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Strayerisms – Opioid Abuse and Buprenorphine

Reuben Strayer, MD and Anand Swaminathan, MD FAAEM
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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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EMRAP_2018_09_September_Written Summary 440 KB - PDF

Strayerisms - Opioid Abuse and Buprenorphine

Reuben Strayer MD and Anand Swaminathan MD

 

Take Home Points

  • The best thing you can do to prevent opioid addiction is to keep opioid naïve patients opioid naïve.
  • If you do prescribe opioids, prescribe in a way that minimizes harm.
  • Move willing opioid misusers into treatment with ED initiated buprenorphine.
  • If the patient is not already in withdrawal, buprenorphine will precipitate withdrawal as it is a partial agonist with higher receptor affinity.

 

  • Overdose deaths in the United States have exceeded peak mortality from guns, HIV and motor vehicle accidents. This is now the leading cause of overall death of Americans under age 50. American physicians have now begun to curtail their opioid prescribing after the 700% increase that led to a prescription opioid addiction epidemic followed by a heroin epidemic and now to an illicitly manufactured fentanyl epidemic. There are still millions of Americans who still misuse opioids and they end up in the emergency department frequently with misuse harms that include apnea and cardiac arrest.
  • Emergency providers are uniquely positioned to intervene on addiction harms because the emergency department is where they are encountered. Patients afflicted with opioid misuse live across a spectrum of disease that can be categorized according to how revealed their misuse is. Do they realize they misuse opioids and if so, will they inform healthcare providers? Among revealed opioid misusers, there is a spectrum of willingness to enter into addiction treatment.
  • There are a series of best practices that have emerged to guide the management of patients at all points along the misuse spectrum, from completely unrevealed misuse to the patient who is fully revealed as a misuser and willing to move to recovery. Also, the spectrum includes the opioid naïve patient who presents with acute pain from fracture or kidney stone to the chronic pain patient who takes hundreds of morphine milligram equivalents daily in the form of prescription and street opiates and repeatedly presents after overdose.
  • The most important way that emergency providers can make an impact in the epidemic is to keep opioid naïve patients opioid naïve so that fewer patients with acute pain are sent down the path to misuse by our prescriptions. Many of us were taught that you can’t trigger addiction with a script for 20 Percocets but we now know that was marketing. We know that some fraction of opioid naïve patients who fill a prescription for opioids will develop addiction arising from that prescription.
  • Once opioid addiction develops, it can be managed but there seems to be a permanent or long-lasting derangement of brain chemistry with profound implications for the patient and their loved ones. Preventing the development of addiction is crucial. This means doing an explicit calculation of the likelihood of benefit and harm every time you consider writing for opioids. The benefit of an opioid prescription is the degree to which opioids ameliorate suffering from pain after safer pharmacologic and non-pharmacologic analgesics have been optimized.
    • There are two types of harms. The immediate harms include nausea, constipation, itching, dysphoria, confusion, falls, inability to work or drive, traffic accidents and overdose.  The second type of harms are the long-term use and misuse harms which are often life-changing or life-ending.
    • You can predict the likelihood of misuse harms with risk factors. Patients with existing substance use including alcohol and tobacco, psychiatric disease, social isolation, disability and adolescents or young adults are more likely to develop misuse and should be prescribed opiates with particular caution.
  • If you decide the likelihood of benefits outweighs harms and you want to send an opioid naïve person home with opioids, the most important way you can decrease the likelihood of that patient developing misuse from your prescription, is to write for a small dose for a brief duration.The duration is crucial. The likelihood of long term use correlates linearly with the number of days’ supply of the first opioid prescription. Give no more than a 3 day supply and tell your patient to flush any unused pills, especially if there are any children or teenagers around. 
    • Hydrocodone and oxycodone seem to be more prone to abuse than alternatives. You would do best to write for less-euphoriant non-combination preparations like immediate release morphine tabs (see the June 2018 episode for a discussion on this).
  • Existing misusers can be grouped according to their degree of being revealed and willing to pursue treatment.
    • Unrevealed patients may present with acute pain and without reports of chronic pain or daily opioid use but strike you as deceptive. You can risk-stratify these patients using red and yellow flags for opioid misuse and using your state prescription drug monitoring program but note that a negative PDMP query doesn’t mean the patient should receive an opioid script. If the PDMP query is negative, go back and do a calculation of the likelihood of benefit and harm for that patient.
