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Original Research

Open Access Special Issue

The impact of coronavirus disease 2019 (COVID-19) on alternatives to opioids protocol for opioid reduction in emergency department

  • Eric H Chou1
  • Toral Bhakta1
  • Ching-Fang Tiffany Tzeng1
  • Andrew Shedd1
  • Matthew Hall1
  • Jon Wolfshohl1
  • Alec Jessen1,2
  • Chinmay Patel1
  • Robin K Chan1
  • Dahlia Hassani1

1Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX 76104, USA

2TCU and UNTHSC School of Medicine, Fort Worth, TX 76109, USA

DOI: 10.22514/sv.2021.243

Submitted: 08 September 2021 Accepted: 22 October 2021

Online publish date: 13 December 2021

*Corresponding Author(s): Eric H Chou E-mail:


The United States (US) is in the midst of both an opioid epidemic and COVID-19 pandemic. The Alternatives to Opioids (ALTO) approach is a useful strategy of utilizing non-opioid options as the first-line pain therapy in the emergency department (ED). Since the COVID-19 pandemic began, more than 40 states have reported a rise in opioid-related deaths. Since there is a potential increasing need for pain management due to limited outpatient resources during the COVID-19 pandemic, it is unclear whether the COVID-19 has affected the effectiveness of the ALTO protocol in reducing opioid administration in the ED. To investigate the impact of COVID-19 on the usage of the ALTO protocol for opioid reduction, this retrospective cohort study was performed to compare patients receiving pain medication in an urban ED during the COVID-19 pandemic (March to August 2020) and patients during the same period from one year prior. The primary outcome was the change in ED opioid administration and out-patient opioid prescriptions. All opioid dosages were converted to morphine milligram equivalents (MME) for data analysis. Secondary outcomes included changes in ALTO medication use, patient satisfaction with pain control, ED length of stay, and rate of left without being seen (LWBS). The mean prescribed MME per discharged patient visit was significantly lower in the COVID-19 pandemic group (3.16 ± 0.31 versus 7.72± 0.31, p < 0.001). There was no significant difference in ED opioid administration, patient satisfaction with pain control, ED length of stay, and rate of LWBS between both groups. In conclusion, during the COVID-19 pandemic, the ALTO protocol can reduce out-patient opioid usage without changing opioid administration in the ED.


Pain management; Alternatives to opioid; Emergency department; COVID-19

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Eric H Chou,Toral Bhakta,Ching-Fang Tiffany Tzeng,Andrew Shedd,Matthew Hall,Jon Wolfshohl,Alec Jessen,Chinmay Patel,Robin K Chan,Dahlia Hassani. The impact of coronavirus disease 2019 (COVID-19) on alternatives to opioids protocol for opioid reduction in emergency department. Signa Vitae. 2022.doi:10.22514/sv.2021.243.


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