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| Recommendations to health-care providers to prevent drug overdoses (JAMA Internal Medicine) |
By Drs. Scott E. Hadland and Evan Wood; and Eri D. Solomon
Opinion article published in JAMA Internal Medicine
North America is experiencing an unprecedented opioid overdose epidemic now driven by illicitly manufactured fentanyl, which has largely displaced prescription opioids and heroin in most drug markets. In the context of high and rising overdose deaths, four proven clinical interventions should constitute a set of “universal precautions” that clinicians and health systems could implement to reduce opioid overdose deaths among at-risk patients, including all patients who use opioids or who may be inadvertently exposed to fentanyl.
The concept of universal precautions originally emerged as a standard approach to prevent infectious disease transmission in health care settings, and the concept has often been extended to other areas of clinical care. While failure to adopt these universal precautions with opioid prescribing may provide important lessons, a success story is the progress in addressing the HIV epidemic among people who inject drugs. Such progress was made possible through recommendations for the universal delivery of a well-defined suite of interventions including sterile-syringe provision, addiction treatment, and antiretroviral therapy.
A universal-precautions framework is overdue for people at risk of opioid overdose. Individuals who present for care with consequences of opioid use have extremely high rates of recurrent overdose and subsequent death. Critically, they may also have frequent contact with health-care settings, presenting to primary and subspecialty care (such as infectious-disease clinics), mental-health facilities, and emergency departments. Rather than demonstrating a positive association of these contacts with health outcomes, studies show that people who use drugs often experience entrenched stigma and rarely receive potentially life-saving interventions.
We view four clinical interventions as highly suited for inclusion in a suite of universal overdose-prevention interventions.
The concept of universal precautions originally emerged as a standard approach to prevent infectious disease transmission in health care settings, and the concept has often been extended to other areas of clinical care. While failure to adopt these universal precautions with opioid prescribing may provide important lessons, a success story is the progress in addressing the HIV epidemic among people who inject drugs. Such progress was made possible through recommendations for the universal delivery of a well-defined suite of interventions including sterile-syringe provision, addiction treatment, and antiretroviral therapy.
A universal-precautions framework is overdue for people at risk of opioid overdose. Individuals who present for care with consequences of opioid use have extremely high rates of recurrent overdose and subsequent death. Critically, they may also have frequent contact with health-care settings, presenting to primary and subspecialty care (such as infectious-disease clinics), mental-health facilities, and emergency departments. Rather than demonstrating a positive association of these contacts with health outcomes, studies show that people who use drugs often experience entrenched stigma and rarely receive potentially life-saving interventions.
We view four clinical interventions as highly suited for inclusion in a suite of universal overdose-prevention interventions.
Medication-assisted treatment: First, timely provision of buprenorphine, methadone, or extended-release naltrexone should be offered as a first-line intervention for individuals who wish to receive medications for opioid use disorder (OUD). Presently, as few as one in five eligible patients receives medication, and despite clear evidence supporting buprenorphine initiation as a service provided by clinicians in emergency departments, where many individuals at risk of overdose present to receive care for drug-use–related complications, this intervention is unavailable in most hospitals. Policymakers in the U.S., including the leadership of the White House Office of National Drug Control Policy, recently called for scaling up routine access to OUD medications, and highlighted systems-level changes that are needed, including improving addiction education for clinicians, creating new and compassionate “low-threshold” clinic models that offer same-day treatment initiation and flexible scheduling, and reducing stigma. This remains an urgent medical priority in need of a comprehensive yet simple guiding framework.
Availability of naloxone: Clinicians and health systems should routinely distribute the overdose reversal medication naloxone to people at risk of overdose. Despite naloxone being remarkably effective at reversing opioid toxicity, recent investigations have shown dismally low health-system provision. In a 2019 U.S. study of commercially insured people with OUD who experienced an overdose, less than one in 20 was prescribed naloxone. Naloxone is typically covered by insurance, and in many settings can be distributed directly to at-risk patients without a prescription using supplies from local health departments and community organizations. Clinical and social support services for people at risk of opioid overdose must begin to view providing naloxone, alongside brief education on its correct use, as the standard of care.
Take-home fentanyl strips: While changes to drug paraphernalia laws may be required in some jurisdictions [including Kentucky, where one is in process], clinicians and health systems should offer take-home fentanyl test strips. Many overdose deaths result from inadvertent fentanyl exposure among individuals not intending to use potent opioids, including those who believe that they are using a different drug (eg, cocaine), prescription pills, or heroin that does not contain fentanyl but in fact does. Test strips, which can assess for the presence of fentanyl in drugs, are inexpensive and increasingly provided free of charge through local health departments. While educational efforts to support clinician understanding of the value of harm reduction programming will be essential, frontline clinicians are well positioned to provide this simple intervention to those at risk of overdose.
