A Rose by Any Other Name: Tertiary Prevention for Opioid Use Disorder
PAIN AND ADDICTION COMMITTEE
Jessica Moore, MD FAAEM
W
hat’s in a name? Specifically, what is meant by the name “harm reduction”?
Harm reduction refers to tertiary prevention: preventing complications of a disease once it is already present. We commonly embrace this practice in medicine, whether it be prescribing aspirin for patients who have had a stroke or scheduling regular ophthalmologic and podiatric exams for those with diabetes. However, for reasons rooted in stigma and misunderstanding, tertiary prevention for opioid use disorder (OUD) is often viewed in a different light. What do we know about harm reduction for OUD? Simply put, it works. Evidence shows that many harm reduction measures are not only associated with reduced morbidity and mortality among patients who use opioids, but they also are associated with positive outcomes for communities as a whole. Various harm reduction measures have been associated with decreased rates of violent criminal activity, decreased publicly discarded injection materials, and even decreased needlestick injuries among first responders.1-4
an overdose, those who use opioids are likely to be in contact with others who use opioids, meaning they may be the ones most likely to successfully reverse an opioid overdose and save a life. Naloxone distribution and overdose training is not associated with compensatory substance use in studies.10,11 Initiation of evidence-based treatments: Buprenorphine
is an FDA-approved medication for OUD (MOUD) that has clearly proven mortality benefit, as well as well-defined benefits in many patient-centered and public-health related outcomes. Prescribing it no longer requires a DATA-waiver (“X-waiver”), so any practitioner with DEA Schedule III privileges can prescribe it. Think about buprenorphine prescribing especially for patients presenting for nonfatal overdose; just as you would for any other chief complaint, treat the underlying cause. Did you know that according to one study, the three-day mortality for patients presenting to the ED after naloxone administration by EMS is higher than the mortality for those presenting for STEMI treated with PCI for a whole year?12 We would not discharge many patients with such a mortality rate, so it is worth taking a few extra minutes to provide good counseling and initiate evidence-based treatments whenever indicated. ED initiation of buprenorphine is associated with superior outcomes compared to delaying to outpatient initiation.13-16 While some cite buprenorphine diversion as a concern, nonprescribed buprenorphine use has actually been associated with decreased rates of opioid overdose17. In other words, diversion of buprenorphine does not seem to come with the same