Nerve blocks, nitrous oxide can be more effective than opioids in treating pain, DO says

Alexis LaPietra, DO, recently helped lead the nation’s second-busiest emergency room in changing treatment protocols for common pain conditions in an effort to reduce opioid use. With the Alternatives to Opioids (ALTO) program in place at St. Joseph’s Regional Medical Center in Paterson, New Jersey, opioids are no longer the first line of defense for the following five conditions:

• Kidney stones.
• Musculoskeletal pain.
• Sciatica/lumbar radiculopathy.
• Headache.
• Extremity fracture/joint dislocation.

Here’s a closer look at the new treatment protocols developed by Dr. LaPietra, the hospital’s medical director of emergency medicine pain management.

Kidney stones: The hospital uses intravenous anti-inflammatory drugs alongside Tylenol and IV lidocaine to manage kidney stone pain. This protocol was adopted based on studies showing that IV lidocaine is more effective than opioids in relieving certain types of pain.

“The feedback from patients so far has been very good, and they rarely require opioids,” says Dr. LaPietra, who is currently working on a study evaluating the effectiveness of IV lidocaine.

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Musculoskeletal pain: For this condition, physicians use an anti-inflammatory drug with Tylenol. Patients with muscle spasms receive a muscle relaxant as well. Topical medications such as Lidoderm patches and Voltaren gel are administered to patients who can’t take an anti-inflammatory drug by mouth or who have significant co-morbidities.

“As a DO, I try to focus in on muscle spasm and areas of dysfunction,” Dr. LaPietra says, noting that she provides osteopathic manipulative treatment when possible. When OMT isn’t an option, Dr. LaPietra and her team have also found success with lidocaine trigger point injections to break up muscle spasms and provide local anesthetic.

“This is great for geriatric patients,” she says. “We try not to use too many medications with them, and we try not to give them too many anti-inflammatories.”

Sciatica/lumbar radiculopathy: For patients with low back pain, the ER follows the same protocols for musculoskeletal pain, but adds medications such as gabapentin, which can help with neuropathic pain from sciatica.

Headache: Adapted from the Cleveland Clinic’s ER headache protocols, the ED uses migraine medications such as Reglan and anti-inflammatory medications along with a fluid bolus. Abortive medications such as Sumatriptan, which is administered subcutaneously and works quickly to abort the headache, are also used.

When patients don’t respond to these therapies, they are given magnesium or valproic acid. And if they are still in pain, the ED will place the patient in observation and consult a neurologist.

“We’re not just putting a Band-Aid on the problem with opioids,” Dr. LaPietra says. “We’re making sure that the headache has been fully evaluated.”

Extremity fracture/joint dislocation: When patients with fractures or dislocations arrive in the ED, they can initially be given nitrous oxide for immediate pain relief while an IV is placed and the injured limb is stabilized. Then, an ultrasound-guided nerve block is administered, which will often completely block the pain. The nerve block is a superior treatment to opioids for this reason, Dr. LaPietra says, noting that opioids work well in masking fracture pain but aren’t able to completely block it the way nerve blocks do.

Implementing protocols

Dr. LaPietra is currently putting together a continuing medical education lecture series on how to implement these protocols in the ER. Physicians who are interested in learning more can email her at lapietra@sjhmc.org.