This project will expand the use of available evidence-based options for pain management in the emergency department (ED), focusing on pain relief and empowering people with tools to use for pain management while minimizing the risk of potential harms from opioid exposure. We will expand utilization of ultrasound-guided local anesthesia for femoral fractures and shoulder dislocations. A full menu of integrative health and medicine techniques will be introduced and available for novel outpatient follow-up (acupuncture, yoga, etc), with patients receiving information on mindfulness and stress reduction techniques to use immediately. Mindfulness and resilience training sessions will be offered to ED prescribers in an effort to decrease personal burnout through experiencing the benefits of this mind-body modality firsthand and allowing them to be more informed when offering these interventions to patients.
Pain is the driving force leading many patients to seek care in the ED. Opioids have become synonymous with pain control and it is imperative that we educate medical professionals on safe evidence-based alternatives to opioids, ensuring that patients are not subjected to unnecessary suffering from pain, while avoiding potential harms from exposure to opioids and increasing patient self-efficacy.
The overarching goal of this project, ‘Alternatives to opioids for pain in the emergency department: Implementing Integrative Health approaches and expanding local nerve block initiatives’ is to provide alternatives to opioids for management of pain in the ED and post-discharge. Specifically, we aim to 1) Decrease the overall MME of opioids administered to patients who suffer from a femoral fracture or shoulder dislocation through increasing use of ultrasound-guided local anesthesia 2) Decrease burnout among ED prescribers through mindfulness and resilience training and 3) Establish a novel referral process to the Osher Center for Integrative Health to allow patients options for evidence-based integrative health approaches to treat pain, such as acupuncture, massage, movement therapy, or mindfulness/stress reduction.
All ED patients with a femoral fracture or shoulder dislocation will be eligible ultrasound-guided anesthesia for pain control. We plan to administer a total of 243 femoral nerve blocks and 68 shoulder joint injections over three years. Any English speaking patients who present with pain, depression or anxiety not requiring immediate psychiatric stabilization or substance use disorder will be eligible to receive information regarding integrative health services and a referral, augmented by phone calls from the project director. It is estimated that 700 patients will be presented the explanation of services and a brief introduction to mindfulness, with 150 (20%) accepting the referral, and 100 patients completing follow-up and a secondary assessment. All ED faculty and residents will be offered the evidence-based mindfulness and resiliency training program. We anticipate at least 46/116 (40%) will partake in the training.
This study will have mixed methods evaluative components. The practice patterns of opioid use for specific conditions before and after education and expansion of nerve block pathways, as well as overall administration and prescribing of opioids within the ED following mindfulness and resiliency training of prescribers will be measured retrospectively. Burnout, perceived stress and resiliency will be measured and compared before and after the mindfulness program for physicians. Follow-up rates for those referred to integrative health will be tracked prospectively and rates of return to the ED as well as number of opioids prescribed between those who did and did not follow-up will be retrospectively evaluated. This project will be informed by available resources from SAMHSA, the American College of Emergency Physicians, and our integrative health colleagues.
