Nonopioid Pain Management

According to the CDC, from 1999 to 2014, the sales of prescription opioids in the U.S. nearly quadrupled, however there was no overall change in the amount of pain Americans reported. Pharmacologic therapy and opioid therapy can be an effective strategy to address a patient's pain. These tools and guidelines offer information about options for pain management.


The American Hospital Association’s Hospital Improvement Innovation Network (HIIN) partnered with Colorado Hospital Association to deliver a four-part webinar series focused on the Alternatives to Opioids (ALTO) method to reducing opioid use in the emergency department setting. In this series, the experts who advised the Colorado ALTO Project shared best practices, lessons learned, and tips for implementing ALTO in the emergency department.

Session One: Alternatives to Opioids (ALTO) Principles and Implementation (May 13, 2019)
Donald Stader, MD, FACEP
Senior Pain Management and Opioid Policy Physician Advisor, Colorado Hospital Association
Section Chair and Associate Emergency Medical Director, Swedish Medical Center (Englewood, CO)

In this session, you will:

  • Discuss the historical context and current state of the opioid crisis facing the United States.
  • Explain the role of opioid reduction and alternatives to opioids in addressing the Opioid Epidemic.
  • Describe principles of pain control using ALTO.
  • Review examples of ALTO implementation and how to implement an ALTO program.

Session Two: Pain Management and ALTO (June 10, 2019)
Donald Stader, MD, FACEP
Senior Pain Management and Opioid Policy Physician Advisor, Colorado Hospital Association
Section Chair and Associate Emergency Medical Director, Swedish Medical Center (Englewood, CO)

In this session, you will:

  • Review of the pathophysiology of pain and how previous practices contributed to the opioid epidemic.
  • Describe the clinical application of ALTO at the bedside.
  • Discuss the cultural changes that need to occur with emergency department staff to better discuss and address pain management utilizing ALTO.
  • Review effects of ALTO implementation on patient satisfaction.

Session Three: ALTO Medications in the ED (July 8, 2019)
Rachael Duncan, PharmD, BCPS, BCCCP
Colorado ALTO Project Pharmacist Expert

In this session, you will:

  • Discuss the use of ALTO medications per the Colorado ACEP Guidelines
  • Describe the novel use of ketamine, lidocaine, haloperidol, and ketorolac for the management of pain, along with cautions
  • Explain the process and policy changes that need to occur prior to implementation of ALTO therapies

Session Four: ALTO Procedures (August 12, 2019)
Donald Stader, MD, FACEP
Senior Pain Management and Opioid Policy Physician Advisor, Colorado Hospital Association
Section Chair and Associate Emergency Medical Director, Swedish Medical Center (Englewood, CO)

In this session, you will:

  • Provide overview of procedural pain control in the ED.
  • Discuss the indications and performance of common procedures for pain control in the ED, including trigger point injections, fascia iliaca blocks, occipital nerve blocks.
  • Explore potential obstacles and opportunities in implementing various ALTO procedures.


  • Executive Summary: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) in Adult Patients in the ICU (Sept 2018). This updates and expands the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU.
  • Opioid Response Strategic Plan 2018-2023 (2018). This strategic plan includes broad goals to guide Denver's response to the opioid epidemic, strategies that support achievement of each goal, and specific actions to be implemented in the next 1-5 years.
  • Addressing Pain in South Carolina (2018). BlueCross BlueShield of South Carolina and the South Carolina Hospital Association came together to create the Opioid Risk Prevention Partnership to achieve the goal of a healthier South Carolina by advancing the conversation about pain, and the appropriate use of alternatives to opioids in pain management, in our community. The Partnership is taking action to support you with conversations you have with patients about the risks of opioids and alternatives to treat pain. Working together, we can have a real impact on shifting perceptions, actions, and outcomes amid this opioid epidemic.
  • Bridgton Hospital -- Tackling the Opioid Crisis in a Rural Community (September 27, 2017): Implementation of medication-assisted treatment (MAT) that pairs nondrug therapies such as counseling or cognitive behavioral therapy with FDA-approved medication to treat patients with opioid use disorder at a primary care facility.
  • Treating Chronic Pain without Opioids. (2017) This CDC interactive training module focuses on treating chronic pain without the use of opioids.
  • Nonopioid Treatments, CDC Webinar. (2016) CDC Recommendations for Nonopioid Treatments in the management of chronic pain.
  • Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. (2016) Many individuals turn to complementary health approaches as part of their pain management strategy. This article examines the clinical trial evidence for the efficacy and safety of several specific approaches — acupuncture, manipulation, massage therapy, relaxation techniques including meditation, selected natural product supplements (chondroitin, glucosamine, methylsulfonylmethane, S-adenosylmethionine), tai chi, and yoga — as used to manage chronic pain and related disability associated with back pain, fibromyalgia, osteoarthritis, neck pain and severe headaches or migraines.

Nonopioid Pain Management Case Examples

  • Colorado ALTO Project (2018). In 2017, CHA and its partners developed the Colorado Opioid Safety Pilot, a study that was conducted in 10 hospital emergency departments (EDs) over a six-month span with a goal of reducing the administration of opioids in those EDs by 15 percent. The cohort of 10 participating sites achieved an average 36 percent reduction in the administration of opioids during those six months, as well as a 31.4 percent increase in the administration of alternatives to opioids (ALTOs).
    Based on the success of the pilot, CHA has launched the Colorado ALTO Project to implement this program in all hospital EDs. Their webpage has resources such as Pilot results report, Colorado’s ACEP 2017 Opioid Prescribing & Treatment Guidelines and other training materials and project resources.
  • Creating Clarity in the Confusion of Treating Pain Patients. (2016) University of Tennessee Medical Center uses a systematic approach to pain management. This approach includes three treatment pathways with one for seasoned providers and the other two geared to those with little experience treating pain.
  • Alternatives to Opiates (ALTOSM) Program. (2016) The ALTO program was launched in January 2016 at St. Joseph’s Regional Medical Center. This program uses targeted nonopioid medications, trigger-point injections, nitrous oxide, and ultrasound-guided nerve blocks to tailor its patients’ pain management needs and avoid opioids when possible.
  • Colorado launched a prescribing program about alternatives to opiates. A total of 8 EDs are currently implementing a guideline developed by the Colorado chapter of the American College of Emergency Physicians.
  • Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. (2017) The American College of Physicians developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain.