Patel NB, et al.

, J Addict Addictv Disord 2024, 11: 167

DOI: 10.24966/AAD-7276/100167

HSOA Journal of
Addiction & Addictive Disorders
Research Article

Effectiveness of ALTO® Pro- research needs to be done to better understand the affects of an
ALTO® program.

gram in Reducing Opioid Pre- Keywords: Abdominal pain; Emergency department; Low back
pain; Migraines; Opioids; Opioid epidemic; Pain; Pain management;
scription Rates in Inspira Wood- Renal colic

bury Freestanding Emergency Introduction

Department (FSED) When it comes to pain, it is one of the most prevalent health care
challenges especially in the United States. Acute pain is reported as
a presenting symptom in over 80% of physician visits [1]. Everyone
Patel NB1* and Baird JF1,2 over the course of their lifetime will experience some form of pain
Department of Emergency Medicine, Rowan-Virtua School of Osteopathic
1 at least once. Whether it is caused by an acute injury or chronic dis-
Medicine, New Jersey, USA ease the treatment of pain and suffering can be traced back to opi-
Inspira Medical Center Mullica Hill Emergency Department, New Jersey,
2 oids over centuries. Opioids come from many sources including raw
USA poppy seeds, synthetic drugs that include fentanyl and methadone,
and semisynthetic drugs which include heroin and oxycodone. The
management and treatment for patients became crucial in effectively
Abstract assessing and treating pain. As a reaction, an initiative that grew trac-
Since the 1990s, the emergence of opioid medications and focus tion in the 1990’s was the declaration of pain as a “fifth vital sign”. Dr.
on treating pain has led the United States to struggle with the opioid James Campbell in 1995, urged the American Pain Society to make
epidemic. Still to this day, countless communities are affected by this change to make drastic improvements in the delivery and assess-
addiction and overdoses due to high opioid prescription rates and ment of pain care [2]. The Joint Commission then also urged that pain
misuse. To combat death and addiction there are many programs is subjective and needed to be accept ed and addressed by physicians
that have been implemented in communities and hospitals to de-
based on patients self-reporting. As a result, there came increased pro-
crease opioid prescriptions. One of these programs started in 2016
motion of newly enhanced pain medications that were narcotics and
is called Alternatives to Opioids (ALTO®) that provides Emergency
then subsequently remarketed as analgesics [3]. Fast forward almost
Departments non-opioid medication protocols to use instead of opi-
3 decades we now face the repercussions of opioid overdoses in the
oid containing medications. This study retrospectively analyzes the
United Sates which in 2017 was officially declared a public health
implementation of ALTO® at the Inspira Woodbury Emergency De-
emergency under section 319 of the Public Health Service Act. From
partment located in South Jersey, that serves an area which has the
1999-2018 the opioid epidemic took close to 450,000 lives [4].
one of the highest opioid prescription rates per capita in the state.
Specifically, we analyzed if ALTO® was effective in reducing total The cause of the opioid epidemic is not due to one factor, but mul-
opioids prescriptions and for certain common diagnosis such as ab- tiple variables intertwined within one another. On the physician level
dominal pain, renal colic, migraines and low backpain. We report in one of the major causes for such a public health crisis is the wide range
this study that although after the implementation of ALTO® it did not
of opioid habits and rates across the country. In 2017 alone, over 191
significantly reduce total opioid prescriptions but did reduce opioid
prescriptions for migraines. Furthermore, it was seen that females
million opioid prescriptions were dispensed to American patients [5].
were prescribed higher rates of opioids than males and young adults Anyone who needs or has taken opioid pain medications can easily
and adults were prescribed higher rates of opioids than children, ad- develop an addiction whether for a short duration or not. Fortunately,
olescent and the elderly. ALTO® proves to have potential in reducing with the increased awareness and initiatives set in place to battle this
opioid prescription rates for certain diagnosis and shows that more epidemic, fatal opioid overdoses in the United States have declined
from the years of 2017 to 2018 [4]. One of such initiatives implement-
ed in 2016 is the Alternatives to Opioids Program (ALTO®) protocol
*Corresponding author: Patel NB, Department of Emergency Medicine, Row- [6]. ALTO® is an educational program for Emergency Department
an-Virtua School of Osteopathic Medicine, New Jersey, USA; Tel: +1 9046252409;
E-mail: [email protected]
providers that provides non-opioid containing protocols for certain
common pain diagnosis. The objective for this program is to see if it
Citation: Patel NB, Baird JF (2024) Effectiveness of ALTO® Program in Reduc- may help lower the rates of opioid prescriptions.
ing Opioid Prescription Rates in Inspira Woodbury Freestanding Emergency De-
partment (FSED). J Addict Addictv Disord 11: 167. Rates of opioid prescriptions also vary depending on location es-
pecially in the United States. When looking at New Jersey specifical-
Received: June 04, 2024; Accepted: June 14, 2024; Published: June 21, 2024 ly, the rate of prescriptions widely varies based on certain counties.
Copyright: © 2024 Patel NB, et al. This is an open-access article distributed
Compared to northern and central parts of New Jersey, South Jersey
under the terms of the Creative Commons Attribution License, which permits un- has the highest rates of opioid prescriptions in the state. More specifi-
restricted use, distribution and reproduction in any medium, provided the original cally counties such as Burlington, Ocean, Gloucester, Atlantic, Cum-
author and source are credited. berland and Cape May [7].
Citation: Patel NB, Baird JF (2024) Effectiveness of ALTO® Program in Reducing Opioid Prescription Rates in Inspira Woodbury Freestanding Emergency Department
(FSED). J Addict Addictv Disord 11: 167.

