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Project Abstract The Ohio State University Wexner Medical Center (OSUWMC) Project AVOID [Alternative to opioids in the emergency department (ED)] will implement, evaluate, and quality assure a screening, intervention, and referral to treatment program for both pain and opioid use disorder (OUD). Our multi-modal approach will reduce opioid exposure amongst patients who are in pain, at-risk for opioid use disorder, or already suffering from opioid use disorder. Opioid overdose deaths remain disproportionally high in Ohio, especially among racial/ethnic minorities, as does morbidity from substance use (e.g., infectious disease, motor vehicle accidents). Yet, efforts to reduce opioid prescriptions contribute to the epidemic of undertreated pain. There is an urgent and imperative need to reduce opioid use for patients at risk of opioid use disorder (OUD) and provide evidence-based alternatives to opioids for pain management in the emergency department (ED). A key advantage of our two large volume EDs and their broad catchment area is the capacity to access diverse and underserved populations. We routinely encounter non-English speaking immigrants, pregnant women, human trafficking victims, racial and gender minorities, and both rural Appalachian and urban populations suffering from extreme poverty. Project AVOID will respond to this need by expanding alternatives to opioids for pain management and reducing the likelihood of future opioid misuse. Our innovative approach adapts the SBIRT framework in an integrated fashion for both pain and disordered opioid use. We will do this by: (i) multi-modal, person-centered approaches to changing practice among existing ED staff and (ii) co-locating parallel support staff from our HealthNow program (i.e. screening, consult service, and post-ED patient assessment/support). Specifically, we will address health disparities related to pain and opioid use disorders by: (i) developing and implementing a system to identify ED patients with moderate to severe pain or history of non-medical opioid use, (ii) expanding non-opioid pain treatments, pain education, and non-medical coping adjuncts for pain, and (iii) improving discharge instructions and referral for pain and OUD. In addition, we will leverage the ED Project AVOID components to engage and reinforce ED provider knowledge of pain responses/help-seeking behaviors across different cultures as well as develop, implement, and quality assure protocols and training procedures for alternatives to opioids and OUD interventions within the ED. Measurable objectives for Project AVOID include assessment of each project goal (e.g., number of patients: (i) screened for pain/OUD, (ii) receiving ED intervention for pain/OUD, and (iii) receiving discharge planning and appropriate referral. Success of our project will be enhanced through a multidisciplinary group of experts (led by Dr. Michael S. Lyons) with previous shared experience on past clinical and research projects surrounding screening and intervention for OUD. Project AVOID will significantly impact the ability to screen and provide evidence-based, culturally competent pain management and OUD intervention for approximately 5,475 (Y1), 7,500 (Y2), 8,000 (Y3) patients, totaling 20,975 ED patients across the proposed 3-year intervention in the Greater Columbus, Ohio region.

The “Improving Emergency Department Management of Acute and Chronic Pain Using Non-Opioid Strategies” project will lead the way to better pain management in Arkansas by training University of Arkansas for Medical Sciences (UAMS) emergency department (ED) physicians and nurses on opioid-sparing pain management strategies. Some quick stats about Arkansas and the UAMS ED: • Arkansas is predominantly rural, with the 6th highest poverty rate in the nation • The state is in the top 10% of states for persons needing opioid use disorder (OUD) treatment, but has poor access to treatment providers and facilities • UAMS is the state’s only academic medical center, has the largest residency training program in emergency medicine, and serves >65,000 patients per year • An average 11,000 patients per year present to the UAMS ED for pain, with nearly ¼ given opioids in the ED • If discharged with opioids, patients receive a mean prescription duration of 36 days but < 1% receive take-home naloxone at the same time We believe that training providers on alternatives to opioids will not only help current UAMS patients, but will also help the rest of the state for years to come. This is because approximately 45% of EM residents remain in Arkansas after graduation, and the majority of ED physicians currently working in Arkansas were trained at UAMS. We are also hopeful that the UAMS ED can also serve as a statewide model for successful pain management without opioids, since Arkansas has had the second-highest opioid prescribing rate in the nation since the early 2010s. In 2016, Arkansan physicians prescribed 114.6 opioid prescriptions for 100 people. While this declined to 75.8 per 100 persons by 2020, this rate is still 75% higher than the national average of 43.3 prescriptions per 100 persons. This project proposes three large initiatives to reduce opioids in the ED: • Education on opioid-sparing pain management, including didactic education, clinical decision support in the electronic medical record, and Academic Detailing (AD) • Peer Navigators, in a slightly expanded role to increase patient knowledge about how to manage pain without opioids, opioid hazards, and take-home naloxone • Implementation of interventional pain procedures like acupuncture and nerve blocks to treat pain in patients for whom opioids are either ineffective or hazardous The impact of these initiatives will be profound, as we estimate that we will be able to affect care for more than 8000 patients per year who present for painful conditions. In addition, once the program is successful, we hope to use our program as a model of aggressive pain management without opioids throughout the State of Arkansas.

