Improving emergency department management of acute opioid withdrawal

Transcription

1 Improving emergency department management of acute opioid withdrawal Michelle Klaiman, MD, FRCPPC, DABAM St. Michael s Hospital, University of Toronto

2 Faculty/Presenter Disclosure Faculty: Michelle Klaiman Relationships with financial sponsors: Grants/Research Support: SMH ED Physician s Association Speakers Bureau/Honoraria: Ontario Pharmacy Association Consulting Fees: n/a Patents: n/a Other: n/a

3 Disclosure of Financial Support This program received financial support from the SMH Emergency Medicine Association This program has received no in-kind support Potential for conflict(s) of interest: none

4 Mitigating Potential Bias Financial support from the Association was used to reimburse the time I spend on this project. I do not endorse any specific products marketed, produced, or sold by the OPA.

5 Objectives Discuss importance of treating acute opioid withdrawal in the ED Review role of buprenorphine Identify steps in creating and implementing a quality improvement project

6

7

8

9 Heroin, methadone (Full agonist) Buprenorphine (Partial agonist) 9 Johnson RE, et al. Drug Alcohol Depend; 2003.

10 JAMA Apr 28;313(16): doi: /jama

11 We aimed to increase ED physician prescribing of bup/nal for AOW by 50% from September 2015 to October 2017.

12 11/14 MD survey 4/15 Group B Rounds 3/16 Grand Rounds #2 9/16 RN Education 12/14 Grand Rounds Opioid Withdrawal Cheat Sheet 1/16 ED Stocking 7/16 Order set

13 Emergency Department Protocol for Acute Opioid Withdrawal Date: MD Instructions: Time: Opioid(s) last used: Time opioid(s) last used: 1. Assess indications for buprenorphine/naloxone: COWS greater then 12 and one of the following: At least 12 hrs since last short acting opioid (e.g. Heroin, crushed OxyContin, Percocet ) At least 24 hrs since last long acting opioid (e.g. PO OxyContin, OxyNeo ) At least 72 hrs since last methadone dose 2. Assess for contraindications: Allergy or hypersensitivity to buprenorphine or naloxone Prescribed methadone or buprenorphine/naloxone Severe liver dysfunction Acute severe respiratory distress Decreased level of consciousness Inability to provide informed consent Acute alcoholism or delirium tremens Paralytic ileus Monitoring: þ COWS at presentation and q2h (form on back) þ Discontinue COWS when COWS less than 5 þ Notify MD to reassess patient when COWS less than 5 or when maximum buprenorphine/naloxone given Medications: Use low dose buprenorphine/naloxone if elderly or risk of central nervous system or respiratory depression o Buprenorphine/naloxone 2/0.5 mg X 2 tabs sublingual q2h for COWS greater than 12, max 2 doses. o Buprenorphine/naloxone 2/0.5 mg X 1 tabs sublingual q2h for COWS greater than 12, max 4 doses. þ Observe patient until buprenorphine/naloxone is fully dissolved under the tongue þ Acetaminophen mg PO q6h PRN for pain, max 4g in 24 hours þ Ibuprofen mg PO q6h PRN for pain þ Ondansetron 4-8mg PO/IV q4h PRN for nausea Name: Signature: MD Discharge orders: o Provide patient with prescription, completed by MD. þ Provide patient with information handout Acute Opioid Withdrawal þ Fax referral to addiction medicine clinic if completed by MD

14 Process Outcome Balance Order Set Use Bup/nal prescribed Bup/nal prescribed by by Ed per ED per month Bup/nal prescribed by addictions per month

15

16

17 Next steps

18

19 Acknowledgements Dr. Amy Cheng Dr. Jenny Chu Dr. Anna MacDonald Dr. Daniel Arourbih Dr. Lorne Costello Dr. Evelyn Dell Dr. Sameer Masood Dr. Karyn Medcalf Melissa McGowan, MHK Kira Bahinski, RN Susan Phillips, RN Daniel Vaillancourt, RN Anne Sylvestre, Pharmacist

20 Thank you!

21 Organizational Providers Lack of awareness in ED Lack of follow up Lack of comfort using COWS Knowledge gap around bup/nal No available order set or guideline Difficult access to bup/nal Patient compliance with treatment Lack of withdrawal recognition Historical factors or atypical presentations Patients presenting with acute opioid withdrawal Equipment Patient Figure 1: Fishbone Diagram

22 RN Triages Patient RN completes assessment MD assesses patient MD begins interventions MD Disposition Planning - Basic History and Physical - Triaging based on severity of presentation - Patient returns to waiting room - More detailed history and physicial - Identificatio n of comorbid risk factors - Initiation of bloodwork as described by medical directives - Performs focused assessment (Hx/Px) - Possible identification of AOW - Benzodiazepi nes - Clonidine - Bup/nal - Anti-emetics, IVF, other supportive care - Admission for AOW - Discharge with family MD, Psychiatry, Addiction services follow up