• Page 2 of 5 •

Therefore, in this study we seek to measure opioid prescription

rates before and after the implementation of ALTO® at the Inspira
Woodbury Emergency Department located in South Jersey. Our pri-
mary objective for this paper is to determine if ALTO® is effective in
reducing opioid prescriptions and to better understand patient demo-
graphics by studying patient age, race, gender, and final diagnosis as
our secondary objectives. Figure 1: Number of patients prescribed opioids pre and post initiation of
ALTO® program.
Methodology
In this study, we did a retrospective analysis of deidentified raw of the 18 patients, 10.26% (n=4) of patients were prescribed an opi-
patient aggregate data from the dates of January 2023 through March oid and 35.90% (n=14) were not. From January 2024 - March 2024
2024. Data was provided by Inspira Health Network IT Department. (Post-ALTO® group) there were a total of 21 patients who had an
Patients who were selected had an ICD-10-10 final diagnosis code for ICD-10 final diagnosis of migraines. Out of the 21 patients, 0% (n=0)
renal colic, migraines, low back pain and abdominal pain. Additional of patients were given opioids and 100% (n=21) did not. There was a
data points of those patients selected were their gender, age, race, and significant difference in opioids prescribed pre and post ALTO® in-
whether they were given an opioid prescription or not. nervation for migraines. Patients who had migraines were prescribed
less opioids than before the invention of ALTO® (p Value = .023).
In order to see if there was a significant change in opioid prescrip-
This data is represented by figure 2.
tions, patients who met the above criteria were separated into two
groups. One of the groups is “Pre-ALTO®” and the second group is
“Post-ALTO®”. Pre-ALTO® groups were patients selected from Jan-
uary 2023 through March 2023. Post-ALTO® groups were patients
selected from January 2024 through March 2024. January through
March from 2023 and 2024 were chosen to keep the months com-
pared constant. The ALTO® program went live in December 2023 in
the Inspira Woodbury Emergency Department and has been running
continuous since.

Pre-ALTO® and Post-ALTO® groups were compared for total

opioids prescribed and for individual ICD-10 final diagnosis codes of
abdominal pain, migraines, renal colic and low back pain. In addition, Figure 2: Number of patients prescribed opioids based on migraines be-
total opioid prescription rates were also analyzed based on race, gen- fore and after ALTO®.
der, age and final diagnosis. Patient race categories were white, black,
Hispanic and other. Patient gender categories were male and female. When looking at pre and post ALTO® intervention for patients
Finally, patient age categories were children aged 1-12, adolescent who had an ICD-10 final diagnosis for abdominal pain, there were a
aged 13-17, young adult aged 18-35, adult aged 36-64 and elderly total of 167 patients from January 2023 - March 2023 (Pre-ALTO®
aged 65 and higher. group). Out of the 167 patients, 12.98% (n=44) of patients were pre-
scribed opioids and 36.28% (n=123) of patients did not receive an
For statistical analysis we used a Pearson Chi-Square test which
opioid. From January 2024 - March 2024 (Post-ALTO® group) there
was evaluated at 0.05 significance level using IBM SPSS statistics
software. were a total of 172 patients who had an ICD-10 final diagnosis for
abdominal pain. Out of the 172 patients, 14.45% (n=49) of patients
Results were prescribed an opioid and 36.28% (n=123) were not. There was
When analyzing the difference in pre and post ALTO® interven- no significant difference in opioids prescribed pre and post ALTO®
tion regarding total opioids prescribed it was determined that from intervention for abdominal pain (p Value = .659). This data is repre-
January 2023 - March 2023 (Pre-ALTO® group) there were a total of sented by figure 3.
230 patients who had a final ICD-10-10 diagnosis of either renal col-
ic, abdominal pain, migraine and low back pain. Out of those 230 pa-
tients, 12.81% (n=62) of patients were prescribed opioids and 34.71%
(n=168) were not. From January 2024 - March 2024 (Post-ALTO®
group) a total of 254 patients were seen with final ICD-10-10 diagno-
sis of renal colic, abdominal pain, migraine and low back pain. Out of
those 254 patients, 14.26% (n=69) of patients were prescribed opioids
and 38.22% (n=185) were not prescribed opioids. It was determined
that there was no significant difference between the number of opioids
prescribed pre and post ALTO® intervention (p Value = .959). This
data is represented by figure 1. Figure 3: Number of patients prescribed opioids based on abdominal pain
before and after ALTO®.
Regarding pre and post ALTO® innervation for patients who had
an ICD-10 final diagnosis for migraines, there were a total of 18 pa- Looking at pre and post ALTO® intervention for patients who had
tients from January 2023 - March 2023 (Pre-ALTO® group). Out an ICD-10 final diagnosis for low back pain it showed that there was