MCHS Pain Management Center Development Morton County Health Systems (MCHS), based in Elkhart, Kansas, will expand non-opioid pain treatment through development of an Emergency Department-based Pain Management Center. MCHS will enhance education and treatment for OUD and address the rampant opioid epidemic in poverty-stricken, rural, agricultural areas. The MCHS service area includes Morton, Stevens, Seward, Haskell, Grant, Finney, Kearney, and Stanton Counties in Kansas, Baca County Colorado, Cimarron and Texas Counties in Oklahoma, and Dallam, Hansford, Ochiltree, and Sherman Counties in Texas. The widely dispersed, heavily minority population is low-income, poorly insured and aging. Employment is predominantly agricultural with the counties reporting between 18-40% of employed adults in this industry. A quarter of the adult population does not have a High School diploma. The service area includes a significant percentage of persons identifying as Hispanic and an average 36% of residents speak something other than English in the home. Because of the social, environmental, and economic factors, service area counties are highly vulnerable to chronic pain, opioid use and addiction. MCHS seeks to address pain management, treatment, and the increased risk for OUD by increasing facility capacity and outreach, providing a pain management center and telemedicine with holistic, multi-disciplinary patient centered care. Potential services include MAT, OT, PT, Chiropractic, acupuncture and Behavioral Health to our medically underserved, Health Professional Shortage area. MCHS has 1 overarching Goal supported by 4 Objectives with measurable Actions and specified tasks. Upon objective completion, project will be well on the way to success. Goal: Reduce opioid use and abuse in the Tri-Point area counties and MCHS service area through development of the MCHS Pain Management Center, providing a multidisciplinary, informed, holistic, patient-centered approach to diagnoses and treatment of injuries and pain, advancing non-opioid drug strategies and education. Pain is an inescapable element of physical labor and the agricultural lifestyle. The risk of injury and need for pain relief is greater while working in agricultural sectors than in most other occupations. The frequency and degree have caused a tendency toward over-prescription and addiction to pain medications. Objective 1- Enhance and improve MCHS ER facility, leveraging new C-Arm and other existing equipment, to diagnose and treat pain, completed by March 2024. Objective 2- Develop a professional medical Pain Management team, serving the public by January 2023. Among KS farm workers, the 12-month prevalence of musculoskeletal pain is high. Long-term exposure to heavy physical work, heavy lifting and carrying, whole-body vibration, and work in awkward postures are risk factors for pain. Objective 3-Expand existing technology systems and capability; access remote injury and pain specialists, state health and mental health agencies via telehealth for MCHS; extend pain management resources to remote communities currently served by MCHS telemedicine, to include activities such as PT and OT coaching, mental health counseling for opioid recipient and other community members beginning immediately upon award. Objective 4-Develop and Implement an on-going extensive education campaign, improving communication, education and quality of care beginning December 15, 2023. Improve reporting for our very high OUD risk region. Unduplicated Individuals to be Served by Award Funds; {including elder care patients} Year 1 Year 2 Year 3 Total 740 {865} 850 {975} 860 {985} 2450 {2825}

We aim to develop and implement person-centered treatment approaches for painful conditions frequently treated at the Emergency Department (ED) of University Hospital. Our population of focus will be patients from the University Hospital ED with substance use disorder, particularly Opioid Use Disorder (OUD), who have high rates of intravenous drug use, and are overwhelmingly resource limited. Our population lives in Newark NJ or the surrounding communities hence it is an urban, predominantly African-American population. Moving forward, we will utilize data to develop informed training programs and tailor existing strategies to ensure an understanding of pain management responses and help-seeking behaviors across different cultures and mental health backgrounds to address provider biases related to behavioral health, cultural, and social determinants of health disparities. We will train both ED and other medical/surgical providers on how to incorporate Medication for Opioid Use Disorder (MOUD) during treatment and prescribe buprenorphine in order to identify people who are in need of treatment for pain and OUD. Across the 3-year grant period, approximately 430 trainees (residents, NP and PA students) and 2,400 patients will benefit from specialty-focused strategies on pain management and MOUD. We will develop strategies to provide pharmacological and nonpharmacological alternatives to opioids using innovative and multidisciplinary strategies that can be initiated in the ED setting. Currently, our pain guidelines is a syndrome-based approach tailored to pain etiology, and utilizes over 30 different nonopioid medications for pain relief. We will continue to develop our pain guidelines by incorporating innovate and less common pharmaceutical approaches for pain (e.g., IV buprenorphine, IV magnesium, and INH nitrous oxide, etc.) and will adopt our strategies to also apply to the prehospital setting through our Emergency Medical Services (EMS). Healthcare providers will be trained on alternative nonpharmacological interventions. ED-Alternative (ED-Alt) bedside interventions will include education on breathing exercises/meditation, visual therapy using virtual reality headwear, and music therapy using audiophones with options that reflect a diverse range of cultures and languages. ED-Alt referrals for acupuncture, meditation, physical therapy, and cognitive behavioral therapy will be given by trained peer navigators and physicians. We will ensure fidelity to our evidence based practices by emphasizing a team-based approach utilizing peer navigators, ED Pharmacists, and clinical decision support systems (CDSS). Our peer navigators and trained ED providers will provide ED patients with brief counseling and instruction on breathing exercises and meditation techniques at the bedside. Navigators will assist in arranging outpatient referrals to ensure appropriate linkage to multidisciplinary MOUD services and ED-Alt referrals. A CDSS will be linked within the Electronic Health Record and will incorporate our updated pain guidelines, tailored order sets based on pain etiology, and MOUD dosing guidelines based on patient history and COWS score. We will work with SAMHSA to catalogue best practices and ensure these strategies are shared with the healthcare field at large. We will share our training on Interdisciplinary Strategies for Managing Opioid Use Disorder, with modules on Cultural Approaches to Pain and Potential Provider Biases, Pain Management Strategies using Innovative Pharmaceutical Approaches and Alternative Nonpharmacological Interventions. We will strengthen our partnerships with community organizations, drug rehabilitation programs, shelters, government agencies, educational institutions, EMS, and our country prison, to disseminate our evidence-based practices on alternatives to opioids for pain.

