Distributing Naloxone in the Emergency Department

1. Distributing Naloxone in the Emergency Department Presenter Date of presentation

2. About META:PHI

3. 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, detoxes, 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

4. 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

5. 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

6. About Naloxone

7. Function of naloxone Naloxone is an opioid agonist that temporarily reverses the effect of an opioid overdose Higher affinity for opioid receptors than opioids Pushes opioids off receptors Reverses CNS depression Naloxone attaches to μ-opioid receptor, displacing the opioid Naloxone has higher affinity for μ-opioid receptor than attached opioid does

8. Why distribute in ED? Naloxone is available free of charge and without a prescription at pharmacies, Public Health, needle exchange programs, etc. However, ED distribution is still important! Pharmacy may not be open when patient is discharged from ED Patient may not be willing or able to go to pharmacy People attending ED for an opioid-related problem are often at very high risk of overdose Receiving a kit from a medical professional (physician or nurse) may have more impact than receiving it from a pharmacist

9. Take-home naloxone indications Naloxone indicated for patients at high risk of opioid overdose: Injects, crushes, smokes, or snorts potent opioids (fentanyl, morphine, hydromorphone, oxycodone) Buys opioids from the street On high dose opioids for chronic pain Has had an overdose previously Recently discharged from an abstinence-based treatment program, detox, hospital, or prison Uses opioids with other sedating substances (e.g., benzodiazepines, alcohol)

10. Instructing Patients

11. Introducing naloxone “You’re at high risk for opioid overdose, so I want to give you this naloxone kit to take with you. It reverses an opioid overdose temporarily and buys some time to call 911 for medical help. You should have it on you at all times, and make sure you let your friends know that you have it, so that you’re able to use it on each other if you need to.”

12. Kit contents • Instructional pamphlet • ID card • Pair of gloves • 2 alcohol swabs • 1 breathing mask • Ampule breaker [IM only] • 2 ampules of naloxone (0.4 mg/ml) [IM only] • 2 cases of naloxone nasal spray [IN only]

13. Signs of opioid withdrawal Can’t stay awake Breathing has slowed or stopped Snoring, gurgling sounds Purple or blue fingernails or lips Tiny pupils Limp body

14. What to do first ! If you think someone is having an opioid overdose... SHAKE & SHOUT Shake victim’s shoulders and shout their name to try to wake them up. 911 CALL 911 Say that someone is not responding and not breathing well.

15. Administering IN naloxone Put on gloves Peel the back off one of the naloxone packages to open and remove the device Hold the device with your thumb on the plunger and a finger on either side of the nozzle Insert the tip of the nozzle into the victim’s nostril until your fingers touch the bottom of the victim’s nose Press the plunger firmly with your thumb to release the dose

16. Administering IM naloxone Put on gloves If possible, remove victim’s clothing to expose either the shoulder or the thigh, and clean the site with the alcohol swab Take the syringe out of its packaging Put the ampule breaker over the top of the vial and break it open Draw the entire vial of naloxone into the syringe Inject into shoulder or thigh (through clothing if necessary) Push plunger until it clicks (needle will retract)

17. After giving naloxone Insert breathing barrier device between the victim’s teeth If victim is breathing slowly or noisily… • Give 1 rescue breath every 5 to 10 seconds If victim isn’t moving, breathing, or making noise… • Give chest compressions (press the victim’s chest hard with the heel of your hand • Give 2 rescue breaths every 30 compressions After 5 minutes, if the victim is still not responding, give a second dose of naloxone

18. Finishing up Ask the patient if they have any questions Fill out the ID card with the patient’s name and the name of your institution Give the patient the kit

19. ED Discharge

20. On discharge Always refer patient to RAAM clinic Refer patient to WMS if has transient housing, lack of social supports, and/or at high risk for relapse Give harm reduction advice

21. 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 and make sure your friends know you have it

22. Wrap-up

23. Key messages 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 Effective addiction treatments are available ED is an ideal environment to distribute naloxone, as it has the potential to reach people at risk of overdose who might not otherwise access naloxone Purpose of META:PHI project is to facilitate adoption of best practices and support clinicians

24. 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 Hardykate.hardy@wchospital.ca Knowledge broker: Sarah Clarke sarah.clarke@wchospital.ca