CASPER — In 2020, Cheyenne Regional Medical Center first experimented with a simple mindset shift that aimed to reduce the amount of opiates patients received at the hospital: Rather than trying to eliminate patients’ pain, medical providers were trained to ask patients how much pain they could tolerate.
That shift, within six months, resulted in a 10% reduction in patients receiving opiates at the hospital’s emergency department, where CRMC had launched an “Alternatives to Opioids,” or ALTO, program.
Those results have translated even more drastically to the Laramie County EMS ALTO program, which launched last year and is one of the first EMS programs of its kind in the nation, said Angela Vaughn, CRMC’s community health project director.
More than 100 paramedics and emergency medical technicians with the Cheyenne Fire and Rescue and Cheyenne American Medical Response were trained through the ALTO program last year, according to Vaughn.
Compared to a control period from January 2020 to May 2022, the number of patients who were given opioids during an emergency response dropped about 28% in the program’s first year.
In 2019, Vaughn reached out to Don Stader — an emergency and addiction medicine physician and opioid expert who has been a part of several initiatives in Colorado that aim to curb the opioid crisis — asking if he would bring the ALTO program to CRMC.
The program trains medical providers to understand pain psychology and conduct assessments to see if patients are tolerating their pain well, in which case they might not need any medication at all.
“I think there’s a much deeper story there than just, ‘Hey, we’re using alternative medicines,’” Stader said. “When you ask the right questions, I think that what you discover is that many people are happy to tolerate pain and, in fact, would rather tolerate it than be exposed to something dangerous like a narcotic.”
Since the ALTO program’s beginnings, Stader and a team at his company, Stader Opioid Consultants, have expanded into the majority of Colorado’s emergency departments. In 2018, Stader and a team of researchers published the first academic study documenting the outcomes of the ALTO program in a Colorado emergency department.
The study compared data from 2015, before the program had been put in place, with data collected in 2016 after the program’s implementation.
Opioid use in the emergency department decreased more than 20% between those two timeframes. Meanwhile, patient satisfaction scores showed “no significant difference” when patients were asked how well their pain was controlled and how likely they would be to recommend the emergency department where they were getting care.
The Colorado Hospital Association also conducted a study over six months across 10 hospital emergency departments that showed the ALTO program had reduced the administration of opioids by an average of 36%.
The opioid crisis in Wyoming
Cheyenne was one of several Wyoming cities, counties, tribes and other governmental entities that joined in a federal lawsuit against opioid manufacturing giants like Purdue Pharma and Johnson & Johnson for their role in sparking a crisis that has killed tens of thousands of people in the U.S.
Wyoming is set to receive $52 million in settlement money from the lawsuit, some of which began making its way to the state last year.
But Wyoming’s struggle with opioids is far from over. Between January and June 2022, opioid overdoses increased by 133% in Laramie County compared to the same time period the year before, said Brice Jacobson of Cheyenne Fire and Rescue.
In January this year, Laramie County EMS responded to 32 overdose cases — the highest monthly number of the past five years, according to a Wyofile investigation. The increase in overdose deaths across Wyoming is partly because of a flood of synthetic opioids, according to the Wyoming Department of Health.
Between 2018 and 2021, overdose deaths rose from 65 to 106; the number of synthetic opioid-involved overdose deaths more than quadrupled while deaths connected with other opioids stayed mostly the same.
Opioids in medical settings
Opioid addiction often starts in medical settings, where patients can develop an addiction to legal pain medications that can lead to using more dangerous drugs like heroin and fentanyl. Though opioid prescriptions fell by nearly 47% between 2012 and 2020, dispensing rates are still especially high in certain areas of the country, according to the Centers for Disease Control and Prevention.
In an emergency response situation where everything has to be packed into a vehicle, providers often have a limited number of medications at their disposal to treat patients experiencing pain. Opiates have often been the most available pain medication at hand.
But when people are given opiates in an emergency response situation, it’s “difficult for the hospital to deviate” from that pain treatment later if the patient has to be hospitalized.
Addiction isn’t the only potential problem with opioids.
As a pain medication, they can also have negative short-term impacts that make it harder for providers to deliver care. They often make people feel nauseous and dizzy. Patients who have taken opioids are sometimes too sleepy to communicate with hospital staff.
In short, patients using opiates aren’t always able to be active participants in deciding what kind of medical care they should receive. That leaves physicians “in a difficult spot about making decisions for patients, rather than with patients,” Stader said.
Over the years, medical providers in Laramie County have expanded their pharmacopeia to include alternative pain medications to opiates.
In 2017, for example, Cheyenne Fire and Rescue started using ketamine in emergency response situations (the hospital has since started using the medication, as well).
Ketamine is a non-opiate pain medication that, while still addictive, is much less so compared to opioids.
The ALTO program seems to be a relatively accessible way for hospitals to decrease patients’ exposure to opiates; training is “really the only cost” associated with implementing the ALTO program, Vaughn said in an email.
She declined to share the cost of the program because that price can vary depending on what kind of training and materials are involved.
“When we paid for this training, we wanted to make sure there was some sort of built-in sustainability,” Vaughn said.
To that end, Stader, whom CRMC contracted to provide the training, made podcasts and videos for CRMC so the hospital could use them when new people come on staff. Because the hospital doesn’t have a steady stream of funding for training, having this sustainability built in was particularly important, Vaughn said.
CRMC is currently trying to get grants to pay for future training.
It’s too early to tell how CRMC’s ALTO program impacts the rate of opioid addictions and overdoses in Laramie County, Jacobson said.
But studies show that even short-term use of opiates can lead to an addiction. Longer-term use only increases that risk.
When patients start off not using opiates in an emergency response situation, hospital staff can manage their long-term care better without having to resort to the medication, Jacobson said.
There are other efforts outside of the ALTO program to address the opioid crisis in Laramie County.
Stader and Vaughn plan to start a Wyoming version of the Naloxone Project, which Stader launched in Colorado in 2021. The project aims for all hospitals, labor and delivery units and emergency departments to give naloxone — a medication designed to quickly reverse opioid overdose — to at-risk patients before they leave the hospital.
In Colorado, 97% of emergency departments and 90% of labor and delivery units now participate in the project.
Vaughn said they’re currently looking at potential legislative changes and policy updates that would help move the project forward.
CRMC and the Laramie County Coroner’s Office, as well as representatives from law enforcement, schools, faith-based organizations and other groups in the community, are also initiating an overdose fatality review starting Thursday.
The review committee will take a deep dive into every overdose case in Laramie County starting from 2021 and publish a report with recommendations for filling resource gaps in the community. Vaughn said the group aims to publish that report in August 2024.
Filling those resource gaps is an ongoing struggle for Wyoming and other rural states.
Cheyenne Regional Medical Center can refer patients with an addiction to places like HealthWorks, Crossroads Counseling and Volunteers of America, which all offer medication-assisted therapy for people trying to overcome an addiction, Vaughn said.
But like other places, and perhaps even more so, Wyoming lacks an abundance of resources for people who need treatment.
“We can refer to those agencies, but we do have a shortage of providers as it pertains to treatment, which can be a big barrier,” Vaughn said. Additionally, CRMC and Cheyenne Fire and Rescue may publish the data they’ve collected from the ALTO program, Vaughn said.
She’s not certain at this point what that process would look like, though it’s likely that Stader would be involved.
“I think that the lessons learned here from Cheyenne’s work are really, really multiple,” he said. “The question is really just how you best get that word out. And that’s something that we’re still actively looking at.”