If you inject drugs, don't do it alone: Clinicians should offer brief education to increase awareness of underused overdose prevention strategies. Even though injecting alone is one of the most prevalent modifiable risk factors for death from overdose, many people who use fentanyl do so by themselves. Clinicians should counsel people who use drugs to avoid using them when they are alone so that someone is available to administer naloxone and call emergency services if needed, and suggest other strategies to reduce fatal overdose, including starting with only a small amount of a drug to assess its potency and avoiding mixing opioids and other sedatives such as benzodiazepines and alcohol.
To implement and scale overdose-prevention interventions across North America’s health-care settings, clinical support tools (such as standardized order sets) as well as culture change will be needed. Specifically, clinicians and health systems must address stigma against people who use drugs, recognize OUD as a medical illness, and view offering overdose prevention as central to care for people who use drugs. Applying a universal-precautions framework could help drive this culture change by clearly and simply stating what standard interventions every clinician should offer in every interaction with a person at risk of overdose.
To be sure, the above-mentioned suite of overdose-prevention strategies is not the only intervention clinicians should offer to people at risk of overdose. Nevertheless, in the context of rising mortality and risk of overdose among people who use opioids, we propose that the messaging on universal precautions should initially focus on routinely offering interventions clearly poised to alter ongoing high rates of overdose death. Additionally, clinicians should prevent the onset of medically caused OUD by avoiding inappropriate opioid prescribing (such as for mild acute pain and many types of chronic pain).
We believe that, given the remarkable ongoing discordance between overdose-prevention interventions and service delivery, the definition of a suite of evidence-based interventions and education in support of clinical culture change are long overdue and should be prioritized so that health systems may apply these universal precautions to close the implementation gap for overdose prevention.
Availability of naloxone: Clinicians and health systems should routinely distribute the overdose reversal medication naloxone to people at risk of overdose. Despite naloxone being remarkably effective at reversing opioid toxicity, recent investigations have shown dismally low health-system provision. In a 2019 U.S. study of commercially insured people with OUD who experienced an overdose, less than one in 20 was prescribed naloxone. Naloxone is typically covered by insurance, and in many settings can be distributed directly to at-risk patients without a prescription using supplies from local health departments and community organizations. Clinical and social support services for people at risk of opioid overdose must begin to view providing naloxone, alongside brief education on its correct use, as the standard of care.
Take-home fentanyl strips: While changes to drug paraphernalia laws may be required in some jurisdictions [including Kentucky, where one is in process], clinicians and health systems should offer take-home fentanyl test strips. Many overdose deaths result from inadvertent fentanyl exposure among individuals not intending to use potent opioids, including those who believe that they are using a different drug (eg, cocaine), prescription pills, or heroin that does not contain fentanyl but in fact does. Test strips, which can assess for the presence of fentanyl in drugs, are inexpensive and increasingly provided free of charge through local health departments. While educational efforts to support clinician understanding of the value of harm reduction programming will be essential, frontline clinicians are well positioned to provide this simple intervention to those at risk of overdose.
If you inject drugs, don't do it alone: Clinicians should offer brief education to increase awareness of underused overdose prevention strategies. Even though injecting alone is one of the most prevalent modifiable risk factors for death from overdose, many people who use fentanyl do so by themselves. Clinicians should counsel people who use drugs to avoid using them when they are alone so that someone is available to administer naloxone and call emergency services if needed, and suggest other strategies to reduce fatal overdose, including starting with only a small amount of a drug to assess its potency and avoiding mixing opioids and other sedatives such as benzodiazepines and alcohol.
To implement and scale overdose-prevention interventions across North America’s health-care settings, clinical support tools (such as standardized order sets) as well as culture change will be needed. Specifically, clinicians and health systems must address stigma against people who use drugs, recognize OUD as a medical illness, and view offering overdose prevention as central to care for people who use drugs. Applying a universal-precautions framework could help drive this culture change by clearly and simply stating what standard interventions every clinician should offer in every interaction with a person at risk of overdose.
To be sure, the above-mentioned suite of overdose-prevention strategies is not the only intervention clinicians should offer to people at risk of overdose. Nevertheless, in the context of rising mortality and risk of overdose among people who use opioids, we propose that the messaging on universal precautions should initially focus on routinely offering interventions clearly poised to alter ongoing high rates of overdose death. Additionally, clinicians should prevent the onset of medically caused OUD by avoiding inappropriate opioid prescribing (such as for mild acute pain and many types of chronic pain).
We believe that, given the remarkable ongoing discordance between overdose-prevention interventions and service delivery, the definition of a suite of evidence-based interventions and education in support of clinical culture change are long overdue and should be prioritized so that health systems may apply these universal precautions to close the implementation gap for overdose prevention.
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