https://www.infirmiere-canadienne.com/blogs/ic-contenu/2024/07/22/patients-besoin-dun-approvisionnement-plus-sur
Because people should not need to choose between their medication and urgent care
By Patty Wilson
July 22, 2024
istockphoto.com/FatCamera
In the emergency department, people taking prescribed safer supply need to continue to have access to their medications.
This article is part of the Canadian Nurse series, Harm Reduction Saves Lives.
In the last few years, prescribed safer supply has emerged as a response to the unregulated toxic drug crisis (Ledlie et al., 2024). Prescribed safer supply offers individuals using unregulated drugs the choice of obtaining prescription alternatives, ensuring a regulated and safer option. For example, a client could move from using unregulated fentanyl purchased on the street to prescribed fentanyl patches.
Courtesy of Patty Wilson
“People who transition to prescribed safer supply go to the emergency department less often and have better health outcomes,” Patty Wilson says.
People who transition to prescribed safer supply go to the emergency department less often and have better health outcomes. However, some people have their prescriptions stopped if they are admitted to hospital (Kolla & Fajber, 2023). Clinical nurses may not understand why someone has been prescribed safer supply or how to manage this medication.
This article gives an overview of prescribed safer supply and relevant nursing assessments and interventions for people arriving at hospital with a prescribed safer supply care plan.
What is prescribed safer supply?
Prescribed safer supply is the prescriber-based model that replaces unprescribed opioids, such as unregulated fentanyl and fentanyl analogues, with prescribed opioids such as tablet hydromorphone, oxycodone, fentanyl patches, tablet fentanyl, and injectable fentanyl that can be taken sublingually.
Medication dosages are titrated based on a person’s opioid tolerance and are usually increased until the client no longer experiences withdrawal. The client would also report that their dependence on unregulated fentanyl has decreased or stopped (Karamouzian et al., 2023; McMurchy & Palmer, 2022). Prescribed safer supply can also apply to other drugs, such as stimulants, benzodiazepines, cannabis, and alcohol.
Why are people prescribed safer supply?
People access prescribed safer supply drugs primarily to reduce their risk of death from the toxic unregulated drug supply. Unregulated and illicitly produced drugs, such as fentanyl, pose risks because individuals cannot measure their dosage, and another substance may be mixed into the drugs without their knowledge.
Early research has shown that people receiving prescribed safer supply drugs have fewer overdoses and decreased health-care costs (Kolla & Fajber, 2023; Ledlie et al., 2024). People taking these medications have reported that they have more control over their drug use, and health-care workers in these programs have noted improvements in clients’ health (Ledlie et al., 2024). These treatments have benefits both for clients and for the health-care system.
Prescribed safer supply differs across the country, and nurses should familiarize themselves with programs in their region. A continuing education resource is the National Safer Supply Community of Practice, which features webinars, program evaluations, evidence briefs, and resources for health-care professionals.
Why do emergency departments pose a problem for accessing safer supply?
Safer supply medications are dispensed daily at pharmacies or within health centres (Ledlie et al., 2024). This means that a visit to the emergency department, even if the person is not admitted, may result in their missing their pharmacy’s or health centre’s business hours and therefore they may miss picking up their medication. A patient should not need to choose between their prescribed safer supply medication and seeking medical care at the emergency department.
Nurses can advocate for patients to receive their prescribed safer supply from the emergency department, including opioid agonist treatment, if applicable. This approach will help reduce opioid withdrawal, which is potentially life threatening.
Opioid withdrawal is important to treat because doing so will help rule out other medical problems. For example, opioid withdrawal and a serious infection have similar signs and symptoms, including increased respiratory rate, sweating, and increased heart rate.
If withdrawal is the issue, these symptoms will go away when someone’s opioid withdrawal needs have been met. In contrast, the symptoms will not go away when a person has a serious infection. Further, nurses can build better relationships with clients and do better medical assessments when they are not in opioid withdrawal.
