Treating Opioid Withdrawal with Buprenorphine/Naloxone META:PHI in the Emergency Department: Implementing Best Practices for Addictions Treating Opioid Withdrawal with Buprenorphine/Naloxone

What is META:PHI? Mentoring, Education, and Clinical Tools for Addiction: Primary Care–Hospital Integration Collaborative project to implement integrated care pathways for addiction throughout Ontario Partnership between hospitals, withdrawal management services, FHTs, CHCs, and community agencies Goals: Improve care for patients with addictions Improve care provider experience Improve population health Reduce service use Provide sustainable care

How it works Patients presenting with addiction-related concerns receive evidence-based interventions and are referred to rapid access addiction medicine (RAAM) clinics for treatment RAAM clinics offer substance use disorder treatment on walk-in basis; no formal referral/appointment needed Patients stabilized at RAAM clinic referred back to primary care for long-term addiction treatment (with ongoing support from RAAM clinic as required) Key components: Integration of care at hospital, RAAM clinic, primary care Training, support, and mentorship from addictions specialists Capacity-building

Role of the ED With support from META:PHI team: Follow best practices for treating urgent alcohol-/opioid-related presentations (e.g., CIWA-Ar protocol for alcohol withdrawal, buprenorphine for opioid withdrawal) Diagnose underlying substance use disorder causing urgent presentations Refer patients to treatment at RAAM clinic

Opioid withdrawal management goals Dispense buprenorphine to relieve withdrawal Provide outpatient buprenorphine prescription Give harm-reduction advice and take-home naloxone Provide referral to RAAM clinic for long term medication-assisted treatment Naloxone HCL

Clinical features of opioid withdrawal Symptoms start six hours after last use of short-acting opioid, peak at 2–3 days, and begin to resolve by 5–7 days Physical symptoms: myalgias, chills, sweating, nausea and vomiting, abdominal cramps, diarrhea, rhinorrhea, lacrimation, piloerection Psychological symptoms: insomnia, anxiety/irritability, restlessness, dysphoria, craving Signs: Sweating, yawning, watery eyes and nose, restlessness

Risks of untreated withdrawal Suicide, if patient cannot access opioids Relapse, with heightened risk of overdose Tolerance to opioids markedly declines within a few days of abstinence Illicit opioids are often laced with fentanyl Patients should never be discharged without a plan for withdrawal management

Buprenorphine Partial opioid agonist with ceiling effect Slow onset and long duration of action Binds tightly to receptors, displacing other opioids and triggering withdrawal Patient must be abstinent from opioids for at least 12 hours and be in mild/moderate withdrawal before the first dose

Advantages of bup treatment Treats withdrawal more effectively than clonidine or opioids Long-term treatment with buprenorphine is much more effective than abstinence-based treatment, and is of comparable effectiveness to methadone treatment Long-term buprenorphine treatment reduces addiction rates, overdose rates, and repeat ED visits Buprenorphine is far safer than methadone or any other opioid so can safely be prescribed by ED and family physicians

Indications for buprenorphine Any patient who presents with a possible complication of opioid use disorder: Overdose Withdrawal Drug-seeking Infection: Sepsis, endocarditis, cellulitis, abscess Depression and suicidal ideation Trauma

Clinical Opioid Withdrawal Scale (COWS) Resting heart rate (≤ 80) 1 (81–100) 2 (101–120) 4 (121+) Sweating 3 Restlessness 5 Pupil size Bone/joint aches Runny nose/tearing GI upset Tremor Yawning Anxiety/irritability Gooseflesh skin TOTAL 5–12 13–24 Mild Moderate 25–36 37+ Moderately severe Severe

Buprenorphine protocol (1) For patients currently in withdrawal: Assess patient using COWS: a score of 12+ indicates it is safe to administer buprenorphine/naloxone Initial dose: 4 mg SL Reassess with COWS in 1–2 hours If withdrawal substantially improved, give 2–4 mg to take home, plus outpatient script If still in significant withdrawal, give another 4 mg SL in ED and reassess again in 1–2 hours Treatment complete when 4–12 mg have been dispensed and withdrawal symptoms are minimal

Buprenorphine protocol (2) For patients not yet in withdrawal: Give an outpatient prescription for 2 mg x 18 tablets Give patient clear instructions: Wait at least 12–16 hours since your last opioid use Make sure your COWS score is at least 12 (give scale) Put 2 tablets under your tongue and let them dissolve Wait 2 hours and measure your COWS score again If still in withdrawal, take another 2 tablets Do not take more than 6 tablets (12 mg) in first 24 hours Next day: Take total first-day amount as single dose Tell patient to follow up with the RAAM clinic within 3 days for ongoing prescription

Common concerns “Buprenorphine will increase length of stay” No need to hold patient until in withdrawal If not in withdrawal, give script for patient to start at home “I don’t know how to prescribe buprenorphine” To prescribe methadone, MDs require special training and certification from CPSO because methadone has higher overdose rate than other opioids But buprenorphine has lower OD rate than other opioids CPSO has no oversight over buprenorphine prescribing ED physicians aren’t providing long-term addiction treatment; they are treating acute withdrawal and giving bridging prescription until patient starts treatment at RAAM clinic

ED discharge Always refer patient to RAAM clinic Prescribe total amount of buprenorphine given in ED as single dose Dispensed daily under observation, or give take-home doses for a few days if patient is reluctant to attend daily Prescription should last until next RAAM clinic Refer patient to WMS if has transient housing, lack of social supports, and/or at high risk for relapse Fax prescription to WMS’s regular pharmacy Write note to WMS informing them of prescription and advising them that patient should attend next RAAM clinic Give harm reduction advice and take-home naloxone

Harm reduction advice To reduce the risk of overdose: Do not inject Take a much smaller opioid dose than usual Start with a test dose Don’t mix opioids with alcohol/benzodiazepines Never use alone - always have a friend with you while you’re using Always carry naloxone If your friend appears drowsy, has slurred speech, or is nodding off after taking opioids: Shake/talk to them to keep them awake Call 911 and start chest compressions Administer naloxone

Wrap-up Treating addicted patients is our responsibility as health care providers Addiction is the same as any other chronic illness: patients need specialist referrals, medication, treatment of co-occurring conditions, and regular follow-up The ED is an opportune setting to intervene, as many patients are motivated to get help for their disorder Effective addiction treatments are available Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

Resources META:PHI website: www.metaphi.ca META:PHI mailing list for clinical questions and discussion (e-mail sarah.clarke@wchospital.ca to join) META:PHI contacts: Medical lead: Dr. Meldon Kahan meldon.kahan@wchospital.ca Manager: Kate Hardy kate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca