(13) Addiction-Informed Opioid-Sparing Pain Care in the ED: ED-ALT Outcomes

Background & Introduction: Emergency departments (EDs) disproportionately care for patients with acute pain and co-occurring substance use disorders (SUD), including opioid use disorder (OUD). Traditional opioid-centric pain management may increase overdose risk and undermine engagement in addiction treatment. Opioid-sparing, addiction-informed alternatives are therefore critical, particularly in urban safety-net settings. The Emergency Department Alternatives to Opioids (ED-ALT) initiative at University Hospital in Newark, NJ, is a SAMHSA-funded, multimodal program integrating pharmacologic and non-pharmacologic strategies to reduce opioid exposure while maintaining effective analgesia.

Methods: We conducted a mixed-methods observational study of 944 adult ED patients enrolled in ED-ALT between 2023 and 2025. Interventions included pharmacologic modalities (IV/IM buprenorphine, IV ketamine, inhaled nitrous oxide, regional anesthesia) and non-pharmacologic modalities (virtual reality, guided meditation, passive and interactive music therapy). Primary outcomes were change in Visual Analog Scale (VAS) pain scores and opioid utilization. Secondary outcomes included opioid prescribing at discharge and ED-initiated medications for opioid use disorder (MOUD). To assess whether underlying addiction status modified analgesic response, we performed multivariable linear regression with change in VAS score as the outcome and SUD diagnoses (including OUD, alcohol, stimulant, cannabis, cocaine, benzodiazepine, tobacco, polysubstance use) as primary predictors, adjusting for pain quality and substance use severity.

Results: Among participants, 28.0% had a documented SUD, including 20.9% with OUD, reflecting substantial addiction burden. Baseline pain severity was high (mean VAS 7.8 ± 1.3). Clinically meaningful pain reduction was achieved across all modalities: pharmacologic interventions resulted in a mean 3.1 ± 1.2-point VAS reduction (n = 493), and non-pharmacologic interventions resulted in a 2.6 ± 1.1-point reduction (n = 451), both exceeding the minimum clinically important difference (p < 0.05). In multivariable regression, no SUD diagnosis—including OUD or polysubstance use—was independently associated with change in pain score after adjustment, indicating preserved analgesic response regardless of addiction status. Pain quality score was independently associated with smaller VAS reductions (p < 0.001), while substance use severity was not. Opioid prescribing at ED discharge ranged from 0.9–8.6%, substantially lower than national ED averages. Among patients with OUD (n = 264), 43.5% initiated MOUD in the ED, with significantly higher initiation among those receiving pharmacologic ED-ALT interventions compared with non-pharmacologic interventions (57.9% vs 27.1%, p < 0.001).

Conclusion & Discussion: In a high-risk, urban ED population with substantial SUD prevalence, a comprehensive ED-ALT program achieved clinically meaningful pain relief without increased opioid exposure and supported high rates of ED-initiated MOUD. Importantly, underlying SUD status did not attenuate analgesic response. These findings support the integration of opioid-sparing, addiction-informed pain management as a scalable strategy to advance opioid stewardship, reduce stigma, and improve linkage to evidence-based addiction treatment in emergency care settings.

References: 1. Beaudoin FL, Scheuermeyer FX, Moriarty T, et al. Emergency Department Alternatives to Opioids (ED-ALTO) implementation: Early outcomes in an academic health system. Acad Emerg Med Educ Train. 2024;7(1):e108-e115. doi:10.1002/aet2.10835. PMCID: PMC9858618.
2. Montague BT, [Include additional author names as appropriate], et al. Outcomes of an Emergency Department Opioid Alternatives Program in a safety-net hospital system. BMC Emerg Med. 2025;25(1):68. doi:10.1186/s12873-024-01168-7.
3. Colorado Hospital Association. Colorado ALTO Project Toolkit: Reducing opioid use in emergency departments through Alternatives to Opioids protocols. Rev ed. Denver, CO: Colorado Hospital Association; 2021. Accessed [provide date you accessed the toolkit]. https://cha.com/opioid-safety/alto-program-toolkit/
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