A pilot program in 10 hospitals in Colorado significantly reduced the use of opioids for pain management in EDs. Although the number of ED visits during the intervention period in 2017 was essentially the same as in the previous year, opioid usage (as measured in morphine equivalent units) was 36% less in the participating EDs-greatly exceeding the 15% decrease the project had set as a goal, according to the Colorado Opioid Safety Collaborative report (http://links.lww.com/AJN/A116).

Patient Ashley Copeland, shown with her mother, was treated for a severe headache with a nerve blocking anesthetic rather than opioid painkillers in the ED at Englewood, Colorado's Swedish Medical Center, one of 10 hospitals that participated in a pilot program to reduce the use of opioids in pain management. Photo by John Daley / CPR News.

"Colorado is at the center of the U.S. opioid epidemic, with the 12th highest rate of misuse/abuse of prescription opioids," Sharon Schultz, past president of the Colorado Emergency Nurses Association (ENA), told AJN. The Colorado ENA undertook the project with the Colorado Hospital Association, the Colorado Chapter of the American College of Emergency Physicians (ACEP), the Colorado Consortium for Prescription Drug Abuse Prevention, and Telligen, a quality improvement organization. "Since pain is the most common reason for admission to EDs, clinicians there are in a strong position to reduce opioid use in a population at high risk for misuse and abuse through alternative pain management strategies."

Ten geographically diverse hospitals were chosen for the pilot, which targeted musculoskeletal pain; chronic abdominal pain; and pain associated with migraine and other headaches, kidney stones, and arm and leg fractures and dislocations. The project utilized the Colorado ACEP 2017 Opioid Prescribing and Treatment Guidelines (http://links.lww.com/AJN/A117), which call for broad adoption of alternatives to opioids for treating pain and multimodal harm reduction methods for patients who use intravenous drugs.

Nurses were key to the success of the project, Schultz said, noting that the Colorado ENA created a toolkit and educated nursing staff at the pilot hospitals. "A core group of Colorado ENA members met with the lead pharmacist to customize education and scripting for the nurses at the participating hospitals. Then, with the project ready to begin in two weeks, the nurses quickly rearranged their schedules to travel to pilot hospitals throughout the state, providing multiple education sessions over the next three months."

The sessions focused on reasons for the new opioid prescribing guidelines, the pharmacology of pain medications, and how to address patient and family concerns about pain management. "Strategies included managing pain, and more specifically, expectations about it," Schultz said. "Common questions from nurses included unfamiliarity with new medication dosages and methods, and how to manage anticipated resistance from patients, families, and even other care providers."

The next step is expanding the project throughout Colorado. Customized nursing education is planned for at least 50 hospital EDs via a "train-the-trainer" model, according to Schultz. "ED providers have struggled to find the right balance for managing their patients' pain effectively," she said. "This project offers real promise for solutions that work for both pain management and reducing exposure to opiate risks."-Serena Stockwell