The Unexpected Pathway to Addiction
It's becoming a more and more common story that begins with someone receiving an injury or having surgery. The patient is prescribed pain control medication by the administering physician or medic, which—depending on the medical situation—can be a highly addictive narcotic. Statistically, this is leading some patients to misuse or misdirect their prescription, or worse, turn to the street to obtain a continuing supply of the narcotic. Why? Because they become addicted to the medication that was originally prescribed for pain management.
Common narcotics prescribed for pain management range from morphine to oxycodone. The specific opioid that has been responsible for a dramatic increase in opioid-related deaths in Massachusetts is fentanyl. Fentanyl is a synthetic opioid analgesic similar to morphine, but at 50 to 100 times the potency. It is administered by injection, transdermal patch or in lozenges. The non-pharmaceutical fentanyl is sold in a variety of forms and can be combined with or substituted for heroin.
One of Governor Charlie Baker's initiatives upon taking office in 2014 was to address the opioid epidemic plaguing the state. In March 2016, he signed Chapter 52 - Acts of 2016, An Act Relative to Substance Use, Treatment, Education and Prevention, (the "STEP Law") a landmark bill to do just that. The legislation focuses primarily on education and prevention at the onset of prescribing pain medications statistically proven to lead to addiction, making physicians, dentists, nurses and other clinical prescribers aware of addiction and providing a better framework to avoid the pathway to addiction from the start.
Brewster Ambulance Service's Toradol Pilot Program
For over a year Brewster Ambulance Service has been lobbying the Massachusetts State Department of Public Health to offer an alternative source of pain management when caring for patients. After a lengthy approval process to run a special pilot program through the Office of Emergency Medical Services, Brewster Ambulance was granted an Advanced Life Support procedure for intramuscular and/or intravenous administration of ketorolac (toradol) as an alternative analgesic. Now Brewster Ambulance is the first EMS agency bringing non-narcotic pain control to communities.
Brewster Ambulance proposed this non-opiate based analgesic for patients suffering from acute moderate to severe pain as an alternative to opiate administration, being the first EMS service in the Commonwealth to provide this option. This program is for a specific demographic of people from 18 to 65 and does not include the pediatric population. Offering toradol equips Brewster Ambulance with a pain medication choice for patients—a choice that also aligns with Governor Baker's new legislation.
This initiative also supports Governor Baker’s opiate task force recommendations to reduce the liberal administration and prescribing of narcotics to patients in the Commonwealth and replace it with non-addictive alternatives. The duration of the program is one year, over which Brewster Ambulance will be collecting data on their use of toradol as an alternative analgesic to show positive impact.
Governor Baker's opiate task force was missing a key component in the pathway to addiction: emergency services including ambulance and fire professionals, who serve on the front line of emergency care in the field, where many people receive their first doses of pain relief in the form of a potentially addictive narcotic.
Proactive Care to Stop Addiction
Brewster Ambulance was seeking creative ways to provide proactive care instead of reactive care. For example, utilizing Narcan® (naloxone HCl) to reverse the effects of an opioid overdose is a reactive response to opioid abuse. The narcotic has already been ingested where the application of Narcan reverses the overdose and ideally the patient recovers. However, the patient is likely already addicted to the opioid that caused the overdose in the first place. The options available to that person since they are already addicted are more limited, and the result is that they will likely have to enter a form of rehabilitation or a recovery program.
By offering a non-addictive option such as toradol for pain management, the patient avoids becoming addicted to a narcotic in the first place. This is a proactive medical practice that will target a population highly susceptible to addiction because they're being introduced to a narcotic in the ambulance. The avoidance of this "gateway to addiction" via EMS is unprecedented and is hoped to show a reduction on the amount of patients who begin or accelerate their addiction.
Putting Controls Around Pathways to Addiction
Another initiative to come out of the new STEP Law is the Non-Opioid Directive. This directive is a process that allows patients, parents of children or health care proxies, to sign a document that declares that they refuse the administration or prescription of opiates in a specific situation and to administer a non-opiate based medication instead.
This directive can be brought to the doctors office, presented to ambulance and/or fire responders at the scene or the patient's home. In many cases, patients may not want fentanyl because they are in rehab and recovering from addiction. At that time, the medic can administer a non-narcotic such as toradol for pain. It makes that patient's intent official and the document can be carried through their continuum of care.
Training Medics and Collecting Data
The Brewster Ambulance team will receive a hybrid of education regarding the administration of toradol, use cases and reporting. The training has already been added to the existing Brewster Ambulance online training platform, and has a specific class that highlights everything in the pilot program, covers all aspects of the drug, when to use it, when not to use it, and includes case-based scenarios with a test at the end that must be passed. Medics will receive that training and will also get hands-on training in the field with supervisors.
The critical component to this program's success is the data. Brewster Ambulance has added data elements and queries to its ePCR (electronic patient care reporting) charting to indicate and track three pain management agents: toradol, morphine and fentanyl. This data will show which ones are being used and how much over the year-long program. In addition, Brewster Ambulance is to provide 100% quality assurance on every toradol case.
Changing a paradigm
There are many points of entry for any addiction and it's virtually impossible to point a finger at any one root cause. In the continuum of care, there are multiple stages from emergency care to rehabilitation to long-term disability care and everything in between. By understanding what starts or perpetuates addiction, addressing the gateways to this epidemic through patient and clinical education, prevention and alternatives such as toradol, we can have a positive impact on the health and well being of those needing proper pain management care.