Author’s Note: The intent of this document is to describe the extent of the opioid crisis and the role of the Emergency Department team in caring for the affected patient population. I have chosen to set aside, for the time being, considerations of specific therapy, notably Medication Assisted Therapy (MAT), as that subject deserves its own white paper.
Scope
With the country’s attention deservedly focused on the COVID-19 pandemic, the fact that the rise in overdoses and deaths associated with opioids occurred during the same time period has some people worried that the awareness of challenges and the resources needed to support an effective response may not be forthcoming.
There’s an epidemic sweeping the country, causing thousands of needless deaths each month and billions in economic damage. The government response is haphazard. Many Americans remain resistant to the prevention and treatment strategies shown to work best.
It’s not Covid-19.
It’s the country’s “other” health emergency: accelerating drug overdoses, which could soon, for the first time, claim 100,000 U.S. lives in a single year. Yet while Washington treated the addiction crisis as a top priority just two years ago, the coronavirus pandemic has made it an afterthought.
According to interviews with leading doctors, lobbyists, members of Congress, and multiple Biden administration aides, proposed reforms include billions of new dollars for treatment and recovery services, a deregulation of addiction treatment medications, making many of 2020’s emergency telehealth allowances permanent, and scaling up harm-reduction offerings like needle exchanges, fentanyl test strips, and naloxone distribution.
STAT News. The ‘other’ epidemic: Amid Covid-19, addiction experts fear Biden could back-burner the overdose crisis https://www.statnews.com/2021/03/02/addiction-overdose-crisis-covid-biden-backburner/
Thankfully, the drive to confront the opioid crisis predated the pandemic, and research and effective methodology recommended to mitigate the effects exist, have been trialed, and are available to those who wish to relocate that success.
Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing—specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment—interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.
Annals of Emergency Medicine. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/policy-statements/information-papers/identification-mgmt-and-trans.-of-care-for-patients-with-ocu-in-the-ed.pdf
The CDC describes a link between the effects of the pandemic on a vulnerable population and how those effects contributed to the increase in opiod-related overdoses and death.
Over 81,000 drug overdose deaths occurred in the United States in the 12 months ending in May 2020, the highest number of overdose deaths ever recorded in a 12-month period, according to recent provisional data from the Centers for Disease Control and Prevention (CDC).
While overdose deaths were already increasing in the months preceding the 2019 novel coronavirus disease (COVID-19) pandemic, the latest numbers suggest an acceleration of overdose deaths during the pandemic.
“The disruption to daily life due to the COVID-19 pandemic has hit those with substance use disorder hard,” said CDC Director Robert Redfield, M.D. “As we continue the fight to end this pandemic, it’s important to not lose sight of different groups being affected in other ways. We need to take care of people suffering from unintended consequences.”
Synthetic opioids (primarily illicitly manufactured fentanyl) appear to be the primary driver of the increases in overdose deaths, increasing 38.4 percent from the 12-month period leading up to June 2019 compared with the 12-month period leading up to May 2020. During this time period:
•37 of the 38 U.S. jurisdictions with available synthetic opioid data reported increases in synthetic opioid-involved overdose deaths.
•18 of these jurisdictions reported increases greater than 50 percent.
•10 western states reported over a 98 percent increase in synthetic opioid-involved deaths.CDC. Addressing the Opioid Overdose Epidemic in the Emergency Department. https://www.cdc.gov/drugoverdose/training/emergency-department/index.html
Addressing the Crisis
An emerging consensus regarding the methods, tools and resources required to confront the crisis provides clinicians and administrative teams a road map for implementing effective countermeasures.
The increase in overdose deaths highlights the need for essential services to remain accessible for people most at risk of overdose and the need to expand prevention and response activities. CDC issued a health advisory today to medical and public health professionals, first responders, harm reduction organizations, and other community partners recommending the following actions as appropriate based on local needs and characteristics:
•Expand distribution and use of naloxone and overdose prevention education.
•Expand awareness about and access to and availability of treatment for substance use disorders.
•Intervene early with individuals at highest risk for overdose.
•Improve detection of overdose outbreaks to facilitate more effective response
CDC. Addressing the Opioid Overdose Epidemic in the Emergency Department. https://www.cdc.gov/drugoverdose/training/emergency-department/index.htmlPeople who have a nonfatal drug overdose are at very high risk for another one.. Emergency Departments (ED’s) have a unique opportunity to save lives by preventing future overdose among patients who have experienced opioid overdoses and among patients at risk of an initial overdose (e.g. frequent ED visits for substance use-related reasons or for pain medicine). Providing optimal care to patients who have overdosed and use of community programs contributes to effective use of the ED.
