In what is possibly a first-of-its-kind approach in the country, Laramie County emergency medical services have undertaken training to reduce the administration of opioids — and the results are encouraging.
“We just analyzed our one year data for that, and we actually had a 28% decrease in opioid administration without any change in patient satisfaction or patient pain control,” said Angela Vaughn, a community health project director through Cheyenne Regional Medical Center.
The reduction in opioid prescriptions is important because experts have identified overprescriptions as one of the key drivers of opioid addiction in the U.S.
In the years leading up to the training, an average of 32% Cheyenne Fire and Rescue patients received non-opioid pain treatments, according to Vaughn. After specialty training and a one year trial period that ended in June, that grew to about 60%.
“This is the first [project] of its kind that we know of where we have completely redone all of the pain protocols, switched up all of the medications and done these really heavy workshops with [over 100 members of] our EMS,” she said.
More data are expected to come from the ambulance service AMR, she said.
Opioids in an emergency
This latest push for opioid alternatives started in the emergency room.
Following similar efforts in Colorado, Cheyenne Regional Medical Center’s ER started to follow an Alternative to Opioid — or ALTO — program, but Vaughn said the initial results weren’t as significant as she hoped.
That could be in part because the effort started during the height of the COVID-19 pandemic — a tumultuous time to introduce new protocols — but also because EMS had yet to be trained on opioid alternatives.
“We still saw a 10% decrease in opioid administration within the first six months,” when just ER staff were trained, Vaughn said. “But then when we queried our providers afterwards, their main barrier was that the patients were coming to them with opioids already on board.”
That is, EMS had already administered opioids to some patients before they got to the hospital.
What makes Laramie County’s program unique is that it goes beyond the ER to train EMS providers.
As the data now show, that novel idea has had significant effects.
Patients were already becoming wary of opioids a few years ago, said Lt. Brice Jacobson, the EMS coordinator for Cheyenne Fire Rescue.
“They’re so afraid that if they get that first dose, they’re now going to be addicted,” he said.
Being able to offer alternatives to opioids for those who didn’t want those drugs to begin with, “we actually get them excited. Those patients are pretty happy with that,” Jacobson said.
Opioid alternatives have historically been fairly limited in the prehospital setting, he said, especially when compared to emergency rooms that can stock more medications. At the same time, he added, they can’t just ignore people’s pain.
“Pain does have a negative effect on the body, especially with healing,” he said.
Now, armed with new research and training through ALTO programs, Jacobson said paramedics in his crew have new protocols for using alternatives to opioids, like intravenous Tylenol and Motrin. While there had been concerns about side effects of alternatives like Ketorolac before, new research has found the risks are lower than anticipated with small doses, he said.
“We just analyzed our one year data for that, and we actually had a 28% decrease in opioid administration without any change in patient satisfaction or patient pain control.”ANGELA VAUGHN, CHEYENNE REGIONAL MEDICAL CENTER
While there was some provider pushback to the new way of doing things, Jacobson said, EMS members are also better trained at talking to patients and assessing how manageable their pain is without opioid intervention.
“I’m also asking … how much pain can you tolerate?” he said. “ And what we find even with that change, a lot of people are like, ‘it’s tolerable. I don’t need this [pain medication].’”
While opioid administrations went down, satisfaction levels have remained largely unchanged, and even improved for some patients, Jacobson found.
He cautions that opioids, including fentanyl, are still the best way to relieve pain in certain instances, like in a major car crash.
“If someone’s in a car accident, they’re in so much pain and they’re having so many injuries, that it’s just not going to be easy to manage with our non-opioid alternatives,” he said. “So our fentanyl, morphine, those kinds of things might be a little bit better for them. But even then, in those scenarios, we’re still using things more specific like ketamine, and then we’re supplementing … with opiates.”
This isn’t the first time firefighters have been on the cutting edge of fighting the opioid crisis around Laramie County, Jacobson said. While high doses of ketamine have been under scrutiny since Elija McClain’s death, Jacobson said, his department has been using small doses to replace opioids since 2017.
“What the data and research have found before we even went this route [with the ALTO project] was we can still use things like ketamine at a lower dose to manage pain,” he said. “And we’d seen a huge reduction in opiates, just on that alone.”
For Jacobson, trying to combat the opioid crisis is also about making sure people understand how prevalent and dangerous it is. The stigma around it makes it harder to know how many neighbors or friends either have or are in recovery from an opioid use disorder, he said.
“[An opioid use disorder] affects everyone equally,” he said. “There’s no prejudice, it doesn’t care who you are. It affects everyone.”
This ALTO project training isn’t free.
It included several videos, audio and an in-person class with an expert.
“The consulting is absolutely worth it, but you do need the funding to do it,” Vaughn said. “And so we’re just kind of waiting potentially until opioid settlement dollars or maybe some grant funding get on board” before expanding training to more EMS groups.
Millions of dollars are flowing into Wyoming via these settlements, which must be spent to directly combat the opioid crisis. According to the OneWyo Opioid Settlement, 65% of those funds are headed to local governments, including counties and towns. A separate settlement will include additional funding for the Eastern Shoshone and Northern Arapaho tribes.
Supporting access to “non-opioid pain treatment alternatives” is allowed via the settlement, but according to a recent RAND Corporation perspective, it’s not getting enough attention.
“This lack of a preventive focus represents a dangerous gap given that pain remains a leading reason people seek health care,” the report states.
“One in six Americans continues to receive prescribed opioids against guideline recommendations for acute back pain and other nonchronic conditions (Mikosz et al., 2020), and among the one in five Americans who report chronic pain, many continue to receive prescribed opioids despite their limited effectiveness (Zelaya et al., 2020).”
For Jacobson, he sees the ALTO project as a good investment, especially when it includes training for both EMS and emergency room providers.
“Funding will be great,” Jacobson said, noting that rural providers may not have access to as much training or information about opioid alternatives.
Still, it’s up to local governments and the Wyoming Department of Health to figure out how to spend the settlement funds, which will likely differ in every part of the state.