The “ALTO” approach

Friday, September 01, 2017 12:24 PM

Incorporating opioid-sparing options into various treatment pathways

by Rachael W. Duncan, PharmD, BCPS, BCCCP

Using non-opioids to address pain management is a novel strategy called Alternatives to Opioids (ALTO). The first Colorado ALTO programs were implemented under the direction of the Colorado Hospital Association and Colorado ACEP in eight emergency departments throughout the state in spring of 2017, the first multi-center effort of its kind. ALTO recommends using opioids infrequently, primarily as second-line treatments, and only after effective non-opioid alternatives have been trialed.

Such programs are not exclusive to the ED setting. Many of the concepts are applicable to inpatient practice, as well as in the community for outpatient providers (see table 1: Opioid Alternatives at Discharge). Through education and partnerships within the community, an ALTO-based multidisciplinary approach can transform pain management practice in Colorado.

Treatment goals

• Utilize non-opiate approaches as the first-line therapy
• Utilize opioids as a second-line treatment
• Opioids can be given as rescue medication
• Discuss realistic pain management goals with patients
• Discuss addiction potential and side effects with those using opioids

The ALTO program utilizes the CERTA concept: channels, enzymes, receptors, targeted, analgesia. The CERTA concept optimizes the following medication classes in place of opioids: Cox-1, 2, 3 inhibitors, NMDA receptor antagonists, sodium channel blockers, nitrous oxide, inflammatory cytokine inhibitors and GABA agonists/modulators. Specific agents include NSAIDs and acetaminophen, ketamine, lidocaine, nitrous oxide, corticosteroids, benzodiazepines and gabapentin.

The protocol targets multiple pain receptors, making use of non-opioid medications, trigger-point injections, nitrous oxide, and ultrasound-guided nerve blocks to tailor a patient’s pain management needs and substantially decrease opioid use. Examples of this approach include:

• Treating renal colic with intravenous lidocaine;
• Managing acute lower-back pain with a combination of oral non-opioids and topical pain medications with directed trigger-point injections;
• Treating extremity fractures with ultrasound-guided nerve blocks; and
• Using an algorithm to manage acute headache/migraine pain with a variety of non-opioid medications.

Only if patients’ pain is not adequately managed using ALTO techniques are opioids used as a rescue medication.

Alternative medications

Ketamine
Ketamine has been used extensively in the emergency department for procedural sedation and rapid-sequence intubation. Recent research has demonstrated that a low (subdissociative) dose (0.1-0.3 mg/kg IV) is safe and effective for pain management. Due to the relatively short-lived analgesic effects of ketamine, the initial bolus can be followed by an infusion of 9-30 mg/hour for sustained effect.

Lidocaine
Lidocaine is an ideal agent for treating visceral and central pain, and also may be useful when narcotics are inefficient or lead to undesirable side effects. Intravenous or topical (5 percent transdermal patch) doses are effective for controlling renal colic and neuropathic pain associated with conditions such as diabetic neuropathy, postoperative or postherpetic pain, headaches, and neurological malignancies. Topical lidocaine also is an appropriate treatment for low back pain and can be prescribed as the 5 percent patch OR found over the counter as the 4 percent patch. Side effects of the drug are minimal when used sparingly.

Trigger-point injections
A focal area of spasm and inflammation (e.g., trapezius, rhomboid, low back) can be associated with chronic myofascial pain syndrome. Palpation of the trigger point should fully reproduce pain, which may be referred to other areas (e.g., nodule or taut band of spasm). Dry needling will cause a disruption of the spastic feedback loop by interrupting abnormal activity in the sensory and motor nerve endings and muscle fibers. Using local anesthetics such as bupivacaine or lidocaine for this procedure often resolves pain and decreases soreness. Indications for this approach include a palpable, taut band or nodule, reproducible pain with palpitation, or a chronic painful condition. Trigger point injection has also been found to be a successful treatment strategy for migraines.

Nitrous oxide
Nitrous oxide is a tasteless, colorless gas administered in combination with oxygen via mask or nasal hood at a maximum concentration of 70 percent. Featuring a rapid onset and elimination (<60 sec), the agent contains both analgesic and anxiolytic properties. It typically is used in combination with a local anesthetic or other pain medications. Pulse oximetry is the only patient monitoring required. There are no NPO requirements, patients can drive after administration and no IV line is needed. There is solid evidence to support its role in the management of pediatric pain and sedation, prehospital pain relief, colonoscopy, and bronchoscopy. Indications for the use of nitrous oxide include laceration repair, incision and drainage, wound care, foreign body removal, central venous access, peripheral venous access, fecal disimpaction, and as an adjunct for dislocations and splinting.

Haloperidol
Haloperidol is a “typical” or first-generation antipsychotic agent. It can be administered intravenously, intramuscularly and orally and often is used for the treatment of psychiatric emergencies. The drug also can be used in low doses as an adjunct treatment for pain and nausea. At doses of 2.5 to 5 mg, haloperidol is effective for the management of abdominal pain and migraine-associated headaches.

All medical providers should be familiar with the ALTO approach by learning new skills such as trigger-point injections and the appropriate administration of medications such as ketamine, haloperidol, lidocaine (IV and topical), gabapentin and NSAIDs. While not all treatment options can be utilized in the outpatient setting (i.e. lidocaine IV and ketamine IV), many of these strategies can still be used (i.e. trigger-point injection for back pain, nitrous oxide for a painful procedure, oral and topical options described).

1. For musculoskeletal pain, consider a multimodal treatment approach using acetaminophen, NSAIDs, steroids, topical medications and low-dose ketamine. Trigger-point injections also can be considered.
2. For headache and migraine, consider a multimodal treatment approach that includes the administration of antiemetics, valproic acid, steroids and triptans. Strongly consider administering a cervical or trapezius trigger-point injection.
3. For pain with a neuropathic component, consider gabapentin.
4. For pain with a tension component, consider a muscle relaxant.
5. For pain caused by renal colic, consider an NSAID, lidocaine infusion and DDAVP nasal spray.
6. For chronic abdominal pain, consider low doses of haloperidol, dicyclomine, diphenhydramine and lidocaine infusion.
7. For extremity fracture or joint dislocation, consider the immediate use of nitrous oxide and low-dose ketamine while setting up for ultrasound-guided regional anesthesia.
8. For arthritic or tendinitis pain, consider an intra-articular steroid/anesthetic injection.

See table 2: Pain Pathways by Indication (opposite page) for specific pathways and medication doses for each indication.