Recommendations from the NYS Department of Health (NYSDOH) and NYS Office of Alcoholism and Substance Abuse Services (OASAS)
• Recognize a previous overdose as a risk factor for and a predictor of a future opioid overdose(s).
• Counsel patients about the risks of overdose and how it may be prevented.
• Ask about current and past substance use, including use of heroin and prescription opioids.
• Recommend disposal of any remaining opioids if not obtained pursuant to a prescription.
• Recommend substance abuse treatment options (e.g. methadone and buprenorphine maintenance) and provide referrals and assistance to obtain treatment through clinics and physicians who prescribe buprenorphine.
• Provide harm reduction referrals for patients not willing or ready to abstain from substance use.
• Instruct individuals and their friends and family on how to recognize and respond to an overdose, including use of rescue breathing and possibly with naloxone.
• Provide take-home naloxone (see below for information on how to register to do so).
• Refer individuals, friends and family to Opioid Overdose Prevention Programs, if one is in your area.
• Educate patients about safe use, storage and disposal of prescription opioids.
• Review and update, as appropriate, existing opioid overdose-related ED policies and procedures.
https://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention//ealth_advisory_ed_interventions_preventing_overdose.htm
Research
While patients suffering from opioid use disorder are often thought to be non-compliant patients, recent research indicates that they are willing and ready to accept assistance from the ED team.
Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence?based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients’ perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the emergency department (ED) to engage with treatment and other patient support services in the acute post–opioid overdose period.
Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED? based research evaluating a patient? oriented approach to engage patients after opioid overdose.
SAEM. A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs https://onlinelibrary.wiley.com/doi/abs/10.1111/acem.14197
There is a significant overlap in patients with unmet Social Determinants of Health needs and those using and/or addicted to opioids.
In addition to providing high-quality acute care around the clock, EDs also function as a key entry point into the health care system for many patients. This is particularly true for vulnerable populations with poor access to care, including many individuals with opioid use disorder. Uniquely situated on the front lines of the opioid epidemic, EDs treat opioid overdoses, as well as the complications of opioid use disorder and long-term addiction daily. As the opioid epidemic continues, EDs will play an integral part in mitigating the human toll on many levels through screening and identification of patients at risk for opioid use disorder, managing acute opioid withdrawal, initiating medication-assisted therapy, and coordinating linkage to outpatient treatment.
EDs will continue to care for patients with opioid overdoses, complications of opioid misuse, and chronic addiction. National calls to declare the opioid epidemic a public health emergency and rapidly increase treatment capacity across the United States must include and engage the emergency medicine community. A robust infrastructure to support, educate, and enable emergency physicians to manage opioid use disorder in an evidence-based fashion and rapidly transition care to outpatient services is a necessary step in turning the tide against an opioid epidemic affecting communities nationwide.
Annals of Emergency Medicine. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department https://www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/policy-statements/information-papers/identification-mgmt-and-trans.-of-care-for-patients-with-ocu-in-the-ed.pdf
Best Practices
The American College of Emergency Medicine (ACEP), the Centers for Disease Control (CDC), and the American Hospital Association (AHA) all have robust and well-researched program guides and resources. The response to the crisis has been collaborative, and are eager to share these best practice guides and tools with anyone willing to research and ask for help.
According to the CDC, each day more than 1,000 people are treated in emergency departments for misusing prescription opioids. Especially when patients are taken to the ED after an overdose and an administration of naloxone, there is an opportunity to assist patients beyond surviving the overdose. Even though patients may be experiencing withdrawal and thus may not be receptive to assistance, hospitals are implementing a number of strategies to reach patients and provide stronger connections to behavioral health services, including:
• The American Society of Addiction Medicine Criteria. ASAM’s criteria are part of a comprehensive set of guidelines that addiction medicine professionals can use to provide a nomenclature for describing the continuum of addiction services.
• Westmoreland County’s Warm Handoff System. This approach embeds case managers in emergency departments during peak times for overdose patients to present.
• Recovery Supports for Overdose Survivors. This program connects individuals who have presented at Rhode Island emergency rooms with an opioid overdose with recovery services delivered by certified peer recovery coaches.
• Warm Handoff Protocol Outlines Steps for Helping Overdose Patients. (2016) The Pennsylvania College of Emergency Physicians and the Pennsylvania Departments of Health and Drug and Alcohol Programs partnered to develop this protocol, which was distributed to emergency departments statewide.
American Hospital Association. Stem the Tide: Addressing the Opioid Epidemic, Ensuring Safe and Effective Transitions of Care. https://www.aha.org/system/files/content/17/opioid-toolkit.pdf
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