1. ED Management of Opioid Use Disorders Education Rounds for ED Nurses META:PHI 2015

2. About META:PHI Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration Goals: – Promote evidence-based addiction medicine treatment – Implement care pathways between the ED, hospital, WMS, primary care, and rapid access addiction medicine clinics Seven sites in Ontario are currently involved, with plans to expand the spread of the project in the future Funding and support provided by the Adopting Research to Improve Care (ARTIC) program (Council of Academic Hospitals of Ontario & Health Quality Ontario) https://www.porticonetwork.ca/web/meta-phi META:PHI 2015

3. The baseline survey is anonymous and entirely optional. You may skip any question that you do not wish to answer. We will not ask you for any personal information. Please tear off and keep the front page with contact information, should you have any questions about the survey or the META:PHI project. Baseline Survey Please return the completed or incomplete survey face down to the facilitator when you leave the presentation.

4. OVERVIEW META:PHI 2015

5. Role of the Nurse In managing opioid use disorders in the ED, nurses play a key role: – Nurses spend more time with patients – Patients are more likely to confide in nurses than in other medical staff – Nurses are more likely to provide discharge advice – Nurses can send patients to the RAAM clinic without a formal MD referral META:PHI 2015

6. Nursing Goals for OUD Patients in the ED 1.Treat presenting problem (overdose, withdrawal, infection, pain etc.) 2.Counsel patient on importance of bup/nx treatment, if initiated by physician 3.Prevent overdose through patient education and naloxone 4.Provide rapid access to an outpatient addiction medicine clinic for long-term medication-assisted treatment META:PHI 2015

7. IDENTIFYING AN OPIOID USE DISORDER META:PHI 2015

8. Identifying an OUD (1) OUDs are difficult to detect if patient does not disclose use Maintain high index of suspicion with risk factors: – Younger – Male – Psychiatric comorbidity – Concurrent addiction to other drugs – On high prescribed opioid doses META:PHI 2015

9. Identifying an OUD (2) Common presentations: – Overdose – Withdrawal – Drug seeking – Infections from injection drug use – Depression – Suicidal ideation – Trauma META:PHI 2015

10. TREATING OPIOID OVERDOSE META:PHI 2015

11. Treating Opioid Overdose in the ED (1) Patient should be provided with naloxone drip and respiratory support Monitor patient for at least six hours after respiratory support discontinued – Monitor for 10 hours if patient has had methadone overdose Resume respiratory support and naloxone drip if signs of toxicity return during the six- to ten-hour interval Most sensitive indicator of toxicity: slurred speech or ‘nodding off’ while engaged in conversation over several minutes META:PHI 2015

12. Treating Opioid Overdose in the ED (2) Initiate bup/nx if the patient experiences withdrawal when the naloxone drip has been discontinued Do not prescribe opioids during ED/hospital stay If the patient demands to leave while still intoxicated and the physician feels they are at high risk for overdose death or injury, they may need a Form 1 – Physician should indicate on the Form 1 that the patient is suffering from an opioid use disorder, which puts them at imminent risk of self-harm META:PHI 2015

13. OPIOID WITHDRAWAL META:PHI 2015

14. Clinical Features of Opioid Withdrawal Time course Symptoms start six hours after last use of IR opioid, peak at 2-3 days, and begin to resolve by 5-7 days (psychological symptoms can last for weeks) Physical symptoms Flu-like (myalgias, chills, nausea and vomiting, abdominal cramps, diarrhea) Psychological symptoms Insomnia, extreme anxiety/irritability, dysphoria, drug craving Complications Suicide, overdose if opioids taken after a period of abstinence, gastric or duodenal ulcer, acute exacerbation of cardiorespiratory illnesses, miscarriage or premature labour in pregnancy META:PHI 2015

