SAN FRANCISCO — If a patient who overdoses on an opioid comes in after getting dosed with naloxone (Narcan), the 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 physician.
Never mind that these patients are at such high risk that they’re basically “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 massive mortality almost back to the same level as that of the general population,” she noted.
While a 2015 randomized trial showed that use of buprenorphine/naloxone (Suboxone) in the ED led to increased engagement in addiction treatment, and some physicians have called for the use of buprenorphine by paramedics at the site of overdose, buprenorphine is still not a standard Treatment in the emergency department (ED) for opioid overdoses.
Stigma is often to blame, LaPietra said
“Addicts have really been looked at with a lot of shame,” she added. “We really kind of thought this is a group that has a moral failing, a lack of willpower. They just can’t get their stuff together. But we can’t demand perfection out of those with opioid use disorder more than any other chronic disease patients.”
According to a synthesis of emerging opioid use disorder programs in EDs, “barriers to implementation include lack of knowledge about treatment options and effectiveness, stigma, community treatment capacity limits, and health insurance and reimbursement policies.”
LaPietra’s co-presenter, Arian Nachat, MD, of the Balboa Naval Medical Center and the VA Medical Center in San Diego, said buprenorphine is especially useful because there’s no way to overdose on it.
“It partially binds to the opioid receptor, and sticks around for 12 to 24 hours,” she explained. “It hangs out a lot longer than the opioids that they’re taking. And it’s one of the safest drugs we have.”
If you don’t have the waiver that allows certain medical professionals to prescribe buprenorphine, new rules implemented in 2021 allow eligible providers to get an alternative waiver that doesn’t require training, Nachat noted, though this waiver limits providers from prescribing buprenorphine to more than 30 patients at one time.
She encouraged attendees to get the full waiver after the mandatory training: “It’s really not that long and probably a good thing.”
She also said it’s useful to use your phone to access the 11-item Clinical Opiate Withdrawal Scale (COWS) to measure how your patient is doing. The scale, which is available via online calculators, produces a 0-48 score after measuring withdrawal symptoms, such as sweating, pupil size, anxiety, and tremor.
Typically, these patients are “all fidgety,” Nachat explained. “They’re sweating, they’re restless, they’re really super uncomfortable.”
She said that if their score is greater than 9.8 mg 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 reassess.”
If the score is still above 9, give a second 8-mg dose. “You can’t overdose them. That’s not a problem,” she stressed.
At this point, their withdrawal symptoms may be lessening, Nachat continued. “You make them feel better, and you have just made your best friend. They are so happy because you took their body out of absolute distress.”
If their COWS score is under 9 after 45-60 minutes, “send them out with a prescription for 8 mg twice a day,” she advised.
In extreme cases — for example, a patient in withdrawal post-naloxone who has a rapid heartbeat with vomiting and diarrhea — COWS scores will be “really high,” Nachat said. In these cases, administer 16 mg of buprenorphine, and repeat if necessary after reassessment at 1 hour. “You may have to help them with some benzos, a little gabapentin, and a nice quiet area 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 intervene, be empathetic, be kind, don’t judge them. They actually tried to do the right thing. They tried to help themselves,” she added.
Consider sending this kind of patient home with a prescription for buprenorphine/naloxone 8 mg twice a day, Nachat recommended, and don’t be afraid of extended-length prescriptions.
Ideally, they’d get a prescription that would last until they follow up with an addiction clinic, she pointed out. “I know a lot of folks from the ED who are really twitchy: ‘I’ve never written for this, I don’t want to write for a 30-day prescription.’ But that’d be a totally 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 quickly get into a clinic, they can return to the ED to renew their prescription, just like any other patient, she said.
LaPietra and Nachat have no disclosures.