Matt Hollifield, MD
Patients with opioid use disorder (OUD) are at a high risk of morbidity and mortality, and are a growing population in our emergency departments. Estimates of one-year mortality after non- fatal opioid overdose range from 5.5% to 10%. In one series, one out of five deaths occur within 30 days of an ED visit and one in 22 deaths will occur within two days. Detox to abstinence programs have low efficacy and patients who fail detox are at especially high risk of overdose with the resumption of use. When buprenorphine is initiated in the emergency department, patients are more than twice as likely to be engaged in substance misuse treatment at 30 days when compared to patients referred to outside treatment programs. OUD is deadly and we have the tools to save lives and make a difference.
In our practice, surveys indicate most of our clinicians realize that medication for treatment of opioid use disorder (MOUD) is effective and OUD is a treatable chronic disease. However, many note that OUD patients are more challenging and less satisfying to treat. Although most would like to offer treatment, many aren’t sure how to do it. Most ED clinicians in our practice report that a major barrier is the ability to refer patients for follow up.
Consider incorporating the following steps into your treatment of OUD patients:
TREATMENT. There are 3 FDA-approved medications for OUD: buprenorphine, methadone and naltrexone. For most EM clinicians, buprenorphine is the safest and easiest to use. Buprenorphine is a mixed opioid receptor agonist-antagonist with weak activity and high affinity at the reward-inducing Mu receptor. Buprenorphine is available alone and in combination with naloxone. Naloxone is added to buprenorphine to prevent abuse from snorting or injecting buprenorphine. Contemporary research suggests the addition of naloxone may not offer many benefits. Overdose on buprenorphine is rare.
Sublingual buprenorphine is easy to administer and provides rapid onset of action. Buprenorphine should be started when patients have at least moderate symptoms of opioid withdrawal, and typically 6-12 hours after last use of short acting opioids such as heroin, and
12-24 hours after long acting opioid use (OxyContin). Because of the long half life of methadone, buprenorphine should not be used within 72 hours of last methadone use. Moderate withdrawal usually means a COWS score of at least 8. You can find a calculator for the COWS score on MDCalc. You should also be aware that fentanyl has a paradoxically long half-life when used chronically. Fentanyl is very lipophilic and can take a long time to clear – make sure to ask your patient about recent fentanyl use. Ask your patient if they are in bad withdrawal and if they want to be started on buprenorphine. If their withdrawal symptoms are mild, it is too early to start buprenorphine. Due to the high affinity of buprenorphine at the mu receptor, giving buprenorphine to an opioid-dependent patient not in withdrawal will precipitate withdrawal, which you then have to manage.
Some patients have experienced precipitated withdrawal or inadequate buprenorphine dosing and will be afraid of starting buprenorphine. This should always be a SHARED DECISION MAKING PROCESS. The patient may know what dose has worked for them in the past. You don’t want to worsen withdrawal and discourage them from getting beneficial treatment. The goal of treating opioid withdrawal with buprenorphine is to make the patient asymptomatic in the ED so that they can focus on addiction treatment without cravings, let alone the misery of withdrawal.
Your options for initiating treatment include starting the patient who is actively withdrawing on buprenorphine in the ED to control their symptoms, prescribing buprenorphine for home initiation, and/or referring for close follow up with a bridge program. But you should offer MOUD because patients withdrawing from opioids are at particularly high risk of overdose and death. The current illicit drug supply is highly contaminated with fentanyl and more potent analogues, making the risk of overdose historically high. Withdrawal is sometimes the motivation for seeking treatment, which may be fleeting, so we have an obligation to intervene where and when we can.
If you’re not sure what steps to take to start buprenorphine, check out the resources available online from a high quality source such as the California Bridge (www.bridgetotreatment.com).
PRESCRIBE. The X waiver no longer exists. You don’t need an X-Waiver to prescribe buprenorphine, just a DEA license. Buprenorphine is safe and effective. We recommend you prescribe enough medication to bridge the patient to follow up, or at least 7 days. Prescribe the dose that was required in the ED to get them out of withdrawal daily for at least 7 days. A typical dose would be Suboxone 8/2 mg SL 1-2 films BID x 7 days.
PROVIDE naloxone if you can. Studies show patients will fill fewer than 5% of naloxone prescriptions, and although it is now over the counter, there is no reason to believe this compliance would be significantly better. If you can dispense take-home naloxone nasal spray this is best practice. If you are unable to dispense naloxone from the ED, please ensure you inform them where they can obtain free naloxone (Utah Naloxone, USARA, health departments, public libraries, etc.) and discharge them with a prescription for naloxone just in case. Anyone
with an overdose, at risk of overdose, or is a friend or family member of someone at risk, should be educated about, and offered, naloxone nasal spray.
REFER for follow up treatment. Know your local resources and refer the patient to an organization that can provide ongoing care. If your health system doesn’t have a bridge program, consider learning about and referring to a telemedicine-based program such as Bicycle Health.
Remember not all patients will be ready the first time you offer them treatment. They have complicated lives and we will never understand everything facing each person. However, invite them to start recovery and make sure they know that you stand ready to help whenever they are ready to start. Even if patients don’t want buprenorphine, offer them naloxone or educate them on how to get it, and refer them to treatment.