    • A positive PDMP query moves the patient from unrevealed to revealed. The right way to use a positive query is to try to move that revealed patient from unwilling to enter into treatment to willing.
    • Partially revealed patients present with an exacerbation of chronic pain and usually report a history of daily opioid use. Many of these patients are being prescribed opioids by one or more doctors. It is important to recognize that, excluding end-of-life pain, patients with chronic pain are either being harmed by opioids or at very high risk of harm by opioids. The data and national guidelines tell us that patients with chronic pain are more likely to be harmed by opioids than helped. In this group, opioids should be avoided in the emergency department and by prescription. Treat symptoms with non-opioid alternatives. When appropriate, express concern that the patient is being harmed by opioids and encourage them to move to treatment. “My job is to manage your pain at the same time I manage the potential for pain medications to harm you.”
    • Many of us see patients who present after opioid overdose. These patients are fully revealed as opioid misusers but come in a spectrum of willingness to be treated for addiction. Most of them are unwilling, especially if they are in acute withdrawal after naloxone administration. Engage these patients. Establish rapport by asking how they got started with narcotics. Some of them are keen to tell their stories. Ask them if they would like to stop? If they are, give them some options.
    • If they are not willing to stop, move to harm reduction mode. Encourage safe injection practices such as a not licking needles, using only when others are around and screening for HIV/HCV.  Refer to your local needle exchange program and discharge with take-home naloxone. Take a supportive stance and tell them you have an open door.
    • For overdose patients who get up and walk out, you can say, “Hey, I know you have a complicated life and I know you wish things were different. When you are ready to make a change, come back. We can help and we never close.”
    • The last type of patient is the patient who is willing to enter into addiction treatment. When you see one of these patients, you have the opportunity to save a life by initiating medication-assisted addiction therapy in the ED.
  • Medication assisted therapy comes in three forms; naltrexone, methadone and buprenorphine.
    • Naltrexone in its depot form with the brand name Vivitrol is a once monthly injection that blocks the actions of opioids. It is basically long-acting Narcan. It is medically imposed abstinence therapy. There is a role for Vivitrol and some patients are great candidates for it. However, most people with opioid addiction will not be interested in or succeed with this therapy because it involves withdrawal which is feared by patients. It does not address the most important cause of relapse, the deranged brain chemistry that causes craving.
    • Methadone is a long-acting full mu receptor agonist that patients with opioid use disorder receive by presenting themselves daily to a clinic. Methadone is effective but is prone to abuse. As a full agonist, it is very dangerous in overdose among a variety of other toxicities. The need to present daily to a clinic is a benefit to some patients who require high engagement but is a barrier for many other patients, especially women who commonly feel threatened at clinics.
    • Buprenorphine is a partial opioid agonist which means that there is a ceiling effect to both its euphoriant potential and toxicity. Buprenorphine is remarkably safe in overdose. You can still die by overdosing on buprenorphine, especially with coingestants. However, it is much safer than methadone. Buprenorphine has a higher affinity for the mu receptor than just about all other opioids. This is important. If you have oxycodone or heroin, the buprenorphine will replace them on the mu receptor but because a partial agonist is replacing a full agonist, the patient will withdraw.
  • Buprenorphine is a highly effective treatment for relieving withdrawal symptoms for most opioid dependent patients. However, if the patient is not already in withdrawal, buprenorphine will precipitate withdrawal. Because it is a partial agonist, you do not get high in the same way you do with other opioids. When you have buprenorphine in your system, oxycodone and heroin won’t work because buprenorphine has higher receptor affinity.
    • Buprenorphine at its best abolishes withdrawal and cravings and protects the patient from overdose and other opioid abuse harms. However, it is not perfect. Buprenorphine is prone to abuse, especially when it is crushed and injected. The preferred preparation is the combination of buprenorphine and naloxone, trade named Suboxone. This is widely misunderstood. The naloxone component is completely inert when Suboxone is taken under the tongue as intended. The naloxone only acts as a mu receptor antagonist when the drug is injected. The purpose of the naloxone in Suboxone is only to prevent abuse by injection. It has no other effect.
    • Buprenorphine is slow in onset which further reduces abuse potential. Like methadone, it has a long dose-dependent duration of action. Because of the ceiling effect, it can be used safely in high doses to prolong the dosing interval to 3-5 days.
  • All of us can dose buprenorphine to treat opioid withdrawal in the ED. To prescribe buprenorphine for addiction requires a special addendum to your DEA license called an X waiver. For physicians, this requires an application process and eight hours of training. Everyone can write for oxycodone, a massively dangerous abuse-prone opioid. But in order to prescribe buprenorphine, a comparatively safe opioid that treats addiction, you have to jump through a series of hoops, so few doctors do.
