https://www.infirmiere-canadienne.com/blogs/ic-contenu/2023/06/05/trousses-de-naloxone-a-emporter
Proposed intervention aimed at reducing crisis of opioid toxicity deaths
By Chris Wenzel
June 5, 2023
SDI Productions | istockphoto.com/asiseeit
Creating a simple standardized process would actually reduce workload stress because there would be no need to determine a patient’s eligibility for a take-home naloxone kit. Every patient who presents to the emergency department, regardless of their presenting complaint or history, would be asked only one question: “We are offering THN kits to all patients/family members; would you like us to provide one for you?”
Takeaway messages
- The COVID-19 pandemic has exacerbated an ongoing crisis of opioid toxicity deaths, with 2021 being the deadliest year on record.
- Take-home naloxone (THN) kits, mass distributed through emergency departments (EDs), can be an effective tool. Despite them being widely available, uptake of THN kits has been poor, largely due to barriers associated with staff workload/time constraints and reliance on criteria-based decision-making.
- Adopting a universal screening/offering method for THN kits in the ED would ease workflow burdens and increase the uptake of THN kits available in the community.
As Canada continues to deal with the ongoing COVID-19 pandemic, a second pandemic has been waging war against Canadians even before COVID-19: opioid abuse and deaths related to opioid toxicity have been worsening since the early 2000s. In 2016, the Canadian government attempted to deal with this crisis through various new initiatives, with debatable success (Government of Canada, 2022). The onset of COVID-19 created further challenges in Canada’s efforts against the opioid crisis, leaving Canadians in a vulnerable state.
Current data show that during the first year of the COVID-19 pandemic, there was a 96-per-cent increase in apparent opioid toxicity deaths, with 7,362 deaths Canada-wide, in contrast to 3,747 deaths the previous year (Government of Canada, 2022). Provinces such as Alberta and British Columbia have seen some of the worst impacts of this crisis, with 1,623 opioid-related deaths documented in 2021, the deadliest year on record for Alberta (Government of Alberta, 2022).
What are take-home naloxone kits?
One of the interventions used to combat deaths due to opioid toxicity is the mass distribution of take-home naloxone (THN) kits. Naloxone is an opioid overdose intervention that can be administered by laypeople. It is safe, viable, and effective in reducing opioid-overdose deaths in the community setting (Gunn et al., 2018). The World Health Organization has identified naloxone as an important tool in combatting the global opioid crisis (O’Brien et al., 2019). A THN kit consists of two components: the naloxone (injectable or intranasal) kit, and standardized training for patients/family members on recognizing and responding to overdoses (Kestler et al., 2017).
In Canada, THN kits are becoming increasingly available to the public through various sites, such as pharmacies. Hospital EDs, owing to their accessibility, provide a critical opportunity to reach vulnerable community members at risk for overdose, as people who overuse or abuse opioids are more likely to present in the ED than at other places of care (Strang et al., 2019). Public health analyses completed in British Columbia have indicated that 54 per cent of persons experiencing an overdose had visited an ED in the previous year, and 19 per cent of those left against medical advice, indicating missed opportunities to intervene (Otterstatter et al., 2018). Since 2016, THN kits have been increasingly available to the public through hospital EDs. Despite this, uptake remains low, as noted by a study conducted in Alberta that showed fewer than half of the patients in an ED who met criteria for being at high risk of an opioid-related death received a THN kit (O’Brien et al., 2019).
Unfortunately, the literature on THN kit implementation programs is limited, and therefore it is difficult to ascertain the barriers that contribute to the poor uptake. It is likely multifactorial, but some common barriers cited include staff lacking education on THN kits/harm reduction, workflow burden, eligibility confusion, and moral distress regarding harm reduction practices (Gunn et al., 2018; O’Brien et al., 2019). All of these barriers are dynamic and present difficulties in addressing them. However, I believe that addressing even one of those factors could have a noticeable impact on the uptake of THN kits in EDs.
How to increase uptake
In most THN kit ED programs, patients are identified via various criteria, ranging from previous opioid overdoses to admission of opioid use or abuse (O’Brien et al., 2019). In theory, such identification makes sense because health-care providers can then allocate resources to those who need them the most. Unfortunately, this approach hasn’t translated well into practice; many patients get missed despite meeting pre-determined criteria (Funke et al., 2021; O’Brien et al., 2019).
