It’s time to embrace opioid addiction drugs in the ER, say experts

SAN FRANCISCO – If a patient who has overdosed on opioids comes in after receiving a dose of naloxone (Narcan), typical protocol is to give them a sandwich and a list of detox facilities before sending them on their way, according to an emergency medicine doctor.

It doesn’t matter that these patients are at such a high risk that they’re “actively dying,” said Alexis LaPietra, DO, of St. Joseph’s University Medical Center in Paterson, New Jersey, during a presentation at the American College of Emergency. Physicians ( ACEP) annual meeting.

However, with the help of buprenorphine, “we can bring this mass mortality almost to the same level as that of the general population”, she noted.

While a 2015 randomized trial showed that the use of buprenorphine/naloxone (Suboxone) in the ER led to increased engagement in addiction treatment, and some physicians called for the use of buprenorphine by paramedics paramedics at the site of the overdose, buprenorphine is still not a standard. emergency department (ED) treatment for opioid overdoses.

Stigma is often to blame, LaPietra said

“Drug addicts were really looked at with a lot of shame,” she added. “We really thought they were a group that had a moral flaw, a lack of willpower. They just can’t put their stuff together. But we can’t demand perfection from those who suffer from related disorders. to opioid use more than any other chronic disorder.

According to a synthesis of emerging opioid use disorder programs in emergency departments, “barriers to implementation include lack of knowledge about treatment options and their effectiveness, stigma, limits of community treatment capacity and health insurance and reimbursement policies”.

LaPietra co-presenter Arian Nachat, MD, of Balboa Naval Medical Center and VA Medical Center in San Diego, said buprenorphine is especially helpful because there’s no way to overdose on it.

“It partially binds to the opioid receptor and stays in place for 12 to 24 hours,” she explained. “It hangs around a lot longer than the opioids they take. And it’s one of the safest drugs we have.”

If you don’t have the waiver that allows some healthcare professionals to prescribe buprenorphine, new rules implemented in 2021 allow eligible providers to get an alternative waiver that doesn’t require training, Nachat noted. , although this waiver prevents providers from prescribing buprenorphine to more than 30 patients at a time.

She encouraged attendees to get the full waiver after the mandatory training: “It’s really not that long and that’s probably a good thing.”

She also said it’s helpful to use your phone to access the 11-item Clinical Opioid Withdrawal Scale (COWS) to gauge your patient’s condition. The scale, which is available via online calculators, produces a score of 0 to 48 after measuring withdrawal symptoms, such as sweating, pupil size, anxiety and tremors.

Typically, these patients are “all restless,” Nachat explained. “They’re sweating, they’re restless, they’re really super uncomfortable.”

She said if their score is over 9, 8mg of buprenorphine should be given. “Then you’re going to wait, you’re going to come back about 45 minutes later, and you’re going to reevaluate.”

If the score is still above 9, give a second dose of 8 mg. “You can’t overdose them. It’s not a problem,” she stressed.

At this point, their withdrawal symptoms may subside, Nachat continued. “You make them feel better and you just made yourself your best friend. They’re so happy because you got their bodies out of absolute distress.”

If their COWS score is below 9 after 45 to 60 minutes, “send them with a prescription for 8 mg twice a day,” she advised.

In extreme cases — for example, a patient in post-naloxone withdrawal who has a rapid heartbeat with vomiting and diarrhea — COWS scores will be “very high,” Nachat said. In these cases, administer 16 mg of buprenorphine, and renew if necessary after reassessment at 1 hour. “You may need to help them out with benzos, some gabapentin, and a quiet, nice place for them to try to minimize stimulation,” she noted.

“These patients feel absolutely the worst. They’re the ones who don’t want to use buprenorphine in the future. So it’s really critical to step in, to be empathetic, to be kind, not to judge them. They actually tried to do the right thing. They tried to help themselves,” she added.

Consider sending such a patient home with a prescription for buprenorphine/naloxone 8 mg twice daily, recommends Nachat, and don’t be afraid of long prescriptions.

Ideally, they would get a prescription that would last until they attend an addiction clinic, she pointed out. “I know a lot of people in the ER who are really nervous, ‘I never wrote for this, I don’t want to write for a 30-day prescription.’ But that would be a perfectly reasonable thing to do.You wouldn’t send a diabetic home with less than a week’s supply to get to their PCP. [primary care physician].”

If you’re limited to writing a 3-day prescription and the patient can’t get into a clinic quickly, they can go back to the emergency room to refill their prescription, just like any other patient, she said.

  • Randy Dotinga is a freelance medical and science journalist based in San Diego.

Disclosures

LaPietra and Nachat did not disclose anything.

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