15. Treatment of Opioid Withdrawal Option 1: Buprenorphine/naloxone (bup/nx) Option 2: Clonidine META:PHI 2015

16. What is Buprenorphine/naloxone (bup/nx)? Sublingual tablet, with long duration of action Partial opioid agonist with a ceiling effect – Doses beyond 24 mg - 32 mg do not have any additional opioid effects – Therefore bup/nx is much less likely to cause overdose than methadone or other potent opioids Binds very tightly to receptor – Displaces other opioids (displacement of fentanyl is slower and less complete) – Can precipitate withdrawal when taken shortly after opioid use META:PHI 2015 Opioids replaced and blocked by buprenorphine (Image from naabt.org)

17. Bup/nx for the Treatment of Withdrawal (1) To avoid precipitating withdrawal, patient should not be given bup/nx until at least 12 hours have elapsed since last opioid use and patient has withdrawal symptoms A score of 12 or more on the Clinical Opioid Withdrawal Scale (COWS) indicates that it is safe to administer bup/nx If the patient is not in withdrawal but will likely be in 2-3 hours, they should be kept in ED until safe to give bup/nx If more than 2-3 hours before onset of withdrawal, – Patient can be discharged and given referral card for RAAM clinic, or – Sent to WMS with instructions to return to ED when in withdrawal META:PHI 2015

18. Bup/nx for the Treatment of Withdrawal (2) Initial dose: 4 mg SL (takes several minutes to dissolve) – Patient should be given only 2 mg SL if elderly or on a high benzodiazepine dose, or if physician unsure if patient is in withdrawal Reassess in 1-2 hours – If substantial improvement of withdrawal, patient should be given 2-4 mg SL to take-home for later in day, plus an outpatient script – If still in significant withdrawal, should be given another 4 mg SL in the ED and reassessed again in 1-2 hours Treatment complete when 4-8 mg have been dispensed and withdrawal symptoms are mild META:PHI 2015

19. Clinical Opioid Withdrawal Scale META:PHI 2015

21. 21 Performing the COWS For each item, write in the number that best describes the patient’s signs or symptoms Rate on just the apparent relationship to opiate withdrawal – For example, if heart rate is increased because the patient is febrile, the increase pulse rate would not add to the score

22. Outpatient Prescription Physician should prescribe the total amount of bup/nx given in ED as a single dose – Medication should be dispensed daily under observation – Script should last until next RAAM clinic Nurse can advise patient to attend RAAM clinic for additional bup/nx treatment – Give patient RAAM referral card Refer patient to WMS if: – Transiently housed – Lacks social supports – At high risk for relapse META:PHI 2015

23. Clonidine Treatment of Withdrawal Not as effective as bup/nx for symptom relief or treatment retention – Some patients may prefer clonidine because it is not an opioid maintenance treatment Treatment using Clonidine: – Clonidine 0.1 mg PO qid PRN – Increase to 0.2 mg if able to check BP prior to dose (hold if BP < 90/60) – Patient can be discharged home/WMS with script for 3-5 days Warn about sedation, postural hypotension, hot baths etc. Additional meds for symptom relief: anti-emetics, (e.g. gravol); trazodone for sleep; Naprosyn for myalgias META:PHI 2015

24. DISCHARGING PATIENTS WITH AN OPIOID USE DISORDER META:PHI 2015

25. Advice on Discharge Advise patient that they have lost tolerance and that they could overdose again if they use their usual dose Inform patient of overdose prevention strategies and provide them with naloxone kit (including 1-2 vials of naloxone) Refer patient to the RAAM clinic using RAAM referral card If bup/nx prescribed during ED visit, ensure patient has script until they can be seen at RAAM clinic META:PHI 2015

26. Distribute Take-Home Naloxone to Patients at High Risk of Overdose Not on methadone or bup/nx, on these medications but started in the past two weeks, or on these medications but continuing to use substances On high dose opioids for chronic pain Treated for overdose (or reports a past overdose) Injects, crushes, smokes or snorts potent opioids (fentanyl, morphine, hydromorphone, oxycodone) Buys methadone or other opioids from the street Recently discharged from an abstinence-based treatment program, WMS, hospital, or prison Uses opioids with benzos and/or alcohol META:PHI 2015

