“Opioid misuse and abuse is a national epidemic of proportions we have never seen.” — Mark Rosenberg, D.O., M.B.A., Chairman of Emergency Medicine, St. Joseph’s Healthcare System
to it, with the tools to manage and address it—to care for patients and to a broader extent, communities.”
doctors who have always regarded pain as something to be managed aggressively and eliminated.
Nitin K. Sekhri, M.D., assistant professor of anesthesiology and med- “We started prescribing more opioids because they were in our ‘toolkit’ and we were told they weren’t addictive, and safer than ical director of pain management at Westchester Medical Center, morphine,” he says. “We ended up with a population that became took part in the working group that reviewed the curriculum. dependent on these meds, and as a society we never arranged for “Our underlying objective was to improve how medical students a way to properly discard the medication. Oxycontin on the street and future practitioners treat pain,” he says. “We plan to increase is $30; heroin is $2. The ALTO program aims to put more tools in education regarding screening tools for physicians before that first the toolbox. So with kidney stones or ankle pain we have other opioid prescription is even written. How do we assess patients at a medications that are not addicting; yet powerful enough, when higher risk of becoming addicted?” The group also aims to advance used correctly, to manage pain to the point of getting patients back a paradigm shift from “subjective pain score” to something more to function.” objective, such as the patient’s ability to function on a day-to-day basis, as a gauge for how effective, and necessary, any given med- The ALTO approach also recruits “non-pharmacological” remedies to relieve pain, such as music by a harpist who is a fixture of the ication might be. emergency room. “Part of ‘pain syndrome’ is anxiety,” he says. “That explains why non-pharmacologic remedies may alleviate the CLINICAL CULTURE CLASH need for other pain modalities.” To address the roots of the opioid epidemic—prescriptions for As another corrective measure, the ER at St. Joseph’s remains painkillers written in the emergency room (ER) at St. Joseph’s proactive in connecting patients with pain management specialists, Healthcare System, a primary teaching site in Paterson, N.J., psychiatrists and primary care physicians—encouraging interaction for students at the School of Medicine, has launched an ALTO among these clinical rotations. (Alternatives to Opioids) program that forges a new approach to managing acute pain. “If I give someone 10 Percocet and send them to their primary “Opioid misuse and abuse is a national epidemic of proportions we have never seen,” says Mark Rosenberg, D.O., M.B.A., chairman of emergency medicine at St. Joseph’s Healthcare System, and associate professor of clinical emergency medicine. When patients visit the Emergency Department with complaints of fracture pain, kidney stones, ankle sprains and migraine headaches, “we find opioids are not only unnecessary; but also, in many cases, are not the best drugs to use,” Dr. Rosenberg says.
care doctor, the doctor may ask if it’s working for them and give them more. But if, instead, I gave you a heating pad, a Lidocaine patch and the correct dose of Motrin or Ibuprofen, the doctor might continue that regimen,” says Dr. Rosenberg. “I can change patients’ entire care plans by sending them home without opioids. And patients who are already dependent on opioids, whether housewives or drug addicts, have no way of recovering unless we provide medically-assisted detox.”
“Of all the programs I’ve started in my career, I’ve never had the degree of buy-in as I have with ALTO, and not only among doctors,” he adds. “We have a significant influx of new patients who’ve been addicted in the past and refuse to go down that road again.”
THE ADVIL ANTIDOTE
From a population health perspective, Dr. Rosenberg says the ALTO program works to usher along a culture change among 14
C H I R O N I A N 2017
At the Touro College of Dental Medicine (TCDM) at New York Medical College, students receive training in prescribing opioids properly when procedures warrant them; and in giving non-narcotics, even Advil, as the default choice for pain management with certain procedures.