POSTED: July 1st, 2019
POSTED IN: EPIC - The Official Newsletter of MOCEP, May/June 2019, Resources, Toxicology,
The number of deaths following opioid overdoses in the Midwest continues to rise. This includes the state of Missouri and areas of the state, such as St. Louis, which tend to drive the overdose death rate in the state. The climbing rate is likely multifactorial. Our heroin or opioid supply continues to be adulterated with fentanyl, fentanyl derivatives, and other synthetic, highly potent, laboratory opioids. In fact in some places, it is likely heroin contaminating the fentanyl supply.
There is also still not enough access for treatment. Most patients that want treatment, still can’t get it. Hopefully, this is starting to change. A program in St. Louis referred to as EPICC (Engaging Patients in Care Coordination) sends recovery coaches to the ED to meet with the patient, arrange follow-up which normally occurs within 1-3 days, and gives them naloxone. In some EDs, patients are also started on buprenorphine if it is appropriate. For those not familiar with recovery coaches, they are patients with opioid use disorders that are now in recovery and are dedicated to helping others. For more about them, please see this post on the MOCEP website: https://mocep.org/2018/06/epicc-a-recovery-coaches-perspective/. At least two other similar programs have been started in other parts of the state. Additionally, more emergency physicians are obtaining their x-waiver so they can prescribe buprenorphine. While I hope this arcane waiver system will one day go the way of the dinosaurs, for now it is a necessary evil. The good news is that there are both in-person courses, which can be found on the MO STR website and pcssnow.org websites, and the full online course which can also be found at pcssnow.org. All are free, and for the time being, you can get reimbursed $500 once you obtain your waiver.
Of course, there is still stigma in both the community and by physicians against using opioid agonist therapy (OAT) such as buprenorphine. Much of this stems from either a lack of understanding or mistrust in the system. To be clear, while an abstinence-based approach may work for an incredibly small amount of people, the literature clearly demonstrates that patients receiving medications such as buprenorphine and methadone do much, much, much better. It’s really not even close. With that said, if patients can’t get or won’t engage with programs that offer OAT or medication for addiction treatment (MAT or medication for opioid use disorder [MOUD]), harm reduction strategies can still be enacted. They should be enacted in patients accepting OAT/MAT/MOUD as well but that is beside the point for now. One very socially acceptable form of harm reduction is naloxone. So is giving out naloxone enough?
No, it is not. Naloxone and harm reduction are necessary but not sufficient.
A recent study in the Annals of Emergency Medicine (PMID: 31229387) clearly demonstrates this, as well as the need for creative solutions such as the EPICC program or Bridge clinics. In Massachusetts, they have large community naloxone programs. These are programs that train bystanders to administer naloxone and then hand it out in order to increase timely access. These programs distributed over 12,000 doses of naloxone between 2013-2015. This is important as data from 2014 demonstrated 92,000 ED visits in the US following an opioid overdose with the numbers increasing since then.
While this sounds great, the data does have a dark side. The authors of this study recently went back to review 3 statewide data sets to look at mortality following a non-fatal opioid overdose (OD). They included patients presenting to an ED after an opioid OD that were discharged from the ED, in other words non-fatal ODs. They included patients from July 2011-September 2015. Any patients with an opioid overdose in the 6 months preceding the study period were excluded. This left 11,669 patients with 112 excluded for dying the same day as the index visit leaving 11,557 patients for analysis. The news gets grim from there. Of the discharged patients, 635 or 5.5% were dead within 1 year. The median age of those who died was only 39 years old (range 31-59). What’s even worse is that if you were going to die, there was a fair chance that it would occur soon after that index overdose. Of those 635 patients, 130 died within a month (20.5%) with 22% (n=29) dying within 48 hours.
So yes, naloxone is useful and we should continue to encourage its distribution. But it is not sufficient and this is further evidence that creative solutions such as bridge clinics, telehealth options, and programs similar to EPICC must be created and sustained.