Lethal and insidious

Peer reviewed by Reuben Strayer and Dr Melissa Allan

How can we help manage addiction?

Addiction is potentially the most lethal disease we encounter in medical practice. As emergency healthcare providers we can have an enormous impact on ‘years of life lost’ by managing this illness well.

The most dangerous thing we can do in emergency is to not continue opioids or buprenorphine / methadone / morphine on admission, and force abstinence upon those suffering addiction. These patients may lose their opioid tolerance; relapse; and potentially die using high grade street opioids. Many of the deaths occur in individuals who have recently undergone a period of opioid abstinence. 

Understanding addiction:

The following videos helped reframe my beliefs on drug addition. Our approach to treatment is most often a didactic “we are the doctor, they need a cure“; when in fact the patient needs our support far more than our treatment algorithms.

The opposite of addiction is not sobriety, it is connection.

What resources do we have in our emergency?

I, like many emergency physicians, am not an expert on substance use and my emergency training consisted of handing out a card with some numbers on and saying ‘good luck’. Listed below are some of the resources at my disposal. You may have others that are working, if so drop them in the comments section for other to see. If you don’t have some of the following, I’d suggest you make it your challenge to advocate for a few so that you have something to offer.

We are a warm and safe place. I often encourage our substance users to stay the night. Remember outside of our emergency most of society is persecuting these people. If we can start a connection we may start the process of healing.

Refer everyone to Substance Use Services Access Team – Vancouver as seen in the above video has a significant drug use problem, we are fortunate to have an access team that connects with users any way they can to the point of even finding them on street if that’s where they will be on a ‘Friday morning’.

Take-home naloxone: A life-saving product that should be offered to every patient and their companions at risk for overdose. This is ideally dispensed in the emergency department. Many jurisdictions have municipal programs set up to help you do this. I’ve even heard of some prescribers giving naloxone along with every opioid script they write to 1. show the gravity of the prescription but 2. to normalise naloxone at home. Even if you can’t do this as a medical provider think of having some in your car or bag. 

Talk about safe use practices. Ask the patient if they lick their needles or cut their drugs with sterile water. Do you discard your cotton with every use? Do you inject with other people around? Do you do a small tester shot to make sure a new batch isn’t too strong? Providing clean needles or referring to a needle exchange does not make your patient more likely to use, it just makes it less likely that they will be harmed by using.

Tell everyone not to use drugs alone (have a buddy with you who can call 911 if you stop talking) and now in British Columbia we have the lifeguard app and supervised consumption sites.

Create a 24 hour Addiction Medicine phone line for advice on management for any medical staff

Offer screening for pregnancy, HIV and HCV, as well as post-exposure/pre-exposure prophylaxis when relevant. Talk about food and housing insecurity. Discuss co-occurring medical, psychiatric and social problems that are often unrecognized and untreated.

Buprenorphine:

The vast majority of patients who attempt abstinence-based treatment will relapse and as mentioned relapsing with fentanyl on the ground can be fatal.

If your patient tells you they do not want buprenorphine because they “want to be clean”, explain that it is similar to a diabetic not wanting insulin. They need a safer alternative to their drug use first and then we can help them get clean by tackling why they needed to use drugs to escape their trauma in the first place.

Your goal when you encounter an opiate use disorder patient who is not in a treatment program is to move them to recovery with buprenorphine. This means administering buprenorphine in the ED, prescribing buprenorphine and referring to outpatient comprehensive medication-based addiction care.

Take home buprenorphine packs with instructions. 

Using buprenorphine to treat withdrawal is very straightforward. The more severe the withdrawal, the better it will work. As long as the patient has at least moderate withdrawal symptoms (such as a score of greater than 12 on the Clinical Opiate Withdrawal Scale – COWS), you can start with 2 mg sublingual (some clinicians will start with 4mg dosing) and continue to dose 2 mg every 30-60 minutes until the patient feels much better. Some guidelines recommend daily doses of 12mg but you may find your patient needs 16mg or more (NB: make sure they are not swallowing the tablet, its goes under the tongue when dosing correctly). Alternatively Reuben has gone for a simpler method of 4-8 mg initially, then another 8mg for most patients and then he discharges them on 8 mg BID until they see an outpatient prescriber. So see what your institution is doing and after you have some experience modify your approach to suit your patients and your department. Induction is only determining what their daily dose is. Once you know whether they need 12mg, 14mg, 16mg etc you then advise the patient to take that as a single dose the next day. The plan is for the patient to stay on this longterm while other services help address prior trauma and allow a person to heal. 

