ALTO- Alternatives to Opiates- Resources for Everyone!

ALTO is for Everyone!  (Here are your Resources)

 ALTO is the administration of Alternatives to Opiates and is an obvious response to the nationwide Opiate Epidemic.   The beauty is these Alternatives can be used by everyone no matter your specialty!

This Initiative was first introduced to Colorado in 2017 by the Colorado Hospital Association as a Pilot project in 10 Colorado Hospital Emergency Departments.[i]  The results were astounding- with a 36% reduction in the use of Opiates along with a 31% increase in the administration of Alternatives to Opiate medication over a 6 month period.

The purpose of this article is not to review the opiate epidemic, or the need for this initiative, but to provide you with easy references to the Resources available for everyone’s practice.

What are “Alternative to Opiate” Medications?  This is NOT a “narcotic free” program- but is simply a program of tools to decrease opiate use.

The goal is to use Non-opiate medications- but also if an opiate is necessary- attempt to provide no more than a 3 day supply.  It is reported after just 7 days,  13.5% of patients become long term users, which is double the rate of 1 day users.[ii]

Examples of Non-Opiates include obviously Acetaminophen along with NSAIDs, but also the use of Ketamine, IV Lidocaine, Topical Lidocaine, Haloperidol, Dicyclomine, Sumatriptan, muscle relaxers, antiemetics, trigger point injections, nerve blocks and steroids.

 OK-  where are my references?

First-  the Colorado ACEP 2017 Opioid Prescribing & Treatment Guidelines[iii] is a great resource and provides a pdf of medications including dosing and indications-  as shown in this table:

ALTO Dosing Chart

Another great resource is the Colorado Hospital Association- Colorado Alto Project.[iv]  This includes video references of the epidemic,  but also references to training materials and reference back to the CO ACEP Treatment Guidelines.

Colorado Hospital Association also provides a very helpful PDF chart as a reference.[v]

Training Videos are available for Cervical Trigger Point injections, Occipital Nerve Blocks, Trigger point Injections of Torso and Lower Back, and Fascia Illiaca Blocks (which are currently being used by my own EDs for Hip Fractures).[vi]

Now what are my resources if I am practicing INSIDE the hospital?  Our system uses EPIC and has loaded an ALTO order set.  We are privileged to simply type in “ALTO” and this is what we get:


If you are on a different EMR or have EPIC without this choice I suggest you speak to your order set committee to have this set up.  It is also a great way to monitor usage of ALTO orders.

I certainly hope this helps make things easier in your management of patients with pain and helps us all fight the opiate epidemic.


Mark Elliott, MD, MBA



[ii] Shah A, Hayes “CJ, Martin BC. Characteristics if Initial Prescription Episodes and Likelihood of Long-Term Opioid Use- United States, 2006-2015. MMWR 2017;66:265-269





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