The types of medication options available for prescribed safer supply depend on the provincial drug coverage or the person’s private health insurance (McMurchy & Palmer, 2022). The dosage of each medication will depend on each program’s dose limit, the person’s opioid tolerance, the circulating unregulated opioid supply, and whether the person has missed dosing recently, resulting in dose tapering. Ideally, the emergency department could continue the client's safer supply prescription.
5 considerations for working with patients receiving prescribed safer supply
1) Conduct frequent pain assessments and adjust dose accordingly
Pain is a common reason people come to the emergency department, but it is very challenging to manage in this environment. If the patient’s pain is not treated effectively, they are more likely to self-discharge (leave against medical advice). Nurses need to assess pain and remember that prescribed safer supply is a baseline and will not treat pain.
A person’s prescribed safer supply baseline dose will not meet their pain needs, and they will require additional medication. People receiving prescribed safer supply will require higher doses of opioids, given at more frequent intervals.
Nurses need to advocate for patients to ensure that they receive appropriate prescriptions to treat pain. If a person receiving prescribed safer supply has a painful condition that would normally be treated with short-acting opioids, they should be considered for short-acting opioids as well.
A COWS assessment is essential for nurses to determine whether the person is in opioid withdrawal, alongside discussion with the patient. In the case of opioid withdrawal, opioids are the safest option to treat this condition.
Other medications to manage opioid withdrawal signs and symptoms, such as loperamide or acetaminophen, should not be used instead of short-acting opioids. Short-acting opioids, such as prescribed safer supply (other than fentanyl patches), provide the fastest relief and may need to be given every hour.
To assess whether a short-acting opioid dose is right for someone used to opioids, nurses need to consider which prescription opioids the person normally takes, how much of any non-prescription opioids (such as unregulated fentanyl) they use, how intense their withdrawal symptoms are (using the COWS measure), and how much those symptoms lessen after they take a dose of a short-acting opioid.
3) Advocate for short-acting opioids as necessary
When someone is in opioid withdrawal for a long period of time, this indicates that they are not maintaining their opioid tolerance while receiving care, thus increasing their risk of overdose after they leave the hospital. Nurses can advocate to have all short-acting opioid orders available as necessary for patient safety, including for opioid withdrawal, for pain, and to maintain opioid tolerance (Magboo, 2023).
Short-acting opioids should be scheduled and given regularly. These orders can be written to be held if the respiratory rate is below 10, allowing some flexibility in managing the patient’s symptoms.
4) Monitor patients for benzodiazepine withdrawal
Across Canada, the unregulated toxic drug supply is becoming more contaminated with other sedating agents, such as benzodiazepines. A person using drugs may be unaware they have been taking benzodiazepines because the drug is being mixed into their drugs without their knowledge.
If the person receiving prescribed safer supply also says they have used unregulated fentanyl for at least 2–4 weeks, nurses should include benzodiazepine withdrawal in their assessment. Benzodiazepine withdrawal can look like opioid withdrawal, whereas some signs and symptoms — such as pins and needles, confusion, hallucinations, paranoia, and seizures — happen only in benzodiazepine withdrawal (Wilson & Day, 2024).
5) Monitor patients for signs of sedation and potential need for naloxone
Sometimes people who are prescribed safer supply will arrive at the emergency department drowsy and difficult to wake up. It is also possible that people might use unregulated drugs, such as fentanyl, in the emergency department because they are in pain or in opioid withdrawal.
Someone who is drowsy and uses unregulated fentanyl should be assessed to see whether they are overdosing. There are many reasons a person might be having a hard time waking up, and the nurse should do a quick assessment to see whether giving naloxone is needed or whether someone’s sedation might be caused by something else.
If the person is breathing at a respiratory rate of 10 breaths or more per minute, with regular respirations, opioids are probably not the cause of their sedation. If the person is breathing below 10 breaths per minute, or their breathing effort is abnormal (e.g., snoring), opioids may be a cause, and the nurse should try to wake the person by calling their name or squeezing their arm.
Nurses should also check the person’s oxygen saturation. The best way to avoid the use of unregulated fentanyl is to treat the person’s pain and manage their withdrawal when they present in the emergency department.
