One of the most common reasons patients head to an emergency room is pain. In response, doctors may try something simple at first, like ibuprofen or acetaminophen. And, at least up until recently, if that isn't effective, the second line of attack has been the big guns.
"Percocet or Vicodin," says Dr. Peter Bakes, an emergency medicine specialist at Swedish Medical Center in Englewood, Colo. "Medications that certainly have contributed to the rising opioid epidemic."
Now though, physicians are looking for alternatives to help reduce opioid use and curtail potential abuse. Ten Colorado hospitals, including Swedish, participated in a six-month pilot project called the Colorado Opioid Safety Collaborative, aimed at cutting their use of the prescription painkillers. Launched by the Colorado Hospital Association, the project is believed to be the first in the nation to include this many hospitals in such an effort.
The collaborating ERs hoped to reduce their opioid use by 15 percent. Instead, Dr. Don Stader, an emergency physician at Swedish who helped develop and lead the study, says the institutions did much better — cutting their use of the drugs by 36 percent, on average.
"It's really a revolution in how we approach patients and approach pain," Stader says, "and I think it's a revolution in pain management that's going to help us end the opioid epidemic."
The overall decrease amounted to 35,000 fewer opioid doses than were prescribed during the same period in 2016.
Their strategy calls for coordination across providers, pharmacies, clinical staff and administrators. And it introduces alternative procedures — using nonopioid patches for pain, for example. Another innovation, Stader says, is using ultrasound to help guide targeted injections of nonopioid pain medicines.
Rather than opioids, such as oxycodone, hydrocodone or fentanyl, Stader says, the doctors now try to use safer and less addictive alternative medicines, like ketamine and lidocaine, an anesthetic commonly used by dentists.
Lidocaine was by far the leading alternative; its use in the project's ERs rose 451 percent. Ketamine use was up 144 percent.
Meanwhile, the use of methadone dropped by about 51 percent and oxycodone prescriptions dropped 43 percent. The use of codeine was cut 35 percent and fentanyl's use dropped by roughly 11 percent.
"We all see the carnage that this opioid epidemic has brought," Stader says. "We all see how dangerous it's been for patients, and how damaging it's been for our communities. And we know that we have to do something radically different."
Claire Duncan, a clinical nurse coordinator in the ER at Swedish, says the new approach has required intensive training of health care providers. She says she was surprised by the pushback from patients.
"They say 'only narcotics work for me, only narcotics work for me,' " says Duncan. "Because they haven't had the experience of that multifaceted care, they don't expect that ibuprofen is going to work, or that ibuprofen plus Tylenol, plus a heating pad plus stretching measures — they don't expect that to work."
The program requires a big culture change, Duncan says, encouraging staff to change the conversation from pain medication only, to ways to treat pain that help patients better understand and cope with it.
Emergency medical workers are all too familiar with the ravages of the opioid epidemic. They see patients struggling with the consequences every day. But Bakes, the ER doctor at Swedish, says this project has changed many minds, empowering health care professionals to combat an opioid crisis they unwittingly helped create.
"I think that any thinking person — or any thinking physician, or provider of patient care — really felt to some extent guilty, but powerless to enact meaningful change," Bakes says.
The pilot project has proven so successful that Swedish and the other emergency departments involved will continue the new protocols and share what they've learned. Stader says the Colorado Hospital Association plans to help spread the word about opioid safety, too; he expects to see the new strategies adopted statewide by year's end.
"And I think if we did put this into practice in Colorado, and showed our success," he says, "this would spread like wildfire across the country."
The 10 hospitals that took part in the Colorado collaboration were scattered all over the state — Boulder Community Health; Gunnison Valley Health; Sedgwick County Health Center; Sky Ridge Medical Center; Swedish Medical Center; UCHealth Greeley Emergency and Surgical Center; UCHealth Harmony Campus; UCHealth Medical Center of the Rockies; UCHealth Poudre Valley Hospital and UCHealth Yampa Valley Medical Center.