    • Most of us haven’t seen many opioid-dependent patients presenting to the ED who are willing to enter into addiction treatment. That is probably because, until recently, we haven’t had much to offer them besides a piece of paper with some phone numbers. That is no longer true. Now we can initiate the most effective treatment for opioid addiction in the emergency department.
      • American physicians and policy makers have for decades taken a view of addiction as a moral failing and that addicts have made bad choices. This has led to the stigmatization of not only opioid addiction but also medication assisted therapy which is viewed as replacing one addiction with another.
      • This is inconsistent with science and has informed decades of misguided policies. The data is abundant and unambiguous. Abstinence does not work for most people addicted to opioids. Their brains have been hijacked by opioids and it seems that in many cases, this is irreversible or takes a very long time to reverse. When patients addicted to opioids are randomized to MAT plus counseling versus counseling alone, the patients with MAT stay in treatment. Cochrane concludes that adding psychosocial support to medication assisted therapy does not add additional benefits.
      • Opioid addiction is not a failure of willpower. It is a disease of deranged brain chemistry and the treatment is an opioid agonist. Medication assisted therapy is not substituting one addiction for another. It is replacing addiction with dependence. The difference between addiction and dependence is everything. People addicted to opioids who are successfully transitioned to MAT stop dying. They stop spending all day, every day, terrified of withdrawal and trying to acquire opioids. They stop injecting street drugs with dirty needles and exposing themselves them to these harms. They stop having their lives ruined and they return to their lives and families.
      • The best way to manage willing addicts who present themselves to the emergency department for addiction treatment is to initiate buprenorphine treatment in the ED. This is an entirely new thing for us. It is not complicated.
      • It is called the warm handoff and it involves three steps.
    • First you need the right patient. This is a patient who is dependent on opioids and is in withdrawal. If the patient is not in withdrawal, buprenorphine will precipitate withdrawal. Most pathways of buprenorphine initiation use the clinical opiate withdrawal scale (COWS). This takes about 90 second to perform. The higher score, the better. Most say that you should not initiate buprenorphine until the score is 8 or 9.
    • Treat the patient with buprenorphine. You do not need an X-waiver to do this.
    • Once the initiation is complete, the last step is follow-up. This is usually sending the patient to a buprenorphine capable clinic. This should be worked out at a departmental level using the resources available in your hospital or community.
    • Discharge the patient. If you have an X waiver, you can send the patient home with a few more days of buprenorphine. This is great if you can, but not necessary.
  • The classic dosing of buprenorphine on day number one is 4-8 mg sublingual. The ceiling effect means that high doses prolong the duration of action without causing dangerous adverse effects. We don’t have any literature on this in the ED yet but if initiating buprenorphine in high doses like 32 mg turns out to be safe, it will allow us to cover patients for several days with a dose given in the emergency department. The addict who is therapeutic on buprenorphine is safe from withdrawal, cravings and overdose.
  • The biggest concern about buprenorphine initiation by emergency doctors is the potential for abuse. Many are concerned about the ED becoming a Suboxone dispensary, attracting even more unsavory patients to the ED and concerned about patients selling Suboxone on the street. Our early experience suggests these concerns are probably overblown. In the era of super-fentanyls, Suboxone diversion is probably a public health win. However, buprenorphine does have potential for abuse and street value and Suboxone abuse and diversion is an important concern.
  • Strayer is hopeful that high-dose buprenorphine will be demonstrated to be safe and effective for ED initiation. Until then, we need to verify that the patient can get a prescription or immediate follow-up, otherwise the patient will start to withdraw and give up. If your patient can’t establish follow-up, have them come back to the ED. The law allows you to dispense more buprenorphine without an X waiver for up to 72 hours. You can dose the patient in the ED on days 1, 2 and 3 without an X waiver. This is long enough in most settings to establish the next link in the chain of recovery.
  • The dose on days 2 and 3 is 16 mg.
  • We know this works. France essentially solved its heroin overdose epidemic in the 1990s by empowering all of the general practitioners to prescribe buprenorphine. Overdose deaths fell by 80%. Baltimore saw similar improvements in opioid death and disease by expanding access to MAT.
  • Gail D’Onofrio and her group at Yale demonstrated that you can make huge gains in treatment retention by starting buprenorphine in the emergency department. Even the surgeon general says we should be doing this so let’s get on it.

 

 

 

Jonathan W., M.D. -

Buprenorphine is exceedingly expensive, and not covered by many insurance plans.

Let's have an open discussion on the pharmacoeconoms on the use of Buprenorphine.

Also, how can Buprenorphine possibly work on a patient with chronic pain who actually needs 80 mg of oyx a day?

Jonathan Wasserberger MD etc

Reuben Strayer (@emupdates) -

thanks, jonathan, for the comment.

buprenorphine monoproduct is available for about $1.50 for an 8 mg tab

https://www.goodrx.com/buprenorphine?drug-name=buprenorphine

bup/naloxone was made generic a few weeks ago

https://jamanetwork.com/journals/jama/fullarticle/2687845

and is available for about $3 per 8 mg/2 mg tab.

not a trivial expense, but even if a patient requires 32 mg bup per day, that's much less expensive than street opioids, and the majority of OUD patients do very well on 8-16 mg/day.

some patients on very high dose opioids for chronic pain will not have cravings abolished even with high doses of bup. these patients require very gradual reductions in their daily MMEs before they can transition to bup.

Michael D. -

Buprenorphine has a MME of 30, compared to a MME for oxycodone of 1.5 (https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Opioid-Morphine-EQ-Conversion-Factors-Aug-2017.pdf). Appropriately dosed buprenorphine should adequately saturate the opioid receptors of an individual on 80mg of oxycodone, even in smaller doses. Bupe adequately prevents cravings for individuals that are taking much higher doses illicitly.

I have been told that the buprenorphine's binding affinity is much higher than that of naloxone, so for individuals that inject Suboxone or Zubsolv, any withdrawal type symptoms they are getting are actually precipitated withdrawal from the bupe knocking other opioids off the receptors, rather than actual action by the naloxone. I have not looked too far into this though, but if true, it would be a great example of the pharma company behaviors described in Dr. Lin's session this month.

Great section Reuben!

Reuben Strayer (@emupdates) -

Thanks for the comment, Michael. The MMEs don't tell the whole story, because bup is a partial agonist. We know that some patients, either because of their high daily MMEs, or other unknown factors/features of their brain chemistry, do not have cravings abolished by bup, even in high doses, and require a full agonist for MAT (methadone). But this is the exception - most OUD patients who are ready to move to recovery do very well with bup, regardless of the particulars of their usual opioid consumption.

The naloxone component of suboxone does have mu receptor antagonist effect when injected (not when taken under the tongue as intended), but you're right that it's hard to know in any individual the relative contributions of naloxone and buprenorphine in precipitated withdrawal, because as you mention, bup by itself will precipitate withdrawal in the opioid-dependent person who still has full agonists in their system.

reub

James C. -

What do you suggest for ER's who don't have docs in the community who are waivered to prescribe? Even if you have an MAT clinic nearby, they may not be able to see your patient within 3 days. Do you have these folks come back every 3 days until they can get in? It's one thing to start it in the ED, it's another thing to ensure ongoing access to the medication in resource poor areas.

Reuben Strayer (@emupdates) -

Good question James. This is a controversial area. I submit that every hour a street opioid-using opioid misuser is therapeutic on buprenorphine is an hour that they are safe, and so I would say that if there are no x-waivered docs available in the community (or on ED staff), they should come back to the ED to get a dose of buprenorphine until comprehensive addiction care can be arranged. This may sound ridiculous at first–no one wants to turn their ED into a bup dispensary–but what is the alternative? The alternative is to send the patient out in withdrawal; and in an era of superfentanyls, that is far more dangerous than any ED discharge that any of us would otherwise contemplate. Access to bup is expanding, not nearly fast enough, but every month communities have more resources. Even patients in remote locations can get addiction care via tele-health. This is not something that is going to be set up by an emergency doc in the middle of a shift, but can be managed by social work or case management. The bottom line is that, in my opinion, OUD patients willing to move to recovery should be provided buprenorphine by essentially whatever means necessary, and if that has to be daily ED visits, so be it.

James C. -

^ Love it. putting my fist up to computer screen for a virtual fist bump.

