A 24-year-old woman is brought to the emergency department (ED) after being discovered with a decreased level of consciousness in a local mall bathroom. Two doses of intranasal naloxone were administered on-site by bystanders. After receiving naloxone, her LOC improved, though she was still mildly sedated upon arrival to the ED. After 1-2 hours in the ED, she is alert and reported using 0.5g of smoked fentanyl prior to the episode. You learn that she has been using non-prescribed opioids on a daily basis for the last 6 months. She has no other significant medical history and is not on any outpatient medications. This is her first opioid poisoning requiring presentation to hospital.
Due to the increasingly toxic street drug supply, the opioid crisis in Canada continues to cause significant mortality and morbidity. In 2019 alone there were 3,823 opioid-related deaths reported across Canada, with approximately 77% attributed to fentanyl and its analogues1. Unfortunately, the incidence of opioid poisonings and opioid-related deaths are increasing annually, with recent spikes noted from March to July 2020 attributed to the impact of the COVID-19 pandemic on local drug supply and drug use patterns2,3. Young people, particularly males, are at highest risk of opioid-related death in Canada1.
People who use drugs have high rates of ED use – up to 7-times more visits than the general population4. Opioid poisonings comprise a significant proportion of these ED visits4. The prognosis for individuals who survive an opioid poisoning is harrowing; studies have demonstrated mortality rates of 5.5-9.4% one year after an ED presentation for opioid poisoning5,6, with the first month after an event being the highest risk5. As such, ED physicians should identify individuals presenting with opioid poisoning as being at high-risk for short-term mortality, and approach each encounter as an opportunity for high-impact, meaningful intervention. Below we discuss some evidence-based, ED-appropriate interventions.
Detox alone is not recommended
Withdrawal management alone is not a safe or effective treatment for opioid use disorder. When administered without linkage to long-term addiction treatment and opioid agonist therapy, withdrawal management alone is associated with higher risks of relapse, infection and death from opioid poisoning7. Opioid agonist therapy (such as buprenorphine or methadone) is the recommended treatment for opioid use disorder, and has been shown to reduce mortality and morbidity associated with non-prescribed opioid use7. If a patient is interested in opioid agonist therapy, ED physicians should facilitate referrals to appropriate outpatient care, such as a local Rapid Access Addiction Medicine clinic or community addiction medicine provider.
Motivational Interviewing / Brief Intervention
Various tools exist to help guide conversations about substance use with our patients. A non-judgmental and compassionate approach is key; every encounter in the ED is an opportunity to restore trust with a population that is often stigmatized in healthcare settings.
Brief intervention can include many different approaches designed to engage, motivate and inform patients about behaviour change, and is ideal for use in the ED where the physician-patient relationship may only include one encounter. Most approaches apply a motivational interviewing framework, which centres around a patient’s autonomy and individual values in the discussion about if, and how, the patient would like to make changes8. Evidence has shown that even one ED encounter using motivational interviewing as an intervention can reduce self-reported non-prescribed opioid use six-months later8.
The Brief Negotiated Interview model is evidence-based and can be easily employed in the course of your history-taking. The Brief Negotiated Interview consists of four steps: (1) engaging the patient and seeking permission to discuss substance use, (2) providing feedback on current substance use and its consequences, (3) assessing decisional balance (weighing pros and cons) and stage of change, and (4) providing a menu of options and assistance in accessing resources if desired9.
Another framework for behaviour-change conversations with patients is SBIRT (Screening, Brief Intervention, Referral to Treatment). It emphasizes the importance of identifying patients who are at risk, initiating a conversation about their values and goals, and the pros and cons of continued opioid use. Critically, it also includes referral for treatment10.
Offering Buprenorphine Initiation
Buprenorphine/naloxone (Suboxone) is a form of opioid agonist therapy and is recommended as first-line treatment for opioid use disorder7. It is a partial opioid agonist that has a lower risk of respiratory depression and opioid toxicity than methadone or other full-agonist opioids. Buprenorphine has many features that make it an accessible treatment option: prescribers do not require special licensure, it is generally covered under provincial drug formularies and private plans, and there is more flexibility in take-home dosing7.
Most importantly – buprenorphine saves lives. Its mortality benefit was demonstrated in a large retrospective cohort study in British Columbia which showed standardized mortality ratios decreased from 11.3 to 2.9 for opioid-dependent patients on buprenorphine compared to those who were not on opioid agonist therapy11.
Buprenorphine is safe and effective to initiate in the emergency department12. A large RCT showed that patients who were started on buprenorphine in the ED were more than twice as likely to be engaged in treatment 30 days after randomization compared to those who received a referral to treatment only (78% vs. 37%). The buprenorphine group also had a greater reduction in the number of self-reported days of non-prescribed opioid use per week (5.4 to 0.9 days)12.
Despite its life-saving benefits, buprenorphine remains underused with only 13% of patients prescribed it in the 12 months following an overdose13. When surveyed, only 20.9% of emergency medicine clinicians felt ready to initiate buprenorphine, identifying lack of training and uncertain outpatient referral processes as barriers14. Despite these challenges, the ED provides a critical opportunity for buprenorphine initiation in this high-risk population.
For guidance on initiating buprenorphine, see links below:
Naloxone (intranasal or intramuscular) is a life-saving intervention that can be used by bystanders to reverse an opioid poisoning prior to the arrival of medical services15. The ED has the potential for significant uptake of take-home naloxone, with two-thirds of patients willing to accept naloxone if it were offered16. The vast majority (86%) of Canadian ED physicians also report willingness to provide naloxone in the ED, but only a small number (13.9%) were actively participating in naloxone distribution programs17. Barriers to implementation include lack of appropriate staffing and allied health support, lack of knowledge, and integration into the ED workflow18. Despite these barriers, the ED remains a critical venue for take-home naloxone distribution, which has been mandated in some provinces18,19.