At Atrium Health we embrace the challenge of reducing pain, alleviating suffering, and improving functional outcomes for our patients, while reducing risks associated with opioid analgesia and improving outcomes for patients suffering opioid use disorder (OUD). We propose to use a quality improvement approach to enhance pain management through opioid sparing multimodal analgesia and improve OUD care through initiation of medications for OUD and harm reduction. This project, entitled Atrium Health Emergency Medicine Service Line Pain and Addiction Care Improvement, will focus on patients presenting to any of 25 Atrium Health emergency departments (EDs) located in North Carolina with complaints of pain or OUD. The populations served by Atrium Health in our initial target regions are the first and third most populous in North Carolina. In addition to the relatively large numbers of patients presenting to our EDs with pain conditions, there is a high prevalence of OUD and overdoses in the catchment area. We predict 600,780 unique patients/year will present to a participating ED with a pain complaint and 6,217 patients/year will present with OUD for totals of 1,802,340 patients with pain and 18,651 patients with OUD during the 3-year project. Prescribing opioids for the management of pain generates risk for our patient population to develop both opioid dependence and OUD. Previous analyses of care delivered to the target population have demonstrated much room for improvement across our service line. We need 1) effective multimodal pain management that improves pain outcomes, connects patients to effective outpatient pain care, and reduces the risks of opioid dependence and OUD; and 2) to provide more effective care to patients who present with OUD, including providing harm reduction, medications for OUD, and connection to ongoing community-based treatment. This project has been designed to address those needs. Our goals are to: 1) improve management of acute and chronic pain among patients presenting to Atrium Health EDs while reducing the harms of opioids, and 2) improve care for patients with OUD who present to Atrium Health EDs. We will achieve these goals through the following objectives: • By month 4, an emergency medicine (EM) pain and addiction task force will be established to oversee development and implementation of strategies to achieve Goal 1. • Improve knowledge of patient centered, trauma informed, opioid sparing pain management among EM providers and nurses as measured by adherence to the protocols and best practices implemented. • By month 6, implement policies and guidelines on treatment of OUD using harm reduction, trauma informed care, medications for OUD, and strong connections to community resources for ongoing treatment.

Inspira Health (Inspira), the largest hospital system in Southern New Jersey (NJ), will implement a multifaceted collaborative and comprehensive approach to optimizing the use of opioid alternatives to reduce the risk of inappropriate use and misuse of opioids. The Inspira ALTO-ED project will be implemented across Inspira’s five Emergency Department (ED) locations serving NJ counties: Gloucester, Cumberland, and Salem. The population of focus are patients presenting with either renal colic, musculoskeletal pain, abdominal pain, and migraine headache. The project uses the Alternatives to Opioids (ALTO) strategy developed by St. Joseph’s University Medical Center, in Paterson, NJ, to encourage the use of non-opiate approaches as first-line treatment for pain conditions. In addition to the ALTO approach, this project also employs various evidence-based strategies, including electronic clinical decision supports (order sets, discharge algorithm), cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), and the targeted distribution of Narcan (naloxone kits). A multi-disciplinary project team of Inspira staff representing pharmacy, emergency medicine, clinical informatics, behavioral health, and nursing will lead this project’s implementation. As an academic teaching network, Inspira is committed to educating others to maximize the quality of medical care. Therefore, this project will also focus education and training of providers and other healthcare professionals as well as patients. The project’s goals are to 1). optimize the use of person-centered non-opioid treatment options for patients at Inspira’s ED locations, who present with either renal colic, musculoskeletal pain, abdominal pain, and migraine headache, to reduce the risk of future opioid misuse, dependence, addiction, and/or overdose; 2). improve access to harm reduction strategies and OUD treatment to reduce prescription drug/opioid overdose-related overdose among Inspira ED patients with pain conditions and diagnosed OUD; 3). improve the knowledge and awareness of non-opioid treatment best practices among Inspira ED physicians and local community-based healthcare providers to improve continuity of care for patients after ED discharge; 4). disseminate the project’s results, lessons learned, and best practices to the healthcare professionals at large to increase the implementation of alternatives to opioids in similar small community hospital settings. To achieve these goals, the project will implement ALTO pain management order sets as well as a discharge algorithm in Inspira’s electronic health record system; develop and implement protocols and training on opioid alternative treatment protocols and best practices; ensure culturally competent care for patients by providing monthly lectures on diversity, equity, and inclusion to clinical staff as well as patient education materials in both English and Spanish; expand access to behavioral therapy as a non-opioid treatment alternative by training behavioral health therapists trained in cognitive behavioral therapy and MBSR; screen, assess, and treatment patients diagnosed with OUD; provide Inspira ED, urgent care, and primary care providers with training and education resources on Buprenorphine prescribing and administration; provide naloxone and overdose education instruction kits to patients at risk of overdose/in active withdrawal (patients who are opiate-tolerant); and collaborate with OUD outpatient provider organizations to create an ED-to-outpatient referral pathway. Inspira will also host annual in-person symposiums to educate local health professionals on the best practices and protocols related to the use of opioid prescriptions and alternatives to opioids. The project team will also share the project’s results and best practices through annual presentations at professional conferences and articles submitted for publication to peer-reviewed professional and academic journals.

The Eskenazi Health Emergency Department Alternatives to Opioids Program Opiates have historically played a critical role in the response to pain management. However, the overuse of these drugs has launched the country into a state of abuse and addiction as well as an opioid overdose epidemic. The emergency department (ED) is a location commonly accessed for pain management making this an ideal location to implement approaches to reduce pain without the use of opiates. A 2018 article in the Advance Journal of Emergency Medicine2 reported 80% of admissions were due to reports of pain. As pain can be an indicator of a potential medical issue or one of the symptoms of a known medical diagnosis, emergency attention may be imperative. Assessing pain differs for each person evaluated as pain tolerance is unique and not generalizable. The Eskenazi Health Emergency Department Alternatives to Opioids program plans to create a pathway for pain management strategies using interventions such as mind-body medicine and non-opioid analgesics. This pathway will assess the medical condition of the patient and the level of pain. These methods will replace the use of opioids for pain management among populations that typically experience pain from their medical diagnosis and prevent exposure to opiates. This deterrence would then divert opportunities for opioid misuse that could potentially escalate to an opioid use disorder (OUD) and provide an alternative form of pain management for those who already struggle with OUD. Eligible medical conditions include, but are not limited to Sickle Cell Disease, gallstones, kidney disease, headaches, fractures, sprains, strains, and other medical conditions, as appropriate. Staff trained in alternative treatments will consult the pathway and determine the implementation strategy. Pharmacological interventions will be implemented by medical staff approved to apply this method of treatment, and a Pharmacy Specialist will consult and provide oversight to pharmacological intervention. Mind-body medicine will facilitate interventions such as guided imagery, music therapy, breathing exercises, and other methods that can also be replicated outside of the ED. In the case of chronic pain, patients will receive referrals to the Eskenazi Health Pain Management Clinic where they will receive pain management education, therapy, and treatment. Through these interventions, the Eskenazi Health Emergency Department Alternatives to Opioids program plans to serve 3,600 unduplicated clients for the duration of the three-year grant period. Goal 1: Project Director will collaborate with ED leadership to identify “baseline” guidance for determining which ED patients are eligible for alternative pain management within the first four months of the program. Goal 2: Implement patient-centered and team-based alternative approaches (e.g., Mindfulness training, Pain Management Clinic, MOUD) in the Eskenazi Health (EH) ED that may assist in pain management without the use of opioids within the first four months of the project, and a minimum of annually thereafter. Goal 3: Project Director and OPOC will implement patient-centered alternative pain treatment strategies, respectful of general ED processes and needs, in the EH ED within the first four months of the project. Goal 4: The Pain Management Clinic provider will implement patient-centered alternative treatment strategies based on regular pain assessments to patients in chronic pain. Goal 5: The Project Director and OPOC will evaluate the alternative pain management modalities implemented to determine the impact of the program on opioid use, and opioid-related morbidity and mortality, monthly.

To address the urgent opioid epidemic public health threat in Northeastern New York State, the Emergency Department Alternatives to Opioids at the Albany Med Health System (ED-ALT AMHS) will adapt evidence-based practices to 1) improve person-centered care (PCC) for those with pain conditions in the ED, 2) implement an ED-ALT program, and 3) increase capacity and coordination of care for those with opioid use disorder (OUD) and pain and opioid use. The project will be implemented in the AMHS four hospital EDs with a greater catchment area of 2.8 million people spanning 25 counties and a combined total volume of over 170,000 annual ED visits. Among these visits, the program will have an impact on an estimated 83,000 (49%) patient encounters in the ED per year with persons reporting pain, among whom an estimated over 37,000 (45%) yearly would be expected to receive an opioid either in the ED or upon discharge without the project intervention (for a total of over 235,000 patient encounters with pain conditions in the ED and over 106,000 patient encounters in which opioids would be prescribed over the three-year project period without the project intervention). The ED-ALT AMHS project will serve our population of focus which includes people residing in rural, urban, and suburban areas with an estimated self-reported 51% female; 16.1% under 18 years; 23.6% 65 years and over; 80% White; 11.9% Black or African American; 1.2% Asian, Native Hawaiian, or Pacific Islander; 0.01% American Indian/Alaska Native; and 3.9% Hispanic or Latino.1 The program aims to improve the culture of person-centered care for all patients in the ED with pain conditions, improve the use of alternatives to opioids (ALTOs) for pain, and strengthen capacity and existing resources for screening, medications, and care for patients with OUD or pain and opioid use in the ED. These aims will be achieved by identifying key performance and outcome gaps in the provision of PCC for persons with pain conditions in the ED through patient interviews and ED provider and nursing staff focus groups and developing and implementing locally-informed PCC strategies and training for ED providers and nursing staff. To improve the use of ALTOs in the AMHS EDs, the project team will 1) develop and implement training for providers and nursing staff in ALTO best practices and directed strategies to address differing pain conditions in the ED; 2) develop electronic health record clinical decision support (order sets and best practice alerts) and 3) train ED providers and nurses in two integrative non-pharmacologic therapies (mindful breathing and music therapies). Additionally, ED provider and nurse training will be expanded through training and education in screening, brief intervention and referral to treatment (SBIRT) and ED provider training in medications for OUD and buprenorphine for pain in the ED. Finally, the proposed project will improve care for patients with pain who use opioids through training and coordination of multidisciplinary care and strengthening partnerships with community organizations.

With a SAMHSA ED-ALT award, Baystate Medical Center (BMC) in Springfield, Massachusetts will create and launch an Emergency Department based Complex Addiction and Pain Service (CAPS) Team. The CAPS team will be a multidisciplinary team of medical professionals with the goal of improving care in pain management and OUD in the BMC ED and addressing continuity of care and follow up disparities that impact residents of Hampden County, which has second highest opioid dispensing rate and the highest rate of drug overdose deaths in Massachusetts. In the three years of the ED-ALT grant project, the CAPS team will serve more than 3,000 residents, with a focus on the Hispanic community who has suffered the greatest impact of the opioid epidemic and the highest rates of drug overdose deaths. The CAPS team will consist of a full-time nurse practitioner with experience in pain management and addiction, a full time bilingual (Spanish/English) substance use disorder recovery coach, and a part time physician supervisor with experience in both emergency and addiction medicine. Supporting the team will be a part time pain management physician, an emergency department clinical pharmacist, hospital-based IT consultant, and biostatistician. The primary role of the CAPS team will be to provide direct care to ED patients with complex painful conditions, those on chronic opioid medications for pain, and for patients with OUD. The CAPS team will also educate ED staff on pain management opioid alternatives, treatment of OUD and culturally competent harm reduction strategies, as well as work with IT consultants to create electronic health record (EHR) structure and programs to promote evidence based, consistent care.

Newark Beth Israel Medical Center (NBIMC) will partner with the RWJBarnabas Health (RWJBH) Institute for Prevention and Recovery (IFPR) on the SAMHSA FY 2023 Emergency Department Alternatives to Opioids Program (ED-ALT) to implement alternatives to opioids for pain management beginning in the ED. NBIMC primarily serves the eastern and southeastern portions of Essex County, New Jersey, which is composed of urban communities and suburban towns. Essex County has a larger proportion of Black and Hispanic or Latino residents than New Jersey as a whole-35.9% of the population is non-Hispanic Black and 24.3% of the population is Hispanic or Latino, compared to 12.3% and 21.5% statewide, respectively. New Jersey has struggled with the opioid overdose crisis in the past decade, with a 133.8% increase in drug overdose deaths from 2013 to 2021. Essex County has been particularly affected, with a 208.3% increase in the same timeframe. In 2021, Essex County had 408 suspected overdose deaths, the most of any county in the state. In the same year, providers in the county wrote 243,920 opioid prescriptions, and law enforcement and emergency medical services administered naloxone 2,084 times, a fourfold increase from 2015. In 2021, Essex County had the most residents admitted for treatment for opioid use in the state, with 4,258 admissions. Some of the most common diagnoses among patients who received opioid prescriptions in the NBIMC ED in 2022 included extremity pain (14.9%), sickle cell crisis (11.2%), chest pain (4.0%), and pelvic and perineal pain (1.5%). The goals of the ED-ALT program are to: 1) expand and utilize evidence-based approaches to treat painful conditions frequently diagnosed in the NBIMC ED, 2) institute a comprehensive education and training program to disseminate information and educate clinical staff and patients on the protocols and best practices related to the use of opioid prescriptions, alternatives to opioids, and medications for opioid use disorder, and 3) identify, grow, and utilize consultation and referral networks and protocols for primary care, specialty pain management, and ED- and hospital-based treatment, communication, and collaboration. The project will utilize three evidence-based practices-Enhanced Recovery After Surgery, Transitional Pain Service, and social prescribing-to effectively treat pain, decrease opioid use, and support self-management of persistent pain. The project proposes to serve 500 unduplicated individuals annually and 1,500 unduplicated individuals over the entire project period with grant funds. The project will measure progress towards goals and objectives by utilizing RWJBH's electronic health record, the Brief Pain Inventory-Short Form, and the Pain Catastrophizing Scale.

