St. Joseph's ER went alternatives-first on pain — 75% of early patients skipped opioids
A Paterson, NJ hospital rebuilt emergency pain care around nitrous oxide, nerve blocks and acupuncture; 75% of its first 300 patients left without opioids.
What was changed
St. Joseph's Regional Medical Center in Paterson, NJ rebuilt pain care in its emergency department around what physicians call alternatives-first: laughing gas (nitrous oxide), ultrasound-guided nerve blocks for fractures, and acupuncture after discharge. Dr. Alexis LaPietra, the department's medical director of pain management, told NPR the old way had to go: 'What we've been doing before didn't have the best results... Let's try a different way besides pills, which I know are easy to take. But they have risks.' The ER sits where, for many patients, the road to addiction began.
The program was not abstinence. Chairman of emergency medicine Dr. Mark Rosenberg told NPR: 'We are not opioid-free... Even though it's alternatives first, we will use whatever pain medication we need.' Among the first 300 patients in the program's first two months, 75% left the ER without needing opioids.
Outside experts NPR consulted saw promise and caveats. Dr. Jeanmarie Perrone of the University of Pennsylvania called it a step in the right direction that other hospitals had tried only at smaller scale, while warning it runs against a longstanding physician culture that equates treating pain adequately with giving opioids, and may draw more negative patient reviews. Rochester neurologist John Markman cautioned that any ER program must keep opioids as an option and learn 'to use them skillfully to minimize the public health risks.'
Why it worked
The emergency room was an on-ramp to addiction: prescription painkillers handed out there began dependency for many patients.
Physician culture treated opioids as the measure of adequate pain care, so simply wanting to prescribe less would not have changed anything.
The program gave clinicians concrete substitutes — nitrous oxide, ultrasound-guided nerve blocks, acupuncture — rather than only a warning.
Alternatives-first rather than opioid-free kept severe-pain patients covered and preserved clinical judgment.
The early result — 75 of every 100 patients leaving without opioids — gave the model numbers that could travel to other hospitals.
What can be applied
To change a default, replace it with a workable alternative — a protocol of options beats a prohibition that leaves clinicians and patients empty-handed.
Aftermath
The CDC had published its national opioid-prescribing guidance in March 2016, weeks before the NPR report, and St. Joseph's physicians said they hoped the ER program would serve as a model for hospitals nationwide. The experts NPR consulted framed the test ahead: whether hospitals adopting alternatives could hold patient-satisfaction scores while unwinding a prescribing culture built around opioids.