Aaron W., MD -

James, I just got my waiver as an ED doc. It's easy and is only $200. That way you can write a RX for a few days to get them to a clinic, home induction is also another option that has been met with success. Also, I have been writing Bupe scripts for "Pain" which does not need an X waiver. I have done this 5 x in the last month with no issues from pharmacists. We are piloting this whole concept at our ED shop in Fort Myers, FL. We don't have robust outpatient Bupe support but we are acting as the vangard to garner more community support.
Here is the link for ASAM (American Society of Addiction Medicine) Waiver course: https://www.asam.org/education/live-online-cme/waiver-training

Cheers! and Thank you Reuben for another fantastic segment. I have been using your material for the last 3 years and changing the way my colleagues view and treat this disease. I am profoundly grateful.

David W. -

Hi,

Great segment! I've developed an algorithm/pathway for use @ the EDs I work at on how to administer since bupe is a new thing for us. It's based on the ED-bridge algorithm ( https://ed-bridge.org/) developed by Andrew Herring an ED physician from Highland hospital in Oakland, CA. He was featured recently in the NY Times.

Would love to see an interview with him about the subject given their experience. Specifically, they recommend larger doses (16-32 mg) for their patients.

There is also a similar program to ed-bridge for inpatient teams: https://www.projectshout.org/

Reuben Strayer (@emupdates) -

thanks david. much of what I discuss around ED-initiated buprenorphine is based explicitly on andrew's work and has been guided by him.

our latest pathway incorporates high-dose bup, which is controversial, but hopefully not for long.

https://emupdates.com/wp-content/uploads/2016/09/EDIB.png

reuben

Kristopher L., M.D. -

What is the history of why they require an X waiver DEA license?

Also would EMRAP be able to provide the X waiver training?

Thanks

Kris

Reuben Strayer (@emupdates) -

Kristopher - the way american law manages addiction treatment is a twisted, wrong-headed approach based entirely on stigma. If you're interested in some of the history, read around the Harrison Narcotics Act and the Drug Addiction Treatment Act (DATA 2000).

https://en.wikipedia.org/wiki/Harrison_Narcotics_Tax_Act
https://en.wikipedia.org/wiki/Drug_Addiction_Treatment_Act

The x-waivering process is tightly regulated and requires 8 hours of training for american physicians. ACEP is developing a emergency doc-focused x-waivering program that I think will make this process more palatable (COI: I am part of this effort). Otherwise, there are a variety of options, including an online course:

https://www.asam.org/education/live-online-cme/waiver-training

reuben

David W. -

Here is a free online DEA-X training: https://pcssnow.org/education-training/mat-training/

Word of warning - it is geared toward office based physicians. I was probably 1 of 2-3 ED physicians.

Sean G., M.D. -

could u cite the research you mention in this segment, or if it is already on emrap tell me where I can find the citations, I have not seen them yet,.Also can u cite the research that shows giving naloxone randomly in the ER to opioid addicts reduce opioid OD? I actually do not believe it exists, I could be wrong but I believe the push for this came from the Boston area study years ago....and that study certainly was not simply handing naloxone out in the ER.
Thanks

Reuben Strayer (@emupdates) -

Thanks for your question Sean. There are no ED-based studies that look at overdose or mortality outcomes. We know that getting naloxone into folks' hands saves lives at a community level, see two studies below. There is no reason to think distributing nalaxone from the ED would be different.

https://www.dropbox.com/s/2l26ialj8iwm5y9/Wheeler%202015%20Opioid%20OD%20Prevention%20-%20MMWR.pdf?dl=0

https://www.dropbox.com/s/jy7aqvab6vtvwv3/Walley%202013%20Opioid%20OD%20Nasal%20Naloxone%20Massachusetts%20-%20BMJ.pdf?dl=0