27. Advice to Patients on Preventing Overdose (1) If you relapse after being abstinent for a few days or longer, you have lost tolerance and could die if you take your usual dose To avoid overdose: – Do not inject – Take a much smaller opioid dose than usual – Take a ‘test dose’ unless you got the drug directly from a doctor’s prescription – Do not mix opioids with alcohol/benzodiazepines – Always have a friend with you if you inject or snort opioids META:PHI 2015

28. Advice to Patients on Preventing Overdose (2) If one of your friends appears drowsy, has slurred speech, or is “nodding off” after taking opioids: – Shake/talk to them to keep them awake – If they cannot be woken up, call 911 and start chest compressions – Do not let your friend ‘sleep it off,’ even if someone watches them overnight META:PHI 2015

29. Advice to Patients on Preventing Overdose (3) The best way to avoid an overdose is to get treatment for your addiction. Please attend the next rapid access addiction medicine clinic. – Give patient referral card and tell them when and where the clinic is – Inform patient that they do not need an appointment; they can just show up during clinic hours Carry naloxone META:PHI 2015

30. Dispensing Take-Home Naloxone Provide patient with naloxone kit in ED if possible, otherwise recommend they get one through RAAM, pharmacy or public health – Dispense one vial of naloxone to patients at temporary risk of overdose (e.g., just started on bup/nx or methadone treatment) – Dispense two vials to patients at ongoing risk – Always dispense two vials to fentanyl users META:PHI 2015

31. Contents of Naloxone Kit – One to two naloxone vials – Two syringes – Alcohol wipes – ID card explaining why patient is carrying medication and syringes META:PHI 2015

32. Administering Naloxone META:PHI 2015 Instruct patient on naloxone use: -Shake the overdose victim, call their name -If they cannot be fully woken up, call 911 -Inject a full naloxone vial into an arm or leg muscle -Start chest compressions -Inject another vial if they don’t wake up in 3-4 minutes

33. Case Scenario – Karen Part 1 Karen is a 30 year old woman who was brought by her friends to the ED after an accidental overdose after injecting fentanyl purchased from a ‘friend’. She was given a naloxone drip and respiratory support. These were discontinued a half hour ago. Her O2 saturation is currently normal. The physician is requesting that Karen stay for several more hours of observation, but Karen is very angry and wants to go home. META:PHI 2015

34. Question What medical intervention would provide to Karen in the ED prior to her discharge? META:PHI 2015

35. Medical Intervention - Karen Work with physician to treat withdrawal using buprenorphine/naloxone – Start bup/nx when: Patient is not on naloxone Patient is in withdrawal (using COWS) 12 hours have passed since last fentanyl dose META:PHI 2015

36. Case Scenario - Karen Part 2 Karen is feeling better after taking 8mg of bup/nx. After six hours of observation she shows no signs of opioid toxicity and is now ready for discharge. META:PHI 2015

37. Question What would be your discharge plan for Karen? META:PHI 2015

38. Discharge Plan -Ensure Karen has been provided with bridging prescription for bup/nx until she can be seen at RAAM (next open clinic day) -Provide Karen with RAAM referral using RAAM referral card -Give advice on overdose prevention and hand Karen overdose prevention pamphlet -Provide Karen with naloxone kit and instructions on administering naloxone META:PHI 2015

39. MANAGEMENT OF COMMON PRESENTING PROBLEMS OF OPIOID USERS META:PHI 2015

40. Infections from Injection Use: Outpatient Treatment Use oral antibiotics that cover staph and strep – Avoid PIC lines Ask about injection drug use and look for indicators Offer bup/nx treatment and refer to RAAM clinic If patient agrees to bup/nx treatment but is not in withdrawal, refer to WMS with instructions to send back to ED upon onset of withdrawal Offer advice on overdose prevention and give naloxone if indicated META:PHI 2015

41. Opioid Prescribing for Minor Injuries *Protocol for ALL patients (not just opioid users) (1) Most minor injuries (muscle strains, contusions, etc.) do not require opioids Combination of acetaminophen and NSAIDs is at least as effective as opioids and much safer META:PHI 2015

