Brenda Pitts sat stiffly in an emergency room cubicle, her face contorted by pain. An old shoulder injury was radiating fresh agony down to her elbow and up through her neck. She couldn't turn her head. Her right arm had fallen slack.
Fast relief was a pill away — Percocet, an opioid painkiller — but Dr. Alexis LaPietra did not want to prescribe it. The drug, she explained to Mrs. Pitts, 75, might make her constipated and foggy, and could be addictive. Would Mrs. Pitts be willing to try something different?
Then the doctor massaged Mrs. Pitts's neck, seeking the locus of a muscle spasm, apologizing as the patient groaned with raw, guttural ache and fear.
"Quick prick," said Dr. LaPietra, giving Mrs. Pitts a trigger point injection of Marcaine, a numbing, non-opioid analgesic.
Within seconds, Mrs. Pitts blinked in surprise, her features relaxing, as if the doctor had sponged away her pain lines. She sat up, gingerly moving her head, then beamed and impulsively hugged the doctor, vigorously and with both arms.
Since Jan. 4, St. Joseph's Regional Medical Center's emergency department, one of the country's busiest, has been using opioids only as a last resort. For patients with common types of acute pain — migraines, kidney stones, sciatica, fractures — doctors first try alternative regimens that include nonnarcotic infusions and injections, ultrasound guided nerve blocks, laughing gas, even "energy healing" and a wandering harpist.
Scattered E.R.s around the country have been working to reduce opioids as a first-line treatment, but St. Joe's, as it is known locally, has taken the efforts to a new level.
"St. Joe's is on the leading edge," said Dr. Lewis S. Nelson, a professor of emergency medicine at New York University School of Medicine, who sat on a panel that recommended recent opioid guidelines for the Centers for Disease Control and Prevention. "But that involved a commitment to changing their entire culture."
In doing so, St. Joe's is taking on a challenge that is even more daunting than teaching new protocols to 79 doctors and 150 nurses. It must shake loose a longstanding conviction that opioids are the fastest, most surefire response to pain, an attitude held tightly not only by emergency department personnel, but by patients, too.
Pain is the chief reason nearly 75 percent of patients seek emergency treatment. The E.R. waiting rooms and corridors of St. Joe's, where some 170,000 patients will be seen this year, are frequently pierced by high-pitched cries and anguished moans.