Colorado ALTO (alternative to opioids) program

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    Last year the Colorado Hospital Association pioneered the ALTO program (alternatives to opioids). Ten hospital emergency departments across the state participated and decreased the use of narcotics from 31-46% (CHA, 2018)!

    Colorado ALTO (alternative to opioids) program

    The ALTO program (alternatives to opioids) in the ED.

    Last year the Colorado Hospital Association (CHA) pioneered the ALTO program. Ten hospital emergency departments across the state participated and decreased the use of narcotics from 31-46% (CHA, 2018)!

    Colorado, as well as the US, is in the grips of an opioid epidemic, as I'm sure you are aware. We have the 12th highest rate of abuse of prescription opioids in the US (CHA, 2017). According to the CHA (2017), "the vast majority of those who become addicted to opioids, both prescription and illicit, received their first dose from a doctor". This effort is to reduce the unnecessary use of opioids, and thus one of the pathways to abuse and addiction.

    The key to the program was creating treatment algorithms based on pain pathways. The idea that all pain can and should be treated with narcotics is not true. All pain is not created equal. So the Colorado ACEP (American College of Emergency Physicians) developed Opioid Prescribing and Treatment Guidelines. (This can be found on the CHA web site.) This method treats pain by targeting the pathway that causes it. They identified the following;
    · Headache/ Migraine
    · Muscoskeletal Pain
    · Renal Colic
    · Chronic Abdominal Pain
    · Extremity Fracture/ Joint Dislocation

    For each source of pain, they prescribe a set of drugs or treatments, always starting with non-narcotics, progressing to opioids as the last resort. As previously stated, a major reduction in opioid use resulted, with no reduction in patient satisfaction scores!

    The medications that are used are familiar to us, but not necessarily as pain medication. Topical as well as IV lidocaine, low dose Ketamine, Toradol, Tylenol, nitrous oxide, Haldol, Benadryl, and a number of antiemetics were all used with good results. Trigger point injection is also an intervention, in which lidocaine is injected directly into a nerve bundle, or muscle fascia. It can relieve muscle tension and spasm, and works well for the release of scalp tension headaches and other muscle pain.

    As a nurse who was involved in the pilot, I can tell you this works. Not only are patients looking for alternatives, but we are providing better care with less risk. Patient satisfaction scores did not go down overall. Hopefully as providers get more experienced in using these protocols, satisfaction will go up.

    Preparing a hospital for the ALTO program is a huge project. Pharmacy, purchasing, IT, and physicians and nurses all have to be on the same page. New standing orders needed to be written, new order sets generated, new dosing guideline for smart pumps, and new products, such as lidocaine patches had to be ordered.

    The Colorado ENA (Emergency Nurses Association) provided nursing education that included scripting in how to explain the program to patients. Nurses explained that we are looking to make patients more comfortable, or reduce their pain. Complete pain relief is not always a realistic goal, as we know. It is also realistic to discuss with patients the risks of narcotics, and the risk of abuse and dangers of having narcotics in the home.

    It will be exciting to see how far we can go. There were many lessons learned that will only serve to improve this model and how it is delivered.

    CHA (2018), Colorado Hospital Association, Colorado Opioid Safety Pilot Results Report, retrieved from Opioid Safety | Colorado Hospital Association

    CHA (2017), Colorado Hospital Association, Colorado Opioid Safety Collaborative
    Last edit by Joe V on Mar 9 : Reason: images missing
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  3. by   JKL33
    The COACEP document contains great information and is worth reading and appears to be one of the main sources of information from which CHA developed their pilot.


    According to the CHA (2017), "the vast majority of those who become addicted to opioids, both prescription and illicit, received their first dose from a doctor".
    ^ An (un-cited) factoid mentioned in the COACEP document (meaning COACEP makes the statement somewhat conversationally; it is not referenced in their document either). I understand it's important for physicians to understand their role in the current state of affairs, but I find this sort of thing really unnecessary at this point. A significant number of people admit to various alterations in "prescription" use, too - not taking the medication as prescribed, taking medications that are not prescribed for them, etc. I find this (quoted) statement either "duh" or, at best, unhelpful, depending on how you look at it. Correlation does not equal causation, and this unfortunate statement implies proximate cause based on...? Nothing. Since we have been increasingly pressured to give narcotics even to children with run-of-the-mill pains in the ED and elsewhere, it's really no surprise that anyone who (eventually) becomes addicted to opioids may have received their first dose from a doctor.

    I work/have worked with too many physicians who I believe truly feel "between a rock and a hard place" - - we need to stop this vilifying of physicians right along with improving the way we treat patients. JCAHO/TJC/JC, IOM, plenty of other entities, patients, hospitals (and their associations), drug companies, physicians, and nurses are "responsible." The end. Time to move forward.

    Anyway, not so much a fan of hospitals and their associations (they're the same ones who will be lobbying against things like safe staffing and other issues directly important to nurses and patients, BTW)...but the COACEP document includes useful information.

    Thanks for posting!

    Colorado Chapter, American College of Emergency Physicians. (2017). 2017 Opioid prescribing & treatment guidelines: Confronting the opioid epidemic in Colorado's emergency departments. (D.E. Stader, III, Ed.). Retrieved from
    Last edit by JKL33 on Feb 27
  4. by   SpankedInPittsburgh
    Hi everybody. I've been an ER Nurse for a long time & I think these guidelines are great. However, from what I seen there are a couple bad-smelling 600 pound Gorillas in the room that nobody wants to deal with. First, our ER is often clogged with obvious drug seeking patients. Often these patients are chronic pain patients who have been on meds for years and for a myriad of reasons (used all there meds, don't think they get enough meds from following physician. have switched to heroin because its dirt cheap and they can sell their meds for cash,,,) seeking treatment for a new pain complaint or some exacerbation of existing pain. In there defense we made these patients what they are. The standard for treating such pain for a very long time was opioids and to battle the effects of tolerance ever increasing doses of the same. Of course the result of this treatment plan is addiction. In short, they are a bunch of poor addicted souls who got started down this road by simply listening to their doctors advice. Anyway I've seen no good answer on what to do with these addicted patients. In my state we have taken some measures that have helped like limiting the amount of opioids that an ER physician but this has simply led to a ER hopping scenario for the patient. The second Gorilla is Doctor fear. Most of my docs are terrified of being accused of not treating a patient's pain and low patient satisfaction scores. Of course the hospital wants to eat its cake and keep it to. So if a doc does the right thing and refuses to write for such a patient and the patient complains the doc gets BBQ'd. What do we do about this? Honestly some solutions seem available. Continue to strictly limit the amount of pain meds ER docs can write. Consider a 30 day limit in addition to the present limit to prevent these patients from simply returning to the ER daily. Network all local ERs to show the patients that hop from ER to ER to keep the supply of pills flowing. Finally, stand by the docs that refuse to be a pez dispenser with MD behind their names.