People who are withdrawing from stimulants, such as cocaine, crystal methamphetamine, or crack cocaine, can also be drowsy. Because stimulant withdrawal does not lower someone’s respiratory rate, the nurse will still be able to give short-acting opioids.
Case study
Mary is a 30-year-old woman who arrives at the emergency department on the advice of her nurse practitioner. She has right lower-leg cellulitis that has not improved after four days of oral antibiotics. She reports general aches, chills, and increased pain in the right leg.
Mary’s home medication includes methadone 150 mg daily and hydromorphone 8 mg tablets, 20 per day. She has been using unregulated fentanyl to control her leg pain but does not usually use it. Her heart rate is 120 beats per minute, her respiratory rate is 20 breaths per minute, and her temperature is 38.9° Celsius.
The nurse completes a pain assessment and COWS with Mary. Her pain is 9/10 and her COWS is 13 (moderate withdrawal). Mary is ordered her usual 150-mg methadone dose. At home, she usually takes 2–3 hydromorphone tablets (16 mg–24 mg) at a time. In the emergency department, she is ordered short-acting hydromorphone 16–24 mg by mouth every 1–2 hours as needed for pain, withdrawal, and to maintain opioid tolerance, but to hold if respiration rate is below 10. The nurse gives Mary her methadone and her first dose of hydromorphone (24 mg) at the same time. The nurse also gives Mary 600 mg of ibuprofen for pain.
Two hours later, Mary is still reporting pain of 8/10, and a COWS of 13. Mary is awake and talking with her friend on the phone to check on her cat in her apartment. The nurse gives Mary another 24 mg of hydromorphone. The nurse returns 90 minutes later to find Mary sleeping. Her respiratory rate is regular at 12 breaths per minute, so the nurse leaves Mary and will check on her in another 30 minutes to offer her more hydromorphone.
Mary’s case highlights the need to understand a patient’s symptoms, medication regimen, and unregulated opioid use. Despite her prescribed methadone and initial hydromorphone dose, Mary's pain and withdrawal symptoms continue. Given her respiratory rate and ongoing symptoms, administering more hydromorphone is the safest option.
This case illustrates effective opioid withdrawal management, preventing patients from leaving against medical advice, and ensuring proper care for underlying conditions, such as serious infections.
Conclusion
In the emergency department, people taking prescribed safer supply need to continue to have access to their medications. Emergency department nurses can advocate for continued access for people’s lifesaving medication. Specific policies around these medications will be different across the country but the assessments and care principles centre on managing pain, opioid withdrawal, and sedation. Assessment and advocacy by emergency department nurses will lower health-care barriers for a person receiving prescribed safer supply.
References
Karamouzian, M., Rafat, B., Kolla, G., Urbanoski, K., Atkinson, K., … & Werb, D. (2023). Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis. International Journal of Drug Policy, 120, 104157. https://doi.org/10.1016/j.drugpo.2023.104157
Kolla, G., & Fajber, K. (2023). Safer Opioid Supply Program Evaluation: A comparison of SOS client outcomes from 2022 and 2023. London Intercommunity Health Centre.
Ledlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, T., … & Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence. International Journal of Drug Policy, 125, 104339. https://doi.org/10.1016/j.drugpo.2024.104339
Magboo, T. (2023). A harm reduction nursing perspective on the care of people who inject drugs with endocarditis [webinar]. Canadian IDU Endocarditis Working Group. https://www.youtube.com/watch?v=_v3lgVji7hM
McMurchy, D., & Palmer, R. (2022). Assessment of the Implementation of Safer Supply Pilot Projects (Ottawa, Ontario; p. 90). Dale McMurchy Consulting. https://www.nss-aps.ca/sites/default/files/resources/2022-03-safer_supply_preliminary_assessment_report_en_0.pdf
Wilson, P., & Day, T. (2024). Benzodiazepine withdrawal in the context of benzodiazepine-contaminated opioids: Practice implications. The Journal for Nurse Practitioners, 20(1), 104858. https://doi.org/10.1016/j.nurpra.2023.104858
Patty Wilson, is a family nurse practitioner in Calgary, Alberta, and former president of the Alberta Nurses Coalition for Harm Reduction.
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