Transcript Presentation on opioid use disorders for

ED Management of
Opioid Use Disorders
Education Rounds for ED Nurses
META:PHI 2015
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
Baseline Survey
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.
Please return the completed or incomplete survey face down to the facilitator when
you leave the presentation.
OVERVIEW
META:PHI 2015
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
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
IDENTIFYING AN OPIOID USE
DISORDER
META:PHI 2015
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
Identifying an OUD (2)
• Common presentations:
– Overdose
– Withdrawal
– Drug seeking
– Infections from injection drug use
– Depression
– Suicidal ideation
– Trauma
META:PHI 2015
TREATING OPIOID OVERDOSE
META:PHI 2015
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
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
OPIOID WITHDRAWAL
META:PHI 2015
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
Treatment of Opioid Withdrawal
Option 1: Buprenorphine/naloxone (bup/nx)
Option 2: Clonidine
META:PHI 2015
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)
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
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
Clinical Opioid Withdrawal Scale
Interval
Date
Time
Resting heart rate (measure after lying or sitting for 1 minute)
0 HR 80 or below
1 HR 81-100
2 HR 101-120
4 HR greater than 120
Sweating (preceding 30 mins and not related to room temp /activity)
0 No report of chills/flushing
1 Subjective report of chills/flushing
2 Flushed or observable moistness on face
3 Beads of sweat on brow or face
4 Sweat streaming off face
Restlessness (observe during assessment)
0 Able to sit still
1 Reports difficulty sitting still but able to do so
3 Frequent shifting or extraneous movements
of legs/arm
5 Unable to sit still for more than a few seconds
Pupil size
0 Pupils pinned or normal size for room light
1 Pupils possibly larger than normal for room
light
2 Pupils moderately dilated
5 Pupils so dilated that only the rim of the iris is
visible
Bone or joint aches (not including existing joint aches)
0 Not present
1 Mild diffuse discomfort
2 Patient reports severe diffuse aching of
joints/muscles
4 Patient is rubbing joints / muscles plus unable
to sit still due to discomfort
META:PHI 2015
0
30m
2h
4h
Interval
Date
Time
Runny nose or tearing (not related to URTI or allergies)
0 Not present
1 Nasal stuffiness or unusually moist eyes
2 Nose running or tearing
4 Nose constantly running or tears streaming down
cheeks
GI upset (over last 30 minutes)
0 No GI symptoms
1 Stomach cramps
2 Nausea or loose stool
3 Vomiting or diarrhoea
5 Multiple episodes of vomiting or diarrhoea
Tremor
0 No tremor
1 Tremor can be felt, but not observed
2 Slight tremor observable
4 Gross tremor or muscle twitching
Yawning (observe during assessment)
0 No yawning
1 Yawning once or twice during assessment
2 Yawning three or more times during assessment
4 Yawning several times/minute
Anxiety or irritability
0 None
1 Patient reports increasing irritability or
anxiousness
2 Patient obviously irritable or anxious
4 Patient so irritable or anxious that participation in the
assessment is difficult
Gooseflesh skin
0 Skin is smooth
3 Piloerection (goosebumps) of skin can be
felt or hair standing up on arms
5 Prominent piloerection
5-12 Mild withdrawal
13-24 Moderate withdrawal
25-36 Moderately severe withdrawal
> 36 Severe withdrawal
META:PHI 2015
TOTAL
INITIALS
0
30m
2h
4h
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
21
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
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
DISCHARGING PATIENTS WITH AN
OPIOID USE DISORDER
META:PHI 2015
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
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
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
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
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
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
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
Administering Naloxone
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
META:PHI 2015
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
Question
• What medical intervention would provide to
Karen in the ED prior to her discharge?
META:PHI 2015
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
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
Question
• What would be your discharge plan for Karen?
META:PHI 2015
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
MANAGEMENT OF COMMON
PRESENTING PROBLEMS OF OPIOID
USERS
META:PHI 2015
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
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
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 highdose 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
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
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
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
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
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
Question
• How would you and the physician manage
Christie’s request?
– What information would you want to gather?
META:PHI 2015
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
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
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
Question
• What would be your discharge plan for
Christie?
META:PHI 2015
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
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
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
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
MANAGING PAIN IN ED PATIENTS
ON METHADONE OR BUP/NX
META:PHI 2015
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
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 opioidnaïve patients
META:PHI 2015
PATIENTS ADMITTED TO HOSPITAL
ON METHADONE
META:PHI 2015
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
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
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
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
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