The ALTO Program: A Strategy to Reduce Opioid use in the Emergency Department
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1 The ALTO Program: A Strategy to Reduce Opioid use in the Emergency Department
2 The ALTO Program: A Strategy to Reduce Opioid use in the Emergency Department Steven F. Nerenberg, Pharm.D. Clinical Assistant Professor Ernest Mario School of Pharmacy Rutgers, The State University of New Jersey Piscataway, NJ Emergency Medicine Pharmacist St. Joseph s Regional Medical Center Paterson, NJ Steven.Nerenberg@pharmacy.rutgers.edu
3 Disclosures I have no actual or potential conflict of interest in relation to this program/presentation. Ernest Mario School of Pharmacy
4 Pharmacist Learning Objectives: Discuss strategies to reduce opioid prescribing in the Emergency Department Identify conditions in which alternatives to opiates may be effective Technician Learning Objective: Identify medications that can be used as alternative to opioids Ernest Mario School of Pharmacy
5
6 Non-opioid first Opioids 2 nd line Realistic pain management goals, manage expectations Discuss addiction potential
7 CERTA Channel, Enzyme, Receptor-Targeted Analgesia
8 Renal Colic Intravenous Lidocaine Ketorolac Acetaminophen
9 Musculoskeletal Pain Trigger Point Injections Acetaminophen Ibuprofen Lidocaine Patch Gabapentin Cyclobenazeprine
10 Lumbar Radiculopathy (Opioid Tolerant) Musculoskeletal Pain + Intravenous Ketamine (0.3 mg/kg, 0.1 mg/kg/hr)
11 Long Bone Fractures Nitrous Oxide Ketamine Ultrasound Guided Regional Anesthesia
12 Migraine Cervical or Trapezius Trigger Point Injection Metoclopramide Acetaminophen Ketorolac/Ibuprofen Valproic Acid Magnesium
13 Proportion of opioid and non-opioid used 71.9% 84.8% % % 0 Opioids Pre-ALTO Post-ALTO Non-opioids
14 patients who received opiates/non-opiates per OPIOIDS 69 diagnosis NON-OPIOIDS Headache 17.5 Back pain Renal Colic 10 0 Headache Back pain Renal Colic Pre-ALTO Post-ALTO Pre-ALTO Post-ALTO
15 Pharmacist s Role Ensure safe and effective medication use Education Counseling Support the Emergency Department
16 The ALTO Program A Strategy to : Reduce Opioid use in the Emergency Department
17 References Cohen V, Motov S, Rockoff B, et al. Development of an opioid reduction protocol in an emergency department. Am J Health Syst Pharm. 2015;72(23): Colman I, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral metoclopramide for acute migraine: meta-analysis of randomized controlled trails. BMJ. 2004;329(7479): Friedman BW, Garber L, Yoon A, et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology. 2014;82(11): Friedman BW, Greenwald P, Bania TC, et al. Randomized trial of IV dexamethasone for acute migraine in the emergency department. Neurology. 2007;69(22): Mauskop A, Varughese J. Why all migraine patients should be treated with magnesium. J Neural Transm (Vienna). 2012;119(5): Mazaheri S, Poorolajal J, Hosseinzadeh A, Fazlian MM. Effect of intravenous sodium valproate vs dexamethasone on acute migraine headache: a double blind randomized clinical trial. PLoS One. 2015;10(3):e Motov S, Mai M, Pushkar I, et al. A Prospective Randomized, Double-Dummy Trial Comparing IV Push Low Dose Ketamine to Short Infusion of Low Dose Ketamine for Treatment Pain in the ED. Am J Emerg Med. 2017;35(8): Motov S, Rockoff B, Cohen V, et al. Intravenous subdissociative-dose ketamine versus morphine for analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015;66(3): Najjar M, Hall T, Estupinan B. Metoclopramide for acute migraine treatment in the emergency department: an effective alternative to opioids. Curesus. 2017;9(4):e1181. Sin B, Tatunchak T, Paryavi M, et al. Use of Ketamine for acute treatment of pain: A randomized, double-blind, placebo-controlled trial. J Emerg Med. 2017;52(5): Soleimanpour H, Hassanzadeh K, Vaezi H, Golzari SE, Esfanjani RM, Soleimanpour M. Effectiveness of intravenous lidocaine versus intravenous morphine for patients with renal colic in the emergency department. BMC Urol. 2012;12:13. Ernest Mario School of Pharmacy
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