At two suburban hospitals, opioids aren't the go-to painkillers

Two suburban hospitals and an emergency department are joining a program to implement new treatment protocols in hopes of decreasing opioid use for patients with certain causes of pain.

Edward Hospital in Naperville, Elmhurst Hospital and the Edward-Elmhurst Emergency Department in Plainfield are taking part in the Alternatives to Opioids Protocol, a program run by Great Lakes Partners for Patients and the Illinois, Michigan and Wisconsin hospital associations as one strategy to fight opioid addiction and overdose deaths.

The program aims to decrease the number of patients exposed to the painkilling yet habit-forming class of drugs, decreasing risk for future issues with dependence.

The program, abbreviated as ALTO, implements standard medications and treatments doctors can consider as a first option before giving opioids to patients who come in with six common causes of pain, known as "clinical pathways": headaches, musculoskeletal pain, abdominal pain, kidney stones, broken extremity bones or joint dislocations.

Doctors at Edward and Elmhurst have completed training on medication combinations and nerve blocking injections to try for these pain presentations instead of automatically giving opioids.

"We want to have alternative treatments that are as effective but with less side effects," said Dr. Daniel Sullivan, chief medical officer and vice president of medical affairs for Edward-Elmhurst Health. "There is confidence that they work."

'Culture shift'

Alternatives such as painkilling patches, lidocaine injections, ketamine or ibuprofen can work for issues including migraines, sore bones or stomach pain - but not for pain from car crashes, burns, shootings, stabbings or other traumas, doctors say. The ALTO program does not address these causes of pain, and it is not trying to eliminate all opioid use.

"If you had a car crash and you're missing an arm, that's not one of the clinical pathways," said Dr. Michael Wahl, medical director of the Illinois Poison Center and one of the Illinois Hospital Association's leaders in the ALTO effort. "You can use whatever is needed to relieve the patient's agony."

Although ALTO isn't for every cause of pain, it still is a "culture shift" for both emergency department personnel and patients, Wahl said.

Doctors need to be familiar with the alternative treatment protocols and when to use them. Nurses need to know how to administer the medications in the proper doses. Pharmacists need to stock the alternative medications and be prepared to make and measure them more often. Patients need to know they might not receive the same treatment they did on previous visits to the emergency department - even if they need help for the same reason.

Doctors at Edward and Elmhurst are using their participation in the six-month ALTO program, which began Jan. 15, as an opportunity for patient education. They are emphasizing the chemical workings of opioids and the dangers of long-term use.

"In the emergency department, we see all sorts of types of painful conditions. A lot of patients have chronic pain and they may be used to getting opiates because they are effective," said Dr. Tom Scaletta, medical director of the emergency services department at Edward Hospital. "It's just not something that actually is good for them."

Medical professionals largely have been receptive to the change, especially once the alternative protocols were entered into their medical records system to provide easy access to "order sets," or suggested treatments, Edward-Elmhurst leaders say. Patients will come around, too, they say, especially once they realize ALTO is the new norm.

"Difficult conversations will become less difficult once people understand this is how we are going to treat people with chronic pain going forward," said Dr. Thomas King, who is implementing ALTO in the Elmhurst Hospital emergency department.

'Treat pain safely'

Edward and Elmhurst hospitals and the Plainfield emergency department are participating in the second cohort of the Midwest ALTO project, along with five other hospitals across the state. They are the only hospitals in the suburbs involved this time around, after the first cohort last year included hospitals in Chicago, Danville, Ottawa, Palos Heights and Urbana.

The hospitals both hope to decrease the percentage of emergency department patients who are given opioids from a baseline set in December 2019. That month, 12% of emergency department patients at Edward and 10.1% at Elmhurst received IV opioids. The baseline rate for the Plainfield emergency department was not immediately available.

Doctors say the goal is to decrease these rates, but not to get to zero.

Even in pain cases that follow the six clinical pathways, such as kidney stones or joint dislocations, Wahl said, it's possible for opioids to play a role.

"Opioids are going to be used as a rescue medication if all of the other mediations fail," he said, "because certainly we still do want to manage people's pain."

Pain management is a quality measure for hospitals.

"But we want to treat pain safely," Wahl said. "Once you take away opioids for pain, you need to provide something else because the patient is still in pain."

DuPage County Coroner Richard Jorgensen called Edward and Elmhurst "ahead of the curve" on adjusting opioid protocols and forming a new mindset about prescribing. He said efforts like this can help decrease the prescribing rate in DuPage County, which stood at 42.2 opioid prescriptions per 100 people in 2017, the most recent year for which data from the Centers for Disease Control and Prevention is available.

Efforts similar to ALTO in New Jersey and Colorado resulted in lower opioid prescribing rates at participating hospitals, doctors said, leading the Midwest group to take the same approach.

Wahl said he hopes more hospitals will follow the lead of the first 13 that have implemented ALTO. Not only will more widespread use of alternatives to opioids lead to clearer patient understanding of treatment plans, but it also could help decrease addiction and overdose deaths.

A preliminary total of 730 people died across the region last year from opioid overdoses in Cook County, excluding Chicago, as well as DuPage, Kane, Lake, McHenry and Will counties, according to the medical examiner and coroner's offices. That total is second in the recent past only to the 740 deaths in 2017, and it's up from 239 in 2014 - the year public health officials across the region started focusing on the opioid crisis.

"Opioids have their own risk, and the more you use them, the more you elevate the risk around the community," Wahl said. "If you understand the risks, you'll be much more reluctant to use them."

Illinois has nation's 9th-lowest rate of opioid prescriptions