that this naming is consistent in all technology and automation systems.
  • Develop Transition of Care Processes. Sound transition of care processes must be in place, especially regarding obtaining medication histories and ensuring medication access post-discharge.

Looking to the future, St. Joseph’s Health plans to expand the program outside of the ED to every inpatient area of the health system.

More information about St. Joseph’s Health’s ALTO program is available at:

Steven F. Nerenberg, PharmD, is the emergency medicine pharmacist at St. Joseph’s University Medical Center in Paterson, New Jersey, and a clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey. He graduated from Albany College of Pharmacy and Health Sciences.

Radhika Pisupati, PharmD, BCPS, is clinical pharmacy manager and PGY1 residency program director at St. Joseph’s University Medical Center. She received her pharmacy degree at the Rutgers University Mario School of Pharmacy.


What Is the Role of the ED in Opioid Prescribing?

Recent federal and state legislation focuses on reducing the quantity of opioids that can be prescribed in the emergency department (ED). For example, multiple state-level chapters of the American College of Emergency Physicians have developed safe opioid prescribing guidelines for EDs.1

Interestingly, this focus continues despite evidence showing that opioid prescriptions originating in the ED comprise approximately 5% of all opioid prescriptions.2,3 Data also shows that EDs dispense 44% fewer pills and 17% lower morphine milligram equivalents than physician office practices, highlighting that while prescriptions for opioids may be frequent in the ED, they are for lower quantities and dosages.4 A recent retrospective cohort study aiming to ascertain which types of physicians were more likely to prescribe a controlled substance to patients who died of a prescription drug overdose reported that emergency physicians gave the lowest number of prescriptions per provider (1.6%) in the 12 months prior to these deaths. The authors state that while these patients frequently present to the ED, they receive most of their opioids elsewhere.2

Despite the lack of evidence implicating the ED as a pipeline for excessive opioid prescribing leading to overdose deaths, it is still critical to properly manage ED opioid prescribing. Addressing the US opioid abuse crisis requires reducing unnecessary opioid prescribing in every practice setting.

Sidebar References

  1. Menchine MD, Axeen S, Plantmason L, et al. Strength and dose of opioids prescribed from US emergency department compared to office practices: Implications for emergency department safe-prescribing guidelines. Ann Emerg Med. 2014;64(4S):S1.
  2. Lev R, Lee O, Petro S, et al. Who is prescribing controlled medications to patients who die of prescription drug abuse? Am J Emerg Med. 2016;34(1):30-35.
  3. Axeen S, Seabury SA, Menchine M. Emergency department contribution to the prescription opioid epidemic. Ann Emerg Med. 2018;71(6):659-667.e3.
  4. Qureshi ZP, Haider MR, Rodriguez-Monguio R, et al. Opioid prescription drug use and expenditures in US outpatient physician offices: Evidence from two nationally representative surveys. Cancer Ther Oncol Int J. 2017;3(3):555611. doi:10.19080/CTOIJ.2017.03.555611.


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