This story is part of NPR's reporting partnership with Colorado Public Radio and Kaiser Health News. John Daley can be found on Twitter @CODaleyNews.
SCOTT SIMON, HOST:
A group of hospitals in Colorado set out to reduce opioid use and achieved some dramatic results. The experiment took place in emergency rooms. From Colorado Public Radio, John Daley explains.
JOHN DALEY, BYLINE: Ashley Copeland endured a headache for a week and a half before coming into the emergency department at Swedish Medical Center near Denver.
ASHLEY COPELAND: This morning, I woke up, and it felt 10 times worse.
DALEY: Her care team determined an irritated nerve, a condition called occipital neuralgia, was causing the pain. Typically, a patient like Copeland would first get an anti-inflammatory, an analgesic like Motrin or a pain medicine like Tylenol. Her ER physician, Dr. Peter Bakes, says the second line of treatment would be...
PETER BAKES: Stronger pain medicines - things like Percocet or Vicodin - medications that certainly have contributed to the rising opioid epidemic.
DALEY: But at Swedish, that's changed. Dr. Bakes treated Copeland with the Motrin and then a nerve blocker. Copeland was soon discharged and advised to use over-the-counter meds for pain.
COPELAND: It was a lot better just because I'm used to going to the doctor if I had a headache and them being like, OK. Let's put you on, like, some really strong painkillers.
BAKES: We were able to effectively treat her without any narcotic pain medicines, and she actually did much better.
DALEY: Swedish was one of 10 Colorado Hospitals, large and small, urban and rural, to take part in a six-month project. They set out to reduce opioid use by 15 percent. But Dr. Don Stader says new research shows the hospitals did much better - a 36 percent drop on average.
DON STADER: We all see the carnage that this opioid epidemic has brought - how dangerous it's been for our patients and how damaging it's been for our communities. And we know that we have to do something radically different.
DALEY: The hospitals coordinated providers, pharmacies, clinical staff and administrators. They changed their protocols and started deploying lidocaine patches for pain or using targeted injections guided by ultrasound, like the one Stader demonstrates in the emergency department.
STADER: It allows us to look into the body to...
DALEY: Stader says they switched from opioid pain medications to alternatives considered safer and less problematic - drugs like ketamine and lidocaine, other medications used as anesthesia.
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DALEY: There was some pushback from patients, says Claire Duncan, one of Swedish's head ER nurses.
CLAIRE DUNCAN: They say only narcotics work for me because they haven't had the experience of that multifaceted care. They don't expect that ibuprofen's going to work or that ibuprofen plus Tylenol plus a heating pad plus stretching measures - they don't expect that to work.
DALEY: And it's been a big deal for the hospital to move away from opioids, too, says Duncan.
DUNCAN: It's definitely a big culture change, encouraging our staff to have those conversations with patients and change the conversation from I'm giving you medications for pain to we're going to do all of these things to help treat your pain, to help you cope with your pain, to help you understand your pain.
DALEY: The new guidelines have allowed health care professionals to help combat the opioid crisis, which they unwittingly helped to create, says ER doctor Peter Bakes.
BAKES: Any thinking physician or provider of patient care really felt, to some extent, guilty, but at least powerless to enact meaningful change.
DALEY: Dr. Lewis Nelson is the chair of emergency medicine at Rutgers New Jersey Medical School in Newark. He says the effort is noteworthy since it focuses on emergency departments in many hospitals - not just one.
LEWIS NELSON: It gives us that breadth of approach. It's something that you don't usually see. I think the results of the study are obviously wonderful.
DALEY: Nelson thinks opioids still have their place in the ER, but in many cases, much safer alternatives are the better way to go. For NPR News, I'm John Daley in Denver.
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SIMON: And that story is part of a reporting partnership between NPR, Colorado Public Radio and Kaiser Health News.
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SIMON: This is NPR News. Transcript provided by NPR, Copyright NPR.