Beta to Alpha is a project of Baylor Research Institute (BRI) for Baylor Scott and White-Fort Worth (BSW-FW) Emergency Department (ED) to create system changes to increase opioid alternatives for ED patients. The project will create a MOUD (Medication for Opioid Use Disorder) Bridge Clinic for patients with Opioid Use Disorder (OUD) to promote their recovery. The project will begin as a "Beta" project in Fort Worth, Texas, and expand as an "Alpha model" to two other EDs in North Texas. BSW is the 12th largest healthcare system in the country and the largest healthcare system in Texas. With funding, SAMHSA can learn how to disseminate best practices for OUD across very large healthcare systems for maximum impact. The population to be served are patients who visit the BSW ED with painful conditions. More than 17,000 patients visited the BSW ED last year with painful conditions. Overall, BSW-FW prescribed opioids over 25,000 times in the ED or hospital. The most frequent presenting painful conditions were gastrointestinal, chest pain, and trauma. 60% of patients were female. More than one-third of patients (39%) were on Medicare, Medicaid, or uninsured. The majority of patients (89%) were between 18 and 64 years old. Patients were ethnically diverse with 25% of patients being Black, 32% Hispanic, 3% Asian, 3% other races, and 37% as White. As one of the largest healthcare systems, BSW treats patients at high-risk for OUD, including people with chronic conditions that lead to pain like kidney failure, dialysis, and sickle cell disease. The project will allow SAMHSA to evaluate the effectiveness of interventions among people with chronic conditions. Strategies and interventions include all required activities and eight allowable activities. To reduce gaps and disparities in the target population identified, Beta to Alpha will: institutionalize alternatives to opioids; increase access to MOUD; improve physician training in ALTO, MOUD, SBIRT, and cultural competence; and connect patients to ongoing care for pain and MOUD. BSW will target the most common ED painful conditions for opioid treatment alternatives. BSW has developed a multi-modal pain management treatment program and an Alternative to Opioids (ALTO) pilot that reduces patient initial exposure to addictive opioids and helps patients with OUD to transition to MOUD and other pain treatments. BSW will add physical therapy consults in the ED as a new alternative to opioids. BSW will train physicians and residents in the ED in best practices for opioid alternatives. In this training, BSW will consult with the SAMHSA-funded Opioid Response Network. Training will include BSW's five residency programs. To identify patients with OUD, BSW will implement the NIDA Quick Screen and NIDA ASSIST assessment. ED physicians will offer patients with OUD an initial MOUD dose. With grant funds, BSW will pursue the Pain and Addiction Care in the ED (PACED) accreditation. In grant years 2 and 3, BSW will expand all practices to two additional EDs in North Texas. BRI will disseminate best practices across local hospitals, medical schools, the American College of Emergency Physicians, and national publications. In a pilot project, BSW was able to initially reduce opioid prescriptions by 59%. This project builds on that success. The goal of Beta to Alpha is to implement alternatives to opioids for pain management in three BSW EDs in North Texas and to reduce opioid misuse. Measurable objectives include: 1) 90% of ED providers will use alternatives to opioids more than opioids for pain management. 2) Reduce BSW targeted ED opioid prescriptions by 20%. 3) 70% of patients in the MOUD Bridge Clinic will remain opiate-free. 4) 70% of patients are connected to long-term OUD care. The total unduplicated number of patients served over the grant period is 375 (75 in year 1, 150 in year 2, 150 in year 3).

The Zuckerberg San Francisco General Hospital & Trauma Center’s Emergency Department Alternatives to Opioid Program (ZSFG ED-ALT) project aims to increase utilization of opioid alternatives to treat acute pain and improve screening and treatment of patients with opioid use disorder (OUD). We will complete these goals by integrating opioid alternatives into ED clinicians’ daily workflow. We will also use the novel tool of substance use navigation to build on our current addiction care infrastructure to more effectively identify patients with OUD, initiate medications for opioid use disorder (MOUD), and link patients with OUD to outpatient care at a partnering clinic site. ZSFG serves an urban, inner city, and underserved patient population as San Francisco’s safety net hospital. It is the only Level 1 trauma center serving the city of San Francisco, and the emergency department sees approximately 75,000 patients per year. ZSFG is also home to the Family Health Center Bridge Clinic, a clinic dedicated to the timely care and follow-up of recently discharged ED patients with substance use disorders. Of patients who present to the ZSFG ED with pain, abdominal pain, chest pain, headache, extremity fractures/pain, and musculoskeletal pain (including back pain) are the most common. In addition, in the last year, approximately 3000 patients presented to the ZSFG ED with OUD while only a small proportion (21%) were started on MOUD and 11-30% are linked to care. Over the course of three years, our goals for ZSFG ED-ALT are as follows: (1) to establish a multidisciplinary workgroup to create treatment algorithms for the five most common painful conditions presenting to the ZSFG ED. These algorithms will integrate non-opioid medication-based therapies into the ED electronic health record, including order panels for automation. Our goals are also (2) to provide an education curriculum to all ED clinicians (physician faculty, residents, fellows, advanced practice providers) regarding alternatives to opioids practice, the current algorithms for the selected 5 conditions, provision of patient-centered and equitable care, and best practices on treatment of patients with opioid use disorder (including MOUD); (3) to assess the effectiveness of an ED clinician education curriculum regarding ED-ALT; (4) disseminate our findings to the larger ED community, and (5) use an in-ED substance use navigator for improved ED screening for OUD, real-time daily clinician guidance regarding treatment of patients with OUD, motivational interviewing for patients with OUD, and effective referral and linkage to outpatient care. Measured objectives include: order panel usage, and clinician knowledge and capability to provide patients in pain with non-opioid management. Additional objectives/measures related to patients with OUD include: number of patients screened, number of those screened positive who are started on MOUD, and number of those who had successful linkage to outpatient care. Over the course of 3 years, ZSFG ED-ALT will serve 1250 unduplicated patients with acutely painful conditions and/or OUD. Our goals are to (1) train 100% of all ED staff by the end of the project period, (2) at least 50% of all patient who present with one of five most common painful conditions receive medications from the order set (3) at least 50% of all ED patients with OUD started on treatment with MOUD, and (4) at least 50% of patients started on MOUD are linked to care. Project staff are multidisciplinary, highly trained and recognized leaders in program implementation, department-wide education, addiction medicine and pharmacotherapy.