42. Opioid Prescribing for Minor Injuries *Protocol for ALL patients (not just opioid users) (2) When opioids are indicated: -IR low-dose opioids should be used rather than high- dose CR formulations -Codeine preparations are effective for acute pain -Prescription should be for no more than 3-5 days -Fentanyl should not be prescribed for acute pain -Benzodiazepines should not be prescribed along with opioids -Warn patients not to drink heavily or take sedating drugs when taking opioids -Warn patients not to drive for 2-3 hours after taking the opioid, for at least the first week META:PHI 2015

43. Patients Admitted with Trauma Suspect opioid addiction if: – Patient requests higher doses than normally required for their degree of injury – Patient requests a specific opioid – Patient demands dose immediately, uses all PRNs – Patient has risk factors for addiction – Patient was on a high opioid dose prior to admission META:PHI 2015

44. Inpatient Trauma Patient and OUD If addiction is suspected yet opioids required: – Avoid PCA pumps and high doses of short-acting parenteral opioids – Total daily dose will probably be higher than usual – Breakthrough doses should be 10-30% of total daily dose – Ask for phone or in-person consult from RAAM physician – Bup/nx or methadone therapy should be initiated by physician if indicated – Refer patient to RAAM clinic on discharge META:PHI 2015

45. Drug Seeking in the ED Patients with OUD sometimes use the ED as a source of opioids – Drug seeking can be difficult to diagnose Clinical features: – Makes aggressive demands for a specific opioid – Not satisfied with non-opioid treatments – Often returns to the same ED with the same presenting complaint – Often on high prescribed doses yet runs out early – Has risk factors for addiction META:PHI 2015

46. Management of Suspected Drug Seeking Contact the patient’s pharmacy Opioids should not be prescribed Physician should tell patient that they suspect patient may have an OUD Inform patient that addiction is a treatable condition If the patient is in withdrawal, prescribe bup/nx If patient is not yet in withdrawal, refer to WMS with instructions to return to the ED when in withdrawal Refer patient to the RAAM clinic META:PHI 2015

47. Case Scenario – Christie Part 1 Christie is a 35 year old woman with neck pain from a motor vehicle accident years ago. She is on Hydromorph Contin 12 mg tid and hydromorphone 8 mg 1-2 tabs qid PRN for breakthrough. She reports that her prescription ended and her family doctor is not available to refill the prescription. She says she has not had medication in two days and that she is in severe pain. META:PHI 2015

48. Question How would you and the physician manage Christie’s request? – What information would you want to gather? META:PHI 2015

49. Management Plan Nurse and/or physician should: – Check patient’s chart to see if she has presented with similar requests previously – Call pharmacy and verify amount and date of last prescription – Call family physician in case they are available to speak META:PHI 2015

50. Case Scenario – Christie Part 2 You find that Christie received a prescription for 240 hydromorphone tabs and 90 Hydromorph Contin tabs 2 weeks ago. You calculate that she has run out 2 weeks early. You review the hospital chart and note that she has made four similar requests for hydromorphone in the last six months. META:PHI 2015

51. Case Scenario – Christie Part 2 (cont’d) After expressing your concerns to the ED physician about her opioid use, they counsel her on buprenorphine/naloxone. Christie expresses to you that she is reluctant to try the medication, citing fears around: worsening pain if she stops her prescription opioids, switching from one addictive substance to another, and being unable to attend the pharmacy everyday. She wants to leave with her regular prescription. META:PHI 2015

52. Question What would be your discharge plan for Christie? META:PHI 2015

53. Discharge Plan a)Discuss with Christie the physician’s diagnosis of an opioid use disorder b)Explain that the physician has given a prescription for a few days until patient can be seen in the rapid access clinic c)Emphasize to the patient that stopping hydromorphone and starting bup/nx will improve her pain, mood and function d)Tell patient to discuss ‘carries’ and going to the pharmacy every day with the RAAM physician META:PHI 2015