Starting buprenorphine in opiate use disorder patients who are not in withdrawal is trickier due to concern for precipitating withdrawal. There are several options.

The classic approach is to do home initiation; writing a prescription and giving specific instructions. Home initiation has been used for years by addiction specialists and it works well. The patient has to be able to endure the development of moderate to severe withdrawal symptoms. The need to suffer through a period of spontaneous withdrawal is an important barrier to successful home initiation. Many patients can still do home initiation and it is an important tool.

Keeping the patient in the ED to await the development of sufficient withdrawal is another option. This allows the patient to be supported through the period of withdrawal symptoms such as the use of medications like clonidine, ondansetron, loperamide, haloperidol, etc. Although these do not work well, they can take the edge off.

Some patients cannot tolerate withdrawal and the prospect of withdrawal even with symptomatic treatment is a barrier too high to breach. An evolving strategy to initiate buprenorphine therapy without subjecting the patient to spontaneous withdrawal is microdosing. This technique takes several days and is for outpatient or inpatient, if there is an indication for admission. This involves the slow administration of very small doses of buprenorphine (such as starting with 0.5 mg on the first day) and then slowly increasing the dose while the patient continues to use their full-agonist. Once you reach a reasonable dose of buprenorphine such as 8 – 12 mg sublingual, you can taper off or just discontinue the full agonist and the patient will not withdraw as they are therapeutic on buprenorphine. See Melissa’s tips below on how to do this.

Mellissa’s quick guide on how she manages substance use:

1. I ask everyone I see if they use street drugs. If they say YES I ask about opioid use.  
2. I give everyone Naloxone Kits and refer to a community drug use team with a card for contact info.
3. If the person uses drugs by injection I ask if they want one of the safer injection kits and give it – with information on how to get clean supplies outside of ED – this should be placed inside the kit you make up.
4. If opioid use – I quickly sort out if they have opioid use disorder – do they use opioids regularly, negative consequences, not able to stop, symptoms of withdrawal if they don’t use…… – if they have opioid use disorder I ask if they have experience or are interested in methadone or buprenorphine – making it clear that people die less often and have better outcomes on these medications – if they are interested in buprenorphine I offer the take home packs.  If interested in methadone – send them to an opiate clinic (I will start it in the right person but you need extra training to do this). It seems like a lot, but it only takes me a few minutes to do.
5. Microdosing of buprenorphine is an option instead of someone waiting to go into withdrawal to start it…sometimes I tell patients about this since they can split the 2mg tablets in the take home kits….but usually people who are familiar with it or have tried it before:

How to treat patients on Buprenorphine when in acute pain:

The same features that make buprenorphine a great treatment for opioid addiction, make it difficult to treat patients therapeutic on buprenorphine with opioids for acute pain. There is no pain that analgesic dose ketamine cannot manage.

Make liberal use of regional anaesthesia. Break out your opioid alternatives to care for these patients. You can have the patient split their daily buprenorphine dose into every 6 to 8 hour intervals which increases its analgesic effects. You can overcome buprenorphine blockade with large doses of full-agonists such as fentanyl, but this could take more fentanyl than you might be comfortable giving.

Here is a useful link below from Bridge to Treatment on how to manage acute pain in these patients: Acute Pain Management in Patients on Buprenorphine (Bup) Treatment for Opioid Use Disorder

Resources

• AAEM – white paper
• ACEP – guidelines – including what to give if you cause a Buprenorphine withdrawal
• Bridge-to-treatment – an American resource but has tons of algorithms for every Buprenorphine scenario you can think of including pregnancy, acute pain, inpatient and outpatient starts.
• Emergency Medicine Cases – Opiate misuse, overdose and withdrawal
• EMU365 – ED initiated Buprenorphine with Ruben Strayer
• EMRAP 2020 – Strayerisms: Opiate Use Disorder Part I
• EMRAP 2020 – Strayerisms: Opiate Use Disorder Part 2
• National institute on drug abuse – Initiating Buprenorphine Treatment in the Emergency Department