Chinese Hospital Emergency Department Alternatives to Opioids (CHED-ALT) program is a patient-centered, multi-disciplinary team based, community-based organization(CBO) partners involved care model that provides proactive care and responsive care through community engagement and evidence-based, non-opioid Medication Assisted Treatment plus Cognitive Behavioral Therapy (CBT) to address unmet pain management and opioids misuse among Asian American and African American racial/ethnic minority groups reside in Chinatown and Tenderloin areas. The program goals are to 1) increase the total number of targeted ED patients using non-opioids therapies; 2) reduce their opioid misuse or addiction risk by maintaining the opioid-prescription rate for post CHED-ALT care patients not to exceed 6.9%. From June to December in 2022, Chinese Hospital served 839 pain-related patients around Chinatown. 142 patients received at least 1 opioid. 95% of ED population served were Asian Chinese, among which, 60% are older adults from age 65 and above, 38% were adults in age group ranging from 18 to 64,2% were age 17 and under. The top 10 pain conditions related primary diagnosis were COVID-19, dizziness, urinary tract infection, nausea/vomiting, chest pain, low back pain, headache, abdominal pain, epigastric pain and cough. San Francisco Chinatown's total population is 10,136. 78.79% is Asian. 16% is between ages 55-64 and 17% is between ages 65-84. From literature review, Chinese American tend to have clinical characteristics of inappropriate pain management and also language issue affecting their health care outcome, we anticipate this aging population will have greater need for pain management. San Francisco Tenderloin area total residents' number is 9942. 38% is Asian, 19% is Hispanic and 7% is African American. Per data from Tenderloin Center created by Mayor London Breed, it has accommodated 124,000 visits in roughly 10-month open period. About 70% of the opioid overdose deaths in 2020 were men between age 35 and 64, and ethnically significant for African American, 5 times more than other racial groups. Based on our ED data, population data in Chinatown and Tenderloin areas, and information from literature review and city drug crisis report. The yearly number of ED patients to be served is projected to be 1600 for year 1, 1750 for year 2 and 1950 for year 3. In another word, 5300 individuals in total will benefit from our program if awarded. To reach our program goals, our interventions and strategies are 1) educating providers on OUD and non-opioids therapies, encouraging them to practice non-opioids therapies in ED; 2) educating patients on opioids risk and non-opioids therapies benefits through community outreach and ED service, encouraging and enrolling patients in non-opioids therapies; 3) engaging patient community, educating CBOs and recruiting them into the care model and encouraging mutual-referrals of qualified patients. Our objectives are to 1) increase number of providers trained on OUD and CHED-ALT care model; increase number of patients received CHED-ALT care; increase number of CBOs through community outreaches and collaborate with CBOs to provide health education and reach out to more targeted patient population in Chinatown and Tenderloin areas.

