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PATERSON HOSPITAL ON FRONT LINES OF DEALING WITH PATIENT PAIN -- AND CURBING ADDICTION
Record - 6/24/2018
"We all have a responsibility to address this epidemic."
Kevin Slavin
President and CEO,
St. Joseph's Health
When Nicole Hayes went home from the hospital with her first baby in 2015 after an emergency C-section, the obstetrician gave her a prescription for a bottleful of painkillers.
In April, when Hayes gave birth to twins, the discomfort following their delivery via Caesarean was worse. But this time, instead of opioids, her doctor ordered a steady regimen of Tylenol and Motrin -- a combination that muted the pain without risk of addiction.
Hospitals are now on the front lines of fighting the opioid epidemic, choosing ways to treat pain without causing addiction.
With one in five patients who use opioids for 10 days -- even as directed -- likely to be using them a year later, the drugs doctors use to address pain are judged not only for the comfort they provide, but for their potential harm as gateways to addiction.
St. Joseph's University Medical Center in Paterson pioneered the use of opioid alternatives to treat pain in its emergency department, an effort that has been nationally recognized. Now the drive to reduce opioid prescriptions has spread to obstetrics, dentistry and other medical specialties at the hospital.
Nerve blocks, trigger-point injections, lidocaine patches and even nitrous oxide -- laughing gas -- are replacing prescriptions for OxyContin or Vicodin. And old medicines-- ibuprofen and acetaminophen -- are being used in combination.
Just last week, the U.S. House of Representatives passed a measure that would fund the expansion of St. Joseph's Alternatives to Opioids (ALTO) program as a model for emergency departments nationwide.
Other health care facilities -- including Englewood Hospital Medical Center, Jersey City Medical Center, AtlantiCare's two Atlantic County hospitals, and 10 hospitals in Colorado -- have already adopted the program and cut their opioid prescribing dramatically.
While the House measure awaits a vote in the Senate, St. Joseph's is expanding the program throughout the hospital and the many sites it provides health care, from same-day surgery to urgent care.
Women giving birth, teens getting impacted wisdom teeth extracted, patients recovering from surgery and those in pain from severe arthritis are receiving fewer OxyContin, Vicodin, Percocet and other opioids, and more alternative remedies.
"We all have a responsibility to address this epidemic," said Kevin Slavin, president and CEO of St. Joseph's Health.
The number of women receiving opioid painkillers after Cesarean deliveries and hysterectomies fell more than 50 percent in six months.
"Times have changed," said Dr. Roger Kierce, head of obstetrics and gynecology at the hospital. "For the lion's share of patients out there, we can get by with alternatives to opioids."
Hayes, whose identical twin girls, Charlotte and Stella, are now seven weeks old, welcomed the attentiveness of the nurses, who stayed on top of her pain with regular doses of Tylenol and Motrin every six hours. The Wayne woman continued the routine for five days at home.
The first time she had a C-section, she was so intent on avoiding the use of opioids she flushed her pills down the toilet. This time, she didn't need to.
"I'm very aware of how addictive it can be," she said.
80 percent of heroin users began with opioid prescriptions
For the hospital, the cost of minimizing opioid prescriptions is actually higher than the old approach, said Slavin, the health system president. A prescription for pain pills is simpler to execute and less expensive than analgesics delivered via skin patches, slow-release infusions or an injection by an anesthesiologist.
"But we see the societal cost," he said.
Between 5 million and 10 million Americans are addicted to opioids, it's estimated, and overdoses of prescription opioids and heroin claimed more than 42,000 lives nationwide in 2016 -- more than 2,200 of them in New Jersey.
"You have to take the longer view-- if somebody gets addicted, there will be higher costs borne by society," Slavin said.
As a teaching hospital, too, St. Joseph's impact extends beyond its walls, as residents and interns take the prescribing practices they've learned to future jobs.
Eight of 10 heroin users started with prescription painkillers, national studies show.
"A lot of the long-term opioid use that's so problematic begins with a prescription after surgery or from an emergency room," said Dr. Eric Kolodny, co-director of opioid policy research at Brandeis University'sHeller School for Social Policy and Management and executive director of Physicians for Responsible Opioid Prescribing, an organization seeking to minimize overprescribing.
Those prescriptions could be for the patient's own use -- or for a friend or family member, who then sells or gives away their leftover pills.
"When we stock people's homes with opioids, we're basically putting heroin pills in their medicine chests," Kolodny said.
And the longer patients takes painkillers like OxyContin or Vicodin, the more likely they are to become dependent. Forty percent of those who use them for 30 days will still be using them a year later, he said.
Federal guidelines released in 2016 recommend just a three-day supply for most people with acute pain. More than a week's worth is rarely needed, according to the guidelines from the federal Centers for Disease Control and Prevention.
Avoiding opioids when alternatives work equally well -- and prescribing as few as possible when they are necessary -- reduces the potential for addiction.
"If I don't give opioids, you're not going to get addicted -- it's that simple," Rosenberg said.
Injections: Opioid alternatives for muscle pain
With his lower back in a spasm and pain shooting down the front of his leg, ShuRon McKinney needed relief. He'd had his share of dings and dents in his job building cell-phone towers. But when he twisted his body to pull a 165-pound antenna from its box and his back froze, he knew something was seriously wrong.
In the St. Joseph's ER, the doctor carefully felt the muscles in his lower back, which had seized up tight as a knot. Then she administered a trigger-point injection directly into the "lumpy, bumpy spot" on the left side of McKinney's waist.
McKinney, 36, of Clifton, felt a twitch all the way down the front of his leg.
"We're in the right spot," said Dr. Alexis La Pietra, a specialist in treating pain without the use of opioids. As a fellow in emergency pain management at St. Joseph's three years ago, she researched and developed the protocols that now are being shared all over the country. "When that muscle twitches, it's actually inactivating the spasm."
McKinney stood up and pronounced the pain half gone.
The alternatives work by addressing the source of the pain -- whether it's a blocked nerve, inflammation or something else -- and not simply blocking the pain signal to the brain.
"Patients are now coming in expecting not to get narcotics," said Dr. Khalid Elhussein, a 10-year veteran of St. Joseph's emergency department, the fourth busiest in the country with more than 170,000 visits a year. Parents have bought their teenaged children with athletic injuries expressly to avoid opiates.
Every doctor in the department follows the same protocols; "doctor shopping" won't work. "In terms of whether I'm going to use opioids, it's always going to be a last resort for me now. I always start with everything else," Elhussein said.
Opioid prescriptions in the ER plummeted this year to less than one-fifth their level before the program began, said Rosenberg: from 4,376 in the six months before the program was instituted to 746 for the six months ending in February.
Staff have embraced the approach because everyone, including the hospital president, has a friend or family member affected by the addiction crisis.
"Essentially our whole hospital is becoming 'ALTO,'" Rosenberg said, using the shorthand for the alternatives-to-opioids program.
But the goal is not to be completely opioid-free -- in the hospital or the emergency department. "When we need them," said Rosenberg, for someone with a pelvis crushed in a car accident, say, or cancer pain that's spread to bone, "we give them."
McKinney himself appreciated the approach. "What she's doing is kind of new to me," he said as La Pietra readied his injection. But he understood the need for the program and didn't object.
"Because of the job I do, I'm always banged up. But I don't want to take too many pills."
Opioids not needed for pain
after wisdom tooth removal
For teenagers, getting rid of impacted wisdom teeth can be a painful rite of passage. The two or three days after the extractions are so reliably awful that drug companies use that time to test new products to kill pain.
Dr. Hillel Ephros, chief of dentistry at St. Joseph's, said he used to prescribe four opioid pain pills a day for four or five days after such surgery. Like other doctors of his generation, he'd been taught that when opioids were used by people with real pain, they didn't cause addiction, and his goal was to keep his patients competely pain-free.
Not anymore.
The change in his practice has been so swift, it's "more of a revolution than an evolution," he said.
Now pain is "something we understand is going to happen," he said. "We try to manage it as best we can." Doctors no longer consider it a "fifth vital sign"-- along with blood pressure, breathing, pulse and temperature -- to be kept totally at bay.
When Sophie Bontempo, a 15-year-old high school freshman, came from Bridgewater to have her wisdom teeth removed a few months ago, Ephros spoke with her and her mother about his effort to avoid prescribing opioids. He hoped to avoid them entirely after surgery, he told Sophie's mom, Lori Bontempo.
Lori wasn't sure how Sophie would do, but was willing to give it a try.
Ephros was helped by a new medication called Exparel. Developed by Pacira Pharmaceuticals, it is a long-acting local anesthesia that is contained within tiny foam bubbles. At the end of the surgery, Ephros deposited it with a needle around the incision site. As it dissolved over the following 72 hours, the anesthetic was gradually released without numbing the whole jaw.
The unique -- and long-acting -- delivery method for pain relief costs considerably more than the conventional numbing medication: $170 a dose for dental surgery, compared to a dollar or two for the usual medicine, which lasts a few hours.
But given the opioid epidemic, said Radhika Pisupati, clinical manager of pharmacy at St. Joseph's, the hospital owed it to patients to allow its use judiciously. The hospital is monitoring the use of Exparel, and one major insurer has agreed to cover that higher expense as part of a bargain in which dental surgeons agree to significantly reduce opioid prescribing.
Ephros did give Sophie a prescription for six Percocet pills, in case she had breakthrough pain over the weekend after the Friday operation.
But the girl never needed it, her mother said.
"I hope more doctors take the same approach," Lori said. "Sometimes I think doctors prescribe too much immediately. Whatever any doctor can do to stop this, I hope they do."
"We all have a responsibility to address this epidemic."
Kevin Slavin
President and CEO,
St. Joseph's Health
On the Web
Watch Dr. Mark Rosenberg of St. Joseph's Health talk about alternatives to opioids. NorthJersey.com