27 11. Encourage the use of non-opioid formulations for pain management As it has become clear that long-term pain management using opioids increases the likelihood of patients developing a substance use disorder, research has intensified on finding effective alternatives. Meanwhile, there are already significant, evidence-based alternatives that physicians are finding useful. Based on an evaluative compilation of the alternative treatments, physicians can consider the following substitutes: • Ketamine has been endorsed by the American Academy of Emergency Medicine, with some limitations for patients who have complications related to psychiatric disorders. • Nitrous oxide has long been prescribed in pediatric situations for pain reduction, and its use seems to be growing as more doctors seek alternatives to opioid-based medications. . • Intravenous lidocaine has been shown to be effective for a variety of specific situations.90 Other non-pharmacological treatments have been developed and tested and well. St. Joseph’s Healthcare System in Paterson, NJ, has developed the Alternatives to Opioids (ALTO) program, which utilizes protocols that primarily target five common conditions: renal colic, sciatica, headaches, musculoskeletal pain and extremity fractures. Administrators say they have successfully treated more than 300 patients under the new program, and they see ALTO as a model that other hospitals can duplicate. Among the alternative therapies called for in the ALTO program are trigger point injections, nitrous oxide and ultrasound-guided nerve blocks. 91 The CDC Chronic Pain Guidelines and National Safety Council recommendations highlight and underscore the need to utilize alternative, non-opioid pharmacologic therapies to treat chronic pain. Physical therapy, occupational therapy, water therapy, acupuncture, yoga, Tai chi and massage have all been recognized as effective interventions to treat chronic pain.92 Astrategyonthistopicinvolveseducatingbothphysiciansandpatientsontheoptionsavailableandtheirconsequences (strength, side effects, etc.). Health care providers can develop and set guidelines that call for the use of non-opioid alternatives. This strategy would include efforts required to stay current with the emerging research and development of new alternatives for pain management, including from the various aggressive research programs undertaken by the National Institutes of Health and the CDC. Goals and Objectives The goal for this play is to develop and institutionalize practices across the health care continuum that minimize the use of opioid-based treatments where possible and appropriate. The objective is to put in place protocols for the active consideration of alternative therapies. Theory of Change Substituting alternative treatments for opioid-based pain management will result in fewer patients who develop substance use disorders resulting from long-term reliance on opioids. Examples The Colorado Chapter of the American College of Emergency Physicians (COACEP) has published guidelines for responding to the opioid crisis, along with practice recommendations that call for non-opioid treatment alternatives as the first course of action in pain management.93 The University of Tennessee Medical Center has developed a protocol of alternative pathways to treatment based on giving priority to non-opioid treatments. The program is described in a video. Resources The American Hospital Association has published materials in support of educational efforts, as well as examples of practices dealing with non-opioid treatments.94 The National Safety Council has published a 2018 report in which it assesses state practices that support the use of non-non-opioid treatments. The CDC has published its 2018 Guideline for Prescribing Opioids for Chronic Pain.95 The research plan of the National Institutes of Health describes NIH’s program aimed at finding alternatives to addictive substances.96