Determining who is or is not eligible for THN kits can be a burdensome practice for health-care providers and is seemingly ineffective (Funke et al., 2021; Gunn et al., 2018; O’Brien et al., 2019). Eligibility for THN kits requires objective evidence that must be uncovered by the health-care provider through various means. Information found in patient charts can be misleading for numerous reasons, e.g., the patient has not accessed health care in the past, or resides in a different city or province. Patients’ account of their medical history can also be unreliable because they may minimize their use of opioids in fear of being stigmatized. These factors can increase workload stress for health-care providers, possibly leading them to avoid offering THN kits (O’Brien et al., 2019).
A viable solution to this dilemma would be to get rid of the criteria-based distribution method and instead ask every patient who presents to the ED whether or not they would like a THN kit.
Implications and conclusion
In a time when workload demands on nurses are growing and the workforce is shrinking, adding more to their workflow may not be a popular choice and could even result in poor uptake. But creating a simple standardized process would actually reduce workload stress because there would be no need to determine a patient’s eligibility for a THN kit. Every patient who presents to the ED, regardless of their presenting complaint or history, would be asked only one question: “We are offering THN kits to all patients/family members; would you like us to provide one for you?” Such an approach would maximize the number of patients who might request a THN kit if they did not have to disclose personal details that may be stigmatizing.
Universal screening would also facilitate a culture change among health-care workers to normalize harm reduction practices such as offering THN kits. This practice could look different across jurisdictions, based on existing policy and procedures. Patients might be asked during the check-in or perhaps at discharge. Other resources might be used to facilitate implementation, such as better practice advisories via electronic charting systems that would automatically remind the nurse to offer THN kits.
Although there has been little research on which measures increase uptake of THN kits in EDs, it is clear that the processes currently in place have poor efficacy and need to be re-evaluated.
References
Funke, M., Kaplan, M.C., Glover, H., Schramm-Sapyta, N., Muzyk, A., Mando-Vandrick, J., et al. (2021). Increasing naloxone prescribing in the emergency department through education and electronic medical record work-aids. Joint Commission Journal on Quality and Patient Safety, 47(6), 364–375. doi: 10.1016/j.jcjq.2021.03.002.
Government of Alberta. (2022). Alberta substance use surveillance system. https://healthanalytics.alberta.ca/SASVisualAnalytics/?reportUri=%2Freports%2Freports%2F1bbb695d-14b14346b66ed401a40f53e6§ionIndex=0&sso_guest=true&reportViewOnly=true&reportContextBar=false&sas-welcome=false
Government of Canada. (2022). Opioid- and stimulant-related harms in Canada. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/
Gunn, A.H., Smothers, Z.P.W., Schramm-Sapyta, N., Freiermuth, C.E., MacEachern, M., & Muzyk, A.J. (2018). The emergency department as an opportunity for naloxone distribution. Western Journal of Emergency Medicine, 19(6), 1036–1042. https://doiorg.ahs.idm.oclc.org/10.5811/westjem.2018.8.38829
Kestler, A., Buxton, J., Meckling, G., Giesler, A., Lee, M., Fuller, K., et al. (2017). Factors associated with participation in an emergency department–based take-home naloxone program for at-risk opioid users. Annals of Emergency Medicine, 69(3), 340–346. https://doi.org/10.1016/j.annemergmed.2016.07.027
O’Brien, D. C., Dabbs, D., Dong, K., Veugelers, P. J., & Hyshka, E. (2019). Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review. BMC Health Services Research, 19(1). https://doi-org.ahs.idm.oclc.org/10.1186/s12913-019-4469-3
Otterstatter, M.C., Crabtree, A., Dobrer, S., Kinniburgh, B., Klar, S., Leamon, A., et al. (2018). Patterns of health care utilization among people who overdosed from illegal drugs: a descriptive analysis using the BC Provincial Overdose Cohort. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 38(9), 328–333. Retrieved from https://doi.org/10.24095/hpcdp.38.9.04
Strang, J., McDonald, R., Campbell, G., Degenhardt, L., Nielsen, S., Ritter, A., et al. (2019). Take-home naloxone for the emergency interim management of opioid overdose: the public health application of an emergency medicine. Drugs, 79(13), 1395–1418. https://doi-org.ahs.idm.oclc.org/10.1007/s40265-019-01154-5
Chris Wenzel, RN, MN, is a clinical nurse specialist with the addictions and mental health department at Alberta Health Services’ South Health Campus, Calgary.
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#addictions
#harm-reduction
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#opioids
#stigma
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