ED physicians should advocate for take-home naloxone to be available within their departments and offer it to all patients presenting with opioid poisoning. To increase accessibility, place the naloxone kit at the bedside as soon as you have identified that it will be part of your discharge plan.
Discuss harm reduction and overdose prevention counselling
Integrating harm reduction approaches into your ED practice creates a safe environment for patients at any stage of change20. Some important points to discuss with your patient:
- Do not use alone.
- Use overdose prevention sites/supervised consumption sites, if available.
- Use a test dose; if using opioids after any period of abstinence (even just a couple of days), use a much smaller dose than usual.
- Always carry naloxone and know how to administer it.
- Don’t mix opioids with alcohol or benzodiazepines.
- Do not re-use or share drug-use equipment (needles, syringes, pipes).
For a comprehensive review of best practices in harm reduction, follow the link: https://www.catie.ca/en/programming/best-practices-harm-reduction
Your patient is now medically stable for discharge. She is willing to discuss her opioid use, and you identify that she is contemplating change; she recognizes some of the health and social risks associated with her opioid use, but does not feel ready to completely abstain from opioids at this point. You share your concerns about her health given her presentation today. You discuss the risks of untreated opioid use disorder and the evidence for opioid agonist therapy . You offer to start buprenorphine, but she declines to do so today. You provide her with a take-home naloxone kit (and instructions on its use) and discuss ways to use opioids more safely (harm reduction approaches). With her permission, you submit a referral to the local Rapid Access Addiction Medicine clinic. You thank your patient for her willingness to talk with you today, and you discharge her from the ED.
- Every encounter in the ED with a person who uses drugs is an opportunity to restore trust with a population that is often stigmatized in healthcare settings. Use of a trauma-informed and culturally safe approach is critical.
- Recognize patients presenting with opioid poisoning as being at high risk for short- and long-term mortality.
- Familiarize yourself with a validated interviewing tool to help facilitate the conversation (Brief Negotiated Interview, SBIRT).
- If a patient is interested, initiate opioid agonist therapy in the ED. Learn how to prescribe buprenorphine.
- Arrange appropriate follow-up. Know the details of your local Rapid Access Addiction Medicine clinic or community addiction medicine provider.
- If you aren’t already, become comfortable discussing harm reduction approaches, resources and supplies; advocate for ED take-home naloxone distribution.
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- 1.Government of Canada . Opioid-related harms in Canada. Government of Canada. https://health-infobase.canada.ca/substance-related-harms/opioids/
- 2.Public Health Agency of Canada . Statement from the Chief Public Health Officer of Canada on COVID-19. Government of Canada. https://www.canada.ca/en/public-health/news/2020/05/statement-from-the-chief-public-health-officer-of-canada-on-covid-198.html
- 3.Moe J, Buxton JA. Don’t forget our dual public health crises. CJEM. Published online May 15, 2020. doi:10.1017/cem.2020.369
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- 9.The Impact of Screening, Brief Intervention and Referral for Treatment in Emergency Department Patients’ Alcohol Use: A 3-, 6- and 12-month Follow-up. Alcohol and Alcoholism. Published online September 27, 2010:514-519. doi:10.1093/alcalc/agq058
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- 14.Hawk KF, D’Onofrio G, Chawarski MC, et al. Barriers and Facilitators to Clinician Readiness to Provide Emergency Department–Initiated Buprenorphine. JAMA Netw Open. Published online May 11, 2020:e204561. doi:10.1001/jamanetworkopen.2020.4561
- 15.Clark AK, Wilder CM, Winstanley EL. A Systematic Review of Community Opioid Overdose Prevention and Naloxone Distribution Programs. Journal of Addiction Medicine. Published online 2014:153-163. doi:10.1097/adm.0000000000000034
- 16.Kestler A, Buxton J, Meckling G, et al. Factors Associated With Participation in an Emergency Department–Based Take-Home Naloxone Program for At-Risk Opioid Users. Annals of Emergency Medicine. Published online March 2017:340-346. doi:10.1016/j.annemergmed.2016.07.027
- 17.Lacroix L, Thurgur L, Orkin AM, Perry JJ, Stiell IG. Emergency physicians’ attitudes and perceived barriers to the implementation of take-home naloxone programs in Canadian emergency departments. CJEM. Published online September 18, 2017:46-52. doi:10.1017/cem.2017.390
- 18.Gunn A, Smothers Z, Schramm-Sapyta N, Freiermuth C, MacEachern M, Muzyk A. The Emergency Department as an Opportunity for Naloxone Distribution. WestJEM. Published online September 10, 2018:1036-1042. doi:10.5811/westjem.2018.8.38829
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This post was copyedited by Emily Stoneham
Reviewing with the Staff
The opioid crisis is a public health emergency. In June 2020, 174 British Columbians died from illicit drug overdoses, setting a new monthly record for the province. As emergency physicians and trainees, some of us will answer the call to take on key leadership roles in helping to mitigate the morbidity and mortality of the crisis. These individuals are crucial, but they are not the only ones who help. No frontline physician is absolved from responsibility or active participation. Part of our continuing medical education must involve learning about opioid agonist therapy such as buprenorphine, as well as becoming familiar with the hospital and community resources available. A public health emergency demands both good leadership and good followership, and we each have a moral obligation to participate.