St. Clare emergency department responds to the opioid crisis

The opioid crisis is well publicized and widespread nationally. Every day, the media reports dangerous trends in overdose-related deaths (Katz, 2017). It is estimated that more than 18,000 deaths in 2014 were due to opioid overdoses, a leading cause of accidental death in the United States (Paparella, 2014). Many of us who work in health care have experienced this issue firsthand, as we work with patients daily who are living with opioid use disorder (OUD). Often, these interactions are frustrating for healthcare professionals and patients, with both feeling helpless. Opioid use disorder is often misunderstood as a social or moral issue instead of as a chronic illness.

Consequently, health care professionals are not trained on the causes and evidence-based treatments of OUD. This educational gap among health care professionals leaves patients feeling they are not respected; they feel treated poorly as well as judged. This leaves the patient who came to seek treatment feeling angry and the health care professional feeling helpless. This lack of coordinated care continues and leaves a vulnerable population in our communities with deadly consequences.

In 2015, there were 718 opioid overdose related deaths in Washington state (DOH, 2017). The following year, the Centers for Disease Control and Prevention released new guidelines for the treatment of chronic pain (Dowell, Haegerich and Chou, 2016). Washington state Governor Jay Inslee wrote an executive order outlining a statewide opiate response plan (Inslee, 2016). The two documents parallel each other, acknowledging that our previous focus on simply reducing the number of opiate prescriptions was not enough. In fact, research indicates such an approach actually causes harm, removing a patient’s legal access to a substance on which they depend physically and emotionally. Without proper medical support, patients turn to illicit forms of the drug. Since implementation of the statewide prescription monitoring program in 2012, a decrease in prescription-related police arrests, treatment-seeking and mortality have been achieved. Banta-Green and Williams (2016), however, identified that heroin-related incidents have increased in all three areas proportionately.

An appropriate and effective response to opioid use disorder and its related deaths must also include a concerted focus on preventing overdose, increasing access to overdose reversal agents, and expanding options for, and access to, treatment of the disease.

The emergency department at St. Clare Hospital was once considered a small, community hospital; however, we have grown into a large ED, treating 120-150 patients daily. The ED at St. Clare serves as a crucial daily resource for the many patients we see with life-threatening illnesses and urgent primary care needs unmet by the overburdened system. Many of our patients live with untreated OUD, and for some we are their only contact with medical care. Historically, EDs have not been viewed as the arena to treat or resolve this chronic issue; however, at St. Clare, we believe in another philosophy. These individuals, frequently stigmatized in other settings or refused pain management, arrive to our department because they need understanding and relief of their symptoms, which we can provide. Our patients need kindness, understanding, pain control and options for medical treatment, such as buprenorphine and naloxone sublingual film.

Naloxone is an opioid reversal agent that can be used when a patient has used an excess of opioids. It does not replace the need for a health care practitioner’s care, but it can and should be used in homes and communities for immediate response to life-threatening or suspected overdoses. Naloxone is easy to use and comes in auto-injector or intranasal kits, similar to an insulin pen or an epinephrine auto injector system. The American College of Emergency Physicians (ACEP) and the Washington State law RCW 69.50.315 recommend that anyone at risk of having or witnessing an opioid overdose be given naloxone and trained to use it (ACEP, 2015). This translates to our patients who use heroin; have significant daily doses of opioids prescribed; or recently underwent a period of abstinence or reduced use secondary to treatment, incarceration or hospitalization. Such patients, as well as their friends and family, should be receiving this drug free of charge.

St. Clare Hospital is working toward this goal. Nurses, pharmacists, physicians and administrative leadership have been meeting to develop a protocol to dispense a “naloxone kit” to at-risk patients upon discharge. This kit would include the medication, simple instructions for use and educational materials on safer opioid use and overdose prevention. This kit will be given following an in-person, one-to-one education session with a trained member of our health care team. We are committed to reducing the harm associated with opioid use disorder in our community. This means reducing overdose-related deaths. It also means providing the staff with the tools to truly help their patients, and to demonstrate to our patients that we believe their lives are worth saving.

American College of Emergency Physicians, Board of Directors. (2015, October). Naloxone Prescriptions by Emergency Physicians. Retrieved August 12, 2017, from https://www.acep.org/Clinical---Practice-Management/Naloxone-Prescriptions-by-Emergency-Physicians/

Bandta-Green, C., Phd MPH MSW, & Williams, J., PhD. (2016). Overview of opioid trends in Pierce County. Alcohol and Drug Abuse Institute, University of Washington.

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1

Inslee, J. (2016). Executive Order 16-09 (State of Washington, Office of the Govenor). Retrieved from http://www.governor.wa.gov/sites/default/files/exe_order/eo_16-09.pdf

Katz, J. (2017, June 5). Drug Deaths in America Are Rising Faster Than Ever. The New York Times. Retrieved August 12, 2017, from https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html

Paparella, S. (2016). A Tale of Waste and Loss: Lessons Learned. Journal of Emergency Nursing, 42(4), 352-354. doi: http://dx.doi.org/10.1016/j.jen.2016.03.025

Opioid-related Deaths in Washington State, 2006–2016 (No. DOH 346-083). (2017). Washington State Department of Health. doi:http://www.doh.wa.gov/Portals/1/Documents/Pubs/346-083-SummaryOpioidOverdoseData.pdf