Outside the box

DO develops protocols to help patients manage pain without opioids

Alexis LaPietra, DO, has spearheaded major changes in pain treatment in the nation’s second-busiest emergency room.


During her emergency medicine residency at St. Joseph’s Regional Medical Center in Paterson, New Jersey, Alexis LaPietra, DO, saw firsthand the devastating effects of opioid addiction. She watched the growing epidemic tighten its grip on the nation as she completed her fellowship in emergency medicine acute pain management, turning her focus toward researching non-opiate therapies for common pain conditions seen in the emergency department.

The result is the hospital’s Alternatives to Opioids (ALTO) program, which launched at the beginning of January and, according to early estimates, has resulted in a 50% reduction in emergency department opioid prescriptions for common conditions.

Following is an edited interview with Dr. LaPietra, who is now the hospital’s medical director of emergency medicine pain management.

What was your role in developing and rolling out the ALTO program?

While rotating in anesthesiology during my residency, I learned about using nerve block injections to relieve pain. That piqued my interest in non-opioid pain therapies. After discussing the idea with my department chair, Mark Rosenberg, DO, I embarked on a self-designed fellowship where I explored approaches to pain management that didn’t involve opioids and, in many cases, worked better than opioids in treating severe pain.

After my fellowship, the findings of my research were used to create new protocols in our emergency department for the five most common pain conditions we see:

  • Headache.
  • Kidney stones.
  • Low back pain.
  • Musculoskeletal pain.
  • Fractures/disclocations.

Before prescribing opioids, the new protocols recommend pursuing non-opioid therapies such as nerve blocks or a combination of anti-inflammatory drugs, Tylenol and IV lidocaine.

In addition, physicians are advised to discuss treatment plans with patients, explaining why opioids may not be the best option. In many cases, patients are happy to learn there’s a non-opioid option because it often means they can drive home from the hospital and won’t experience the side effects of nausea and constipation.

In addition to changing our ED protocols, we took ALTO hospital-wide by discussing the program and its benefits with other departments. We want to ensure that patients’ follow-up visits align with their ED experience as much as possible.

Why are opioids so widely used for the treatment of pain?

Opioids are regulated by the FDA and classified as safe for medical use. They work really well. They take your pain away, and you only have to take one little tablet.

The problem is that they are chemically similar to heroin. The prescribing of opioids was well-intentioned, but the medical community may not have fully grasped the addiction potential or the side effects of these medications. Pharmaceutical promotion and advertising, especially consumer advertising, was also a contributing factor to the popularity of opioids.

How did your osteopathic training inform your work on this project?

Osteopathic training emphasizes the idea that you are treating a human being. That notion helps me appreciate that providing alternatives to opioids can empower patients. It’s not all about one medication, especially a medication that has so many risks. It’s about a holistic approach to pain management. Osteopathic thinking helped me build the new “opioids last” protocols, and it helps me be a better physician every day.

What has been the impact of the program so far?

Looking at the first two months of the program, preliminary data tells us that for 300 patients who would likely have been prescribed opioids before, roughly half to three-quarters received non-opioid therapies. That’s at least a 50% reduction in opioid prescribing for patients with acute headache, kidney stones and low back pain, which are the conditions we analyzed the data on.


  1. George Cheriyan DO

    It would be interesting to see if Osteopathic Manipulative Medicine (OMM) has a role in managing pain in these protocols. There was a similar study done to ankle sprains and the effect of OMM on pain at a busy ED setting in the Bronx. Thanks for article and great work by the physician. http://www.ncbi.nlm.nih.gov/pubmed/14527076

  2. E. Dan Arellano DO

    Dr. Raymond,
    The article mentions IV Lidocaine for tx pain (HA, Kidney stones, etc.) Can you provide me some information regarding dosage and frequency of IV Lido. I recall seeing a migraine article about the use of IV Lidocaine. If it does work, I would like to implement it in my practice. Thank you.

  3. Jda

    Great article.

    How does one implement these alternative pain management modalities into their ER? Must an ER physician be certified/obtain fellowship in a specific field to use nerve blocks or certain modalities?

  4. Jon Schriner DO, FACSM

    Each year with more exposure you gain more knowledge. I know now what I did not know then. Been there seen that done that hundreds of times. When I tell patients that I have done thousands of that, it means something. When they say I am an expert in my field, it means something.

  5. Elena Rodriguez, D.O.

    Hello Dr. LaPietra. First I want to tell you that I think what you are doing is an excellent approach to such a horrible epidemic….congratulations! I think your approach would be very useful at the hospital where I’m doing my residency. I just sent you an email to see if you could please share your protocol with me.

    Thank you!

  6. Rajiv Verma

    Excellent article Dr. LaPietra. Thank you for taking the time to delve further into this topic with meaningful research at your residency program. I think the approach you describe could be useful for me as a clinician in a primary care setting. I just sent you an email to see if you could please share your protocol with me.

    Thank you!

  7. Tim Ayers

    I am a little worried to see how quickly so many are abandoning opioids in exchange for what ultimately are less effective treatments. Are we doing this for any other reason than we are scared of the DEA and or being labeled as someone who’s not helping with the opioid crisis ? The data show the drug deaths are actually caused by poly drug combinations and it’s a little bit of a misnomer to call it strictly an opioid epidemic. Look these alternative treatments are simply not sufficient for anything other than mild or moderate pain. We all know that in our hearts. We just want them to work so we can avoid pain patients and any legal trouble they may bring, we’re not basing this on hard science. That’s the ugly truth here

  8. Pingback: American Osteopathic Association – ALTO®

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