Sean G., M.D. -

Thanks Reuben, Actually I think there are very good reasons to believe the results of distributing naloxone in the ER might be different than providing a harm reduction program as in the mass study(second citation) so the second citation was the one I had mentioned the study in Mass....which involved hours of training in the recognition of OD and the use of nalaoxone and involved social workers, addicts and their loved ones. Individuals willing to take a 4 hour class with their loved ones or significant others and learn all the issues around this subject are a very different cohort than random Er Opioid abusers There is no reason to believe you are testing or dealing with the same people. That was my point. The first study I have not done a detailed critique of but simply looking at the map of naloxone distribution centers and mortality due to opioid od it is quite obvious that their is little correlation.... that is Cali has a large number of distribution centers and a low death rate due to OD. New Mexico has a large number of centers and a high death rate. there are states w no centers and very low death rates and basically it is all over the board, so at least the map would suggest the mortality is not correlated with the number of naloxone distribution centers, You mention a few other studies that you suggested paraphrasing "really prove the benefit of handing out naloxone"...I would be interested in seeing those as well. I have significant personal experience with loved ones who have been dealing with opioid addiction for many years I have at least 7 friends some nurses, EMS and others in different careers who have died from heroin or other opiate OD, I have multiple friends whose children have died...as I am sure many of us here do. I have been really disappointed w Emraps take on this since i started listening to Emrap in about 2004. I have not missed a single month in 14 years, and I have yet to hear a chapter on this subject I agree with. In the 90's I was a young EM doc with a fiance addicted. I spent hours in NA meetings and after with her and her numerous addict friends, I heard all their stories and how they saw the ED as an "easy mark" I saw first hand how useless Methadone could be for many users. Then I listened to Jim (dont know how to spell his last name sounds like Dushwam tell me and everyone listening that the likelihood the back pain patient in the ED at 1 am asking for percocet was addicted was about 1% or less. I was chided when I suggested it was closer to 50% in my ER. Jim told me at an AAEM conference "Don't tell me its different in your ER"....So I guess he was right...it wasnt different, its just that my number was accurate and his was false. Well 20 years later its all over dateline, Time, MSNBC etc...now we are being told how many morphine eq we can Rx. In the 90's I was an outlier because I rx's number 20 of percocets or similar...I was told I was undertreating pain....I should be Rx long acting short acting and enough for say a week. Now I am an outlier again...I Rx 20 morphine tabs 15 mg for acute pain and now thats "too much" even on Emrap here one of the new guys (past 5 years or so) was referring to Rx 6-8 tabs for acute pain....6 or 8? I thought we would anticipate 3-5 days of need for an opiate for a legit reason???? most are 4-6 hour drugs, one to two...its simple math. A proper Rx for 3-5 days is between 12-40 tabs of a shor acting opiate....6-8 is silly. All u do with 6-8 is force the patient with real pain to return or go to another prescriber when he runs out after day 1...now he is labeled a "drug seeker" because he is coming back. This is why I am an outlier on the AZ PMP site, because everyone is Rx'ng like no more than 10 pills and i am still doing 20. This drives me nuts as I have not changed my practice in 20 years other than to move to morphine when possible(the one Emrap chapter on this I agreed with).This new govt oversight is bollocks IMO we docs do not need a Governor to tell us how many pills to Rx. Lastly I am not sold on giving out naloxone without an actual training program until we have actual data on exactly that. I can see many logical outcomes of handing out naloxone to addicts that could potentially result in MORE OD's as I am well aware of how the mind of an addict works. The buprenorphine thing I am not sold on either. I would like to see studies that show people who are Rx this drug having a lower 5 year mortality and substance abuse rate than those who have not been Rx'd that. I do not believe we have any studies like that. If we show less addiction issues in one year, that doesnt mean a whole lot to me. I check the PMP site on pretty much everyone seeking pain relief and the percentage of people I have seen on Buprenorphine as their ONLY opioid is about 5%. 95% of the people I check continue to receive other opiates from multiple providers. I am very suspicious when a study comes out and pushes a drug....any drug. Finally Emrap addressed this in Sept I believe with the doc who discussed the role of bias in drug studies. I always knew this was true and personally feel it corrupts just about all the studies done in the US on drugs and medical devices. So sorry to unload on you this is years of frustration you are seeing here and I know your discussion on this is only partially related to this rant. It is my opinion that the opioid abuser is no different than any other addict. They can not be convinced to rehab, they can not be changed from without,. The desire to stop using MUST come from the individual, if it originates outside the individual it is doomed to failure. The real cure for a drug addiction just can not be another drug...if you think about it logically it should be obvious just how ridiculous that postulate sounds. I know you want to help your patients and we are all looking for an answer, we all want to "do" something. Sometimes we should not "do" however. Sometimes we can only "not do" such as not Rx'ng opiates to opiate naive pts Sorry again for unloading but I am insanely frustrated with western Medicine's approach to pain. Its as if we believe pain has no purpose here, or pain is an evil. Pain is an important part of life and the idea that it is our job to be sure people experience no pain or as little pain as possible is just inane. And it is that very logic that has resulted in the US being 10% of the world population yet using 90% of the worlds opiates. Ok...I'm done. Let me thank you reuben for all u have taught me. As much as I carry on I have learned an immense amount from everyone here at Emrap, its just this area of pain management that I whole heartedly disagree with. This probably is related to my practicing Taoism and Buddhism.
Cheers,
Sean

Reuben Strayer (@emupdates) -

Sean -

I appreciate your reply. I think there are a lot of emergency providers (and a lot of folks in general) who share many of the concerns you raise. Some of your points are in my opinion right on and frustrating to me as well, some of your points I think are discordant with the science, and some of your points are controversial and we don't have a certain answer. I'm going to try to address as many of them as I can - there are a lot of issues you're bringing to the table here.

Take home naloxone. We are not certain that handing out naloxone to OUD patients from the ED saves lives, and some are concerned that having naloxone around encourages drug users to engage in more risky behavior. I think naloxone should be available in public places where opioid overdoses are more likely, similar to how AED's are available in places where VF/VT is more likely. Based on my own appraisal of the science and knowledge of opioid users' behavior, I think the likelihood of benefit in handing naloxone to an opioid user exceeds harms, and so I do it and recommend it. But if you wanted to take a principled decision that the science isn't strong enough at the moment and you believe the likelihood of benefit does not exceed harm for THN, I wouldn't strongly disagree with you. I will stipulate, however, that the vast majority of entrenched opioid misusers in america in 2018 are not trying to get high, they are trying to avoid withdrawal (including hyperalgesic pain–many daily opioid users who present to medical attention in pain are in fact in withdrawal or something like withdrawal). These folks are, in my opinion, unlikely to be emboldened by having naloxone on hand; they use heroin (or what they think is heroin) because it's cheaper and more accessible than pills. Since the heroin supply has become contaminated with fentanyl and superfentanyls, we have seen a huge spike in overdose deaths–these are the folks whose lives can be saved by THN. But overall I agree there is some controversy among experts around THN.

I suspect Jim Ducharme would agree with you, today, that he and many of us were misled by pain experts who were being paid by pharmaceutical companies; we know a generation of physicians was essentially duped into believing that using opioids to treat pain does not cause addiction. I myself had the feeling, many years ago, that the percocet prescriptions I was handing out for back pain (as I was trained to do) were not helping these patients, and in fact that is exactly why I became interested in this topic. So I'm with you on this point - you recognized, as many of us did, that the consensus and the guidelines were wrong. It took the medical establishment 15 years to figure it out, and we're still struggling to figure it out.

This dovetails into your concerns around the prevalence of bias in industry-sponsored studies. I could not agree with you more here. It is obvious to everyone who is engaged in this topic that the drug and device industry will do whatever they can get away with to sell more product. Purdue Pharma and Oxycontin is the most horrifying/egregious example, but it's everywhere and I, and probably all of the EMRAP contributors, are just as distressed about it as you are.

Outpatient opioid prescribing in opioid-naive patients. Again, we are still recovering from the misinformation most of us were taught. We know that some of these patients given an opioid prescription for pain are set down the path to misuse by that prescription, and we know that the likelihood of an opioid-naive patient developing long term use from an opioid prescription correlates directly with the duration of that prescription, which is basically the number of pills. I (and all of us who are focused on this issue) are in complete agreement with you that we do more harm than good attempting to get the patient to zero pain, that the goal should not be zero pain. For the vast majority of acutely painful conditions, the pain is worse at first and improves over days. This means that for severe acute pain, after maximizing analgesia with fewer harms than opioids, and after considering how likely the patient in front of you is to be harmed by opioids, that you prescribe enough pills for round-the-clock for 24-48h, and then maybe a few more for days 3 and 4. Around ten morphine tabs for most patients with severe acute pain, in addition to high dose acetaminophen and ibuprofen, is probably about right and the right way to manage pain while managing the potential for opioid harms.

Sean I think you are correct or partially correct in almost all your concerns, except your concerns about buprenorphine. There is really no room for argument here, the science is absolutely unequivocal, buprenorphine is the most effective way to reduce deaths in opioid addiction, by far. There is a mountain of data to support that statement, but among the most convincing was the french experience in the 90s: when France was in the midst of a devastating heroin overdose epidemic, they discarded the traditional (stigma-based) approach to addiction care and massively expanded access to bup, and overdose deaths fell by 80%. ( https://goo.gl/dxevF9 ) This is not at all surprising when you understand how people die from opioid abuse and how bup works. Entrenched opioid addicts will do anything to avoid withdrawal and cravings, and for most of them in america at the moment, the only way to do that is with injectable street opioids, because of cost/availability. Injectable street opioids have always been lethal, but they have become much more lethal in the past few years. Regardless of how an OUD patient developed their addiction, once they are addicted, their brain chemistry is deranged and for the vast majority of them, regardless of how much they want to be sober, abstinence therapy will not work, it's not a question of willpower, it's deranged brain chemistry. OAT (opioid agonist treatment for addition, aka MAT) is not replacing one addiction for another, it is substituting dependence for addiction, and the difference between dependence and addiction is the difference between returning to a relatively normal life and being found dead in a Wendy's bathroom with a needle in your arm. It's not that simple but really, it is that simple. The way to stop opioid overdose deaths is to adopt France's strategy, which is to saturate the country (and therefore saturate addicts' mu receptors) with buprenorphine, because the OUD patient who is therapeutic on bup is protected from withdrawal and cravings (and the desperate, extremely dangerous behaviors that result), protected from the harms of street opioids (which have never been more lethal), and protected from overdose, because of bup's ability to block the action of more dangerous opioids. So the way to stop people from dying of opioid overdose is to make bup easier to get than heroin. This should be more of a public health project than an emergency medicine project–making bup easier to get than heroin should be done on the streets and in clinics, not in the ED, but at the moment that's not happening, because of our stigma-driven approach to addiction care, because the american healthcare system and the process by which we make laws in america is no longer able to meet the needs of the country. So we in emergency medicine have to expand the scope of our practice, because the emergency department is where OUD patients are, and getting OUD patients on bup is what is needed. Is bup a perfect therapy? of course not. Is bup abused? of course. Will every patient started on bup stay alive and street drug-free? of course not. But in 2018, with street opioids contaminated with ultrapotent fentanyls, sending an opioid-addicted person out of the ED in withdrawal cannot be justified, that is a far, far, far riskier discharge than any of us would ever consider in any other context. We know how to mitigate that risk; so even if dealing with opioid-addicted people is hard, and even if getting these people on bup from the ED is a pain in the ass, it's what we have to do. I'm going to paste an email from one of my recent residency grads below.

Sean I appreciate your engagement with this, what you have seen and learned, and your frustrations, many of which I share. We as a community are still trying to figure this out, we don't have all the right answers, we will probably make more mis-steps, and have a long way to go. I'm glad to have thoughtful people like you to help us along the way.

reuben

Hey Strayer,

Hope all is well up where you are. Things have been great down in South Florida. Community EM has been a transition from academic EM to say the least, but in the end I'm glad I ended up back home.

I noticed the recent push for buprenorphine in acute opioid withdrawal you've been advocating for and wanted to share my hospital's program with you.

A patient presenting to our ER with ANY opioid use disorder diagnosis (overdose, withdrawal, requesting detox, "drug seeking", etc) undergoes a MAT (medically assisted treatment) consultation by psych unit nurses and pharmacists trained to identify good candidates for outpatient detox. Either the ER Dr. or Psychiatrist on call orders a dose of 8mg buprenorphine. We observe for 1 hour and they usually blossom into thankful and motivated people willing to continue therapy. We then refer them to our outpatient behavioral health MAT clinic the following day to continue treatment. We don't prescribe anything from the ER except for IN Naloxone which they leave with in-hand from the ER.

I was very suspicious of the program initially and was concerned we were breeding a new type of "buprenorphine seekers" but we have not seen anything like this. After seeing these patients return to the ER for other non related complaints and seeing how this turned their lives around, I became a believer. This really does work.

Eric

J. B. L., M.D. -

I was both inspired and appalled by the segments on opioid abuse in the USA. The history behind it is fascinating and scary. my country of Israel, we do not as yet have a problem - but all the ground work is there- forced use of the pain scale by the Ministry of Health, ( a quality marker), general feeling by practitioners that Percocet is benign, etc. I was wondering if Dr. Strayer would be interested in writing with me an opinion piece - or more appropriately a call to arms for my country's national journal ( it is in English and is indexed)
Best

Reuben Strayer (@emupdates) -

JBL - feel free to email me

emupdates@gmail.com

reuben

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