54. Depression and Suicidal Ideation Regardless of whether patient sees psychiatry or is admitted: – Inform patient that opioid addiction treatment will likely rapidly improve their mood and functioning  Bup/nx treatment should be initiated if patient goes into withdrawal in the ED or in hospital  If patient agrees to bup/nx treatment but is not in withdrawal, send to WMS with instructions to send back to ED with onset of withdrawal  On discharge, refer patient to RAAM clinic (give referral card) and ensure they have a bridging script for bup/nx if started in the ED META:PHI 2015

55. Urgent Psychiatry Referral Patient should be referred to psychiatry if they: – Have recently attempted suicide – Have refused bup/nx treatment or remain severely depressed despite bup/nx treatment – Have major risk factors for suicide (e.g., recent loss, feasible suicide plan) META:PHI 2015

56. Outpatient Psychiatry Referral Patient may need outpatient psychiatry referral if they:  Have major symptoms of anxiety, depression, etc.  Are not at imminent risk of self-harm META:PHI 2015

57. MANAGING PAIN IN ED PATIENTS ON METHADONE OR BUP/NX META:PHI 2015

58. Addressing Misconceptions about Pain Patients on Methadone or Bup/nx Stable doses of methadone or bup/nx do not relieve acute pain – Patients have developed tolerance to analgesic effects of methadone or bup/nx Often require higher opioid doses to overcome tolerance Treating acute pain will not trigger a relapse – Denying opioids to patients who need them may be more likely to cause relapse, should the patient seek access to illicit opioids in an attempt to manage pain Patients on methadone or bup/nx who are in acute pain are rarely drug-seeking META:PHI 2015

59. Protocol for Acute Pain Management Patient should be maintained on their usual dose of methadone or bup/nx Physician should prescribe standard non-opioid analgesia Opioids can be prescribed if the patient’s pain condition warrants it Ensure the patient understands which opioid they are being prescribed Physician should start with usual dose for that pain condition then titrate rapidly if that dose is inadequate – Research has shown that patients on opioid maintenance may require 30-100% higher opioid doses than opioid- naïve patients META:PHI 2015

60. PATIENTS ADMITTED TO HOSPITAL ON METHADONE META:PHI 2015

61. Protocol for Admitted Methadone Patients Nurse or physician should cancel patient’s methadone at outpatient pharmacy Ask pharmacy for dates methadone was dispensed in the past week Physician should lower dose if 72 hours or more have elapsed since last dose If pharmacy or prescriber cannot be reached, patients should be given small amount of methadone (e.g., 15 mg) If patient is about to be admitted and methadone not available, physician should: – Prescribe oral controlled release morphine qid; initial daily dose should probably not exceed 45 mg qid (180 mg) – Not co-prescribe benzodiazepines – Titrate daily to relieve withdrawal symptoms; hold if drowsy META:PHI 2015

62. Risk Factors for Methadone Toxicity in Hospitalized Patients Taking benzodiazepines or atypical antipsychotics Taking medications that inhibit methadone metabolism (e.g., quinolone antibiotics) Hepatic failure Renal failure Respiratory impairment META:PHI 2015

63. Avoiding Methadone Toxicity Physician should avoid or use low doses of benzodiazepines and atypical antipsychotics Closely monitor patient daily for signs of toxicity Observe patient for slurred speech or ‘nodding off’ while engaged in conversation over several minutes Monitor QT interval – High serum methadone concentration can cause QT prolongation META:PHI 2015

64. Management of Toxicity If signs of toxicity, physician should hold methadone until clear, then resume at a much lower dose Sedating drugs should be discontinued If rapidly developing hepatic, renal, or respiratory failure, dose should be reduced, even if no obvious signs of toxicity META:PHI 2015

65. ICU Patients on Methadone Intubated, obtunded patients will still go through severe withdrawal if their methadone is abruptly discontinued Patients should be provided with regular doses of hydromorphone, titrated to relieve agitation When patient is awake and alert, methadone can be resumed (at a lower dose, via G tube) META:PHI 2015