J Addict Addictv Disord ISSN: 2578-7276, Open Access Journal Volume 11 • Issue 2 • 1000167
DOI: 10.24966/AAD-7276/100167
Citation: Patel NB, Baird JF (2024) Effectiveness of ALTO® Program in Reducing Opioid Prescription Rates in Inspira Woodbury Freestanding Emergency Department
(FSED). J Addict Addictv Disord 11: 167.

• Page 3 of 5 •

a total of 45 patients from January 2023 - March 2023 (Pre-ALTO®

group). Out of the 45 patients, 14.14% (n=14) of patients were pre-
scribed an opioid and 31.31% (n=31) were not. From January 2024
- March 2024 (Post-ALTO® group) there were a total of 54 patients
with low back pain. Out of the 54 patients, 18.18% (n= 18) were pre-
scribed opioids and 36.36% (n=36) were not. There was no significant
difference in opioids prescribed pre and post ALTO® for low back
pain (p Value = .814). This data is represented by figure 4.

Figure 6: Number of patients prescribed opioids by gender.

There was a significant difference in the age of patients prescribed

opioids who had ICD-10 final diagnosis of either abdominal pain, re-
nal colic, low back pain and migraines. Patients who are considered
young adults to adults were more frequently prescribed opioids than
Figure 4: Number of patients prescribed opioids based on low back pain the elderly, adolescent and children (p Value = <.001). This data is
before and after ALTO®. represented by figure 7.

Pre and post ALTO® intervention for patients who had an ICD-
10 final diagnosis for renal colic showed that there was a total of 0
patients from January 2023 - March 2023 (Pre-ALTO® group). From
January 2024 - March 2024 (Post-ALTO® group) there were a total
of 7 patients with renal colic. Out of the 7 patients, 28.57% (n= 2)
were prescribed opioids and 71.43% (n=5) were not. There was no
significant difference in opioids prescribed pre and post ALTO® for
renal colic (p Value = N/A). This data is represented by figure 5.

Figure 7: Number of patients prescribed opioids by age.

Based on patient race, there were 64.12% (n=84) of patients who

were white, 22.14% (n=29) who were black, 11.45% (n=15) who were
Hispanic, and 2.29% (n=3) who were categorized as other. There was
no statical difference in between race and opioids prescribed (p Value
= .959). This data is represented by figure 8.

Figure 5: Number of patients prescribed opioids based on renal colic be-

fore and after ALTO®.

For our secondary objectives we analyzed opioids prescribed

based on patient gender, age and race. There was a total of 131 pa-
tients who had an ICD-10 code for renal colic, abdominal pain, low
back pain, or migraines prescribed opioids from our selected time
frame of January 2023 - March 2023 and January 2024 - March 2024.
Out of those 131 patients, 77% (n=102) of patients were females who
received opioids versus the 22.14% (n = 29) of patients who were
Figure 8: Number of patients prescribed opioids by race.
male and received opioids. There was a significant difference in opi-
oids prescribed between male and females. There were more females
prescribed opioids than males who had the same ICD-10 final diagno- Lastly, out of the total population of patients who were pre-
sis of either abdominal pain, renal colic, low back pain and migraines scribed opioids (n=131), 70.99% (n=93) were for abdominal pain,
(p Value = .009). This data is represented by figure 6. 3.05% (n=4) were for migraines, 1.53% (n=2) were for renal colic,
Next, when looking at opioids prescribed and age, .76% (n=1) and 24.43% (n=32) were for low back pain. There was no significant
were children, 0% (n=0) were adolescent, 32.06% (n=42) were young difference between ICD-10 final diagnosis and opioids prescribed (p
adult, 58.02% (n=76) were adult and 9.16% (n=12) were elderly. Value = .072). This data is represented by figure 9.