This project will expand the use of available evidence-based options for pain management in the emergency department (ED), focusing on pain relief and empowering people with tools to use for pain management while minimizing the risk of potential harms from opioid exposure. We will expand utilization of ultrasound-guided local anesthesia for femoral fractures and shoulder dislocations. A full menu of integrative health and medicine techniques will be introduced and available for novel outpatient follow-up (acupuncture, yoga, etc.), with patients receiving information on mindfulness and stress reduction techniques to use immediately. Mindfulness and resilience training sessions will be offered to ED prescribers in an effort to decrease personal burnout through experiencing the benefits of this mind-body modality firsthand and allowing them to be more informed when offering these interventions to patients. Pain is the driving force leading many patients to seek care in the ED. Opioids have become synonymous with pain control and it is imperative that we educate medical professionals on safe evidence-based alternatives to opioids, ensuring that patients are not subjected to unnecessary suffering from pain, while avoiding potential harms from exposure to opioids and increasing patient self-efficacy. The overarching goal of this project, ‘Alternatives to opioids for pain in the emergency department: Implementing Integrative Health approaches and expanding local nerve block initiatives’ is to provide alternatives to opioids for management of pain in the ED and post-discharge. Specifically, we aim to 1) Decrease the overall MME of opioids administered to patients who suffer from a femoral fracture or shoulder dislocation through increasing use of ultrasound-guided local anesthesia 2) Decrease burnout among ED prescribers through mindfulness and resilience training and 3) Establish a novel referral process to the Osher Center for Integrative Health to allow patients options for evidence-based integrative health approaches to treat pain, such as acupuncture, massage, movement therapy, or mindfulness/stress reduction. All ED patients with a femoral fracture or shoulder dislocation will be eligible ultrasound-guided anesthesia for pain control. We plan to administer a total of 243 femoral nerve blocks and 68 shoulder joint injections over three years. Any English speaking patients who present with pain, depression or anxiety not requiring immediate psychiatric stabilization or substance use disorder will be eligible to receive information regarding integrative health services and a referral, augmented by phone calls from the project director. It is estimated that 700 patients will be presented the explanation of services and a brief introduction to mindfulness, with 150 (20%) accepting the referral, and 100 patients completing follow-up and a secondary assessment. All ED faculty and residents will be offered the evidence-based mindfulness and resiliency training program. We anticipate at least 46/116 (40%) will partake in the training. This study will have mixed methods evaluative components. The practice patterns of opioid use for specific conditions before and after education and expansion of nerve block pathways, as well as overall administration and prescribing of opioids within the ED following mindfulness and resiliency training of prescribers will be measured retrospectively. Burnout, perceived stress and resiliency will be measured and compared before and after the mindfulness program for physicians. Follow-up rates for those referred to integrative health will be tracked prospectively and rates of return to the ED as well as number of opioids prescribed between those who did and did not follow-up will be retrospectively evaluated. This project will be informed by available resources from SAMHSA, the American College of Emergency Physicians, and our integrative health colleagues.

The ALERT Project is designed to decrease opioid prescribing and increase the use of opioid-sparing medications and interventional procedures for pain patients seen in three safety net emergency departments (EDs) in rural Berkshire County, MA. To this end, ALERT will implement computerized, opioid-sparing order sets for patients presenting musculoskeletal pain, dental pain, headache, kidney stones, and abdominal pain. In addition, because pain is a biopsychosocial phenomenon, the most complex patients will receive a multidisciplinary assessment, a comprehensive care plan, and navigation services to help them access hospital- and community-based services, including medical and behavioral health care, addiction treatment, restorative therapies, complementary and integrative therapies, and services to address unmet basic needs. The population of focus is men and women (age 18 and older) who frequently seek pain care in the three EDs operated by Berkshire Health Systems (BHS). In CY2022, 16,185 unduplicated pain patients were seen in the BHS EDs, 13.8% of whom identified as racial minorities and 4.5% as Hispanic/Latino. The geographic catchment area is Berkshire County. Although the population identifies predominantly as White (86.2%), the county is increasingly diverse, with a 54% increase in the Hispanic/Latino population in the past 10 years. A center of arts, culture and recreation, Berkshire County is a popular retirement destination and tourist area. The county’s median household income ($63,169) is lower than the state ($89,026) and the US ($70,784). The beauty of the Berkshires and the state’s progressive approach to the rights of sexual and gender minorities have attracted many LGBTQ+ people to the area. Over three years, ALERT will implement opioid-sparing order sets for 10,500 pain patients (1,500 in Year 1 and 4500 in Years 2 and 3). Care plans will be developed for 330 patients (90, 120 and 120 in Years 1, 2, and 3), and 660 patients will receive navigation services (180, 240, and 240). Need: The need for the proposed project stems from the high rate of opioid-related mortality in Berkshire County (48/100,000 population in 2021), the high opioid-prescribing rate (501/1000 compared to 333/1000 nationwide), and the lack of a system of care for pain patients who rely on the ED. Goal 1 is to implement a set of evidence-based, order sets to increase the use of opioid-sparing approaches to treat the high-priority pain conditions seen in the BHS EDs, along with a rigorous system of continuous performance improvement. Goal 1 Objectives include conducting a progressive series of Health Stream and 1:1 training sessions such that, by June 30, 2024, 80% of ED providers are prepared to implement all five non-opioid order sets and deliver interventional procedures for pain (intraarticular injections, trigger point injections, and sympathetic nerve blocks), thereby significantly decreasing opioid prescribing, and monitoring ED provider performance using the ALERT Dashboard. Goal 2 is to conduct comprehensive, multidisciplinary, multimodal assessments of patients with high utilization of ED services and create plans for tapering or avoiding opioids for pain management across the continuum of care. Goal 2 Objectives include designing and implementing new clinical protocols and initiating interdisciplinary team assessments and care planning for 10 patients per month beginning January 1, 2024. Goal 3 is to provide patient navigation services to engage patients in comprehensive care plans for pain management outside the ED. Goal 3 Objectives are to initiate navigation beginning March 1, 2024; to monitor its effectiveness, and, by the end of the project, to connect 80% of patients to at least one service and 50% to two services. Evidence-based practices incorporated into ALERT include a Provider Learning Community; continuous, data-based performance improvement; community-based restorative therapies, and patient navigation.