EDsareaphysicallycontainedenvironment,with a defined population of patients, doctors, nurses, pharmacists, and therefore a great place to pilot these ideas.” Robert Valuck, PhD, RPh is the director of the Colorado Consortium for Prescription Drug Abuse Prevention (“the Consortium;” head- quartered within the Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of Colorado Anschutz Medical Campus, Aurora, Colorado). He says that, while the ED-focused ColoradoALTOProjectisaimedatreducingacute prescribing to opioid-naïve patients, its initial and ongoing success has, as hoped, attracted attention from other spe- cialties outside the ED. His organiza- tion, along with the Colorado Medical Society (CMS; Denver, Colorado), have now partnered with CHA for a new phase of the collaboration, the CO’s CURE initiative. This project is aimed at reducing opioid administration in the inpatient setting by extending the program’s learnings to subspecialties like surgery, urology, and family and hospital medicine. “This is an important piece,” says Valuck. “It’s eas- iest to stop opioid use disorders by not exposing people in the first place, but chronic pain is still challenging. Patients are understandably afraid of not having their pain controlled and of with- drawal, so we have a lot more work to do.” Tad-y says that the CO’s CURE initiative and other programs coming out of this collaboration are built on a new understanding of the role of harm reductioninmanagingopioidusedisorders.“The critical pillars to getting a hold on this crisis are: limit opioid prescriptions, use alternatives when possible, reduce the stigma of addiction, and actively treat addiction.” pain—headache, unspecified abdominal pain, long bone fracture, musculoskeletal/low back pain, and kidney stones. The goal was to reduce opioid prescriptions by 16%. “And it worked really well,” says Tad-y. “We saw an average 36% reduction in opioid prescriptions in the first six months of the pilot, with a corre- sponding 31% increase in the administration of ALTOs.” With such compelling initial results, the project is now undergoing a planned expansion to eventually include all Colorado EDs. A key advantage of the program, in Wald’s view, is that it is peer-driven, with guidelines developed by and for prescribers in specific sub-specialties. Since announcing the successful results from the pilot, the Colorado ALTO project has been able to recruit more than 85% of Colorado’s hospital and freestanding EDs to be trained in the approach. “It speaks to what state-wide collaboration can bring especially when backed by opinion of a pro- fessional society.” In fact, she says, SCL Health’s active participation in the broader rollout includes reaching into Montana for peer-to-peer education and program recruitment. All involved acknowledge that EDs hold sway over just a tiny segment of the opioid prescribing milieu, but as Wald says, “you can’t boil the ocean.Youhavetostartwithascope-ableproject. Both at SCL Health and in her previous role as physician-advisor to the Colorado Hospital Association (CHA; Greenwood Village, Colorado), Wald has been part of an important statewide, multi-organization, public-private, collaborative initiative to address the opioid epidemic, starting in Colorado hospital EDs. The initiative, which has been jointly led by the CHA and its numerous partners, is called the Colorado ALTO (Alternatives to Opioids) Project. Its goal is to change opioid-prescribing patterns at EDs throughout the state, by implementing pain-management and prescribing guidelines developed by the Colorado chapter of the American College of Emergency Physicians (CO-ACEP; Northglenn). The guidelines and training are aimed at redirecting how ED physi- cians, nurses, pharmacists, and other staff think about pain management; instead of choosing opioids first, evidence-based pathways present treatments that, in many cases, have been proven to be more effective and safer in specific situations. Examples include combination acetaminophen and ibuprofen for headaches, migraine-specific medications, and lidocaine trigger-point injec- tion or patches for musculoskeletal pain. “Acriticalmessageoftheguidelinesandtheproject isthatwearenottellingprescriberstoignorepain, or to never use opioids for any situation,” says Darlene Tad-y MD, current physician-advisor to CHA. “The message is, there are many proven, successful alternatives for acute pain that we should try first. We want to treat pain effectively and ALTOs are a good way to do that.” TheALTOProjectwaspilotedin10EDsthroughout the state in 2017 and concentrated on pain management for the five top presentations of 22 BIOSCIENCECOLORADO / / 2019-2020