J Addict Addictv Disord ISSN: 2578-7276, Open Access Journal Volume 11 • Issue 2 • 1000167
DOI: 10.24966/AAD-7276/100167
Citation: Patel NB, Baird JF (2024) Effectiveness of ALTO® Program in Reducing Opioid Prescription Rates in Inspira Woodbury Freestanding Emergency Department
(FSED). J Addict Addictv Disord 11: 167.

• Page 4 of 5 •

the elderly. These results show that the young adult and adult popula-
tion are a high risk for future reliance, addiction, and even overdoses
due to increased opioid prescription rates amongst other ages. United
Sates data from 2021 showed that the 35- to 44- age group is expe-
riencing the most opioid overdose deaths and an 83% increase since
2019 [13]. Results from another study also showed that the preva-
lence of prescription opioid use amongst young adults in the US are
still high despite knowing the risks of misuse [14]. These previous
study findings in conjunction with our study findings prove that dis-
covering new ways to minimize unwarranted opioid prescriptions to
at risk ages and effective patient screening tools are more important
Figure 9: Number of patients prescribed opioids by ICD-10 Diagnosis. than ever to help reduce exposure to opioid pain medications.

When looking at opioids prescribed based on race and final patient

Discussion
diagnosis, non-significant results can be explained as previously stat-
In this study, we sought to examine whether Alternatives to Opi- ed by not enough sample size. Further research still needs to be done
oids (ALTO®) would be effective in decreasing opioids prescription to understand opioid prescription rates and patterns based on race and
rates at the Inspira Woodbury Emergency Department located in certain diagnosis to better understand community demographics and
South Jersey which has one of the highest opioid prescription rates in how to deliver proper opioid related resources for at risk populations.
the state. It was found that even though the implementation of ALTO®
did not significantly change the total number of opioid prescriptions Conclusion
prescribed, it was effective in reducing opioid prescriptions for pa-
tients who presented with migraines. Data from 2019 showed that in Our findings suggest that Alternatives to Opioids (ALTO®) was
America 15% of the population experience them [8,9]. And histori- not significantly effective in reducing total opioid prescriptions but
cally opioids are still commonly prescribed to patients with migraines was effective in reducing opioid prescriptions for patients with mi-
[10]. With these results from our study, ALTO® shows promise in graines who presented at the Inspira Woodbury Emergency Depart-
minimizing opioid prescription rates for patients who present with ment. Based on these results ALTO® has shown the potential to
migraines and decreasing the number of patients exposed to opioid minimize opioid prescriptions for certain diagnoses and to be a great
medications. With less patients prescribed opioids there are less pa- tool for Emergency Departments to employ to provide education and
tients at risk for developing future addiction. Furthermore, although resources for providers to reduce opioid prescriptions. In our study
ALTO® did not significantly affect opioid prescription rates for the population, women were associated with increased rates of opioids
other diagnosis such as low back pain renal colic and abdominal pain, prescribed than men and that young adults and adults were associat-
further research still needs to be done on the effects of ALTO® and ed with higher rates of opioids prescribed than children, adolescents
opioid prescription rates. One of the reasons hypothesized why there and the elderly. Our study limitations include variable patient pain
was not more significant change in our study is due to small sample tolerance, potential repeat patient emergency department visits and
size. Instead of looking at 3-month pre and 3-month post ALTO® in- excluding admitted patients from our study population. For the future,
tervention further research should analyze a larger duration of time to it would be beneficial for new studies to look at longer term affects
yield more significant results. Another reason that may have affected of ALTO® and to include a diverse array of Emergency Department
our study is due to the fact that ALTO® may need more time to run locations across the nation.
and take affect on provider prescription habits and patterns.
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J Addict Addictv Disord ISSN: 2578-7276, Open Access Journal Volume 11 • Issue 2 • 1000167
DOI: 10.24966/AAD-7276/100167
Citation: Patel NB, Baird JF (2024) Effectiveness of ALTO® Program in Reducing Opioid Prescription Rates in Inspira Woodbury Freestanding Emergency Department
(FSED). J Addict Addictv Disord 11: 167.

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DOI: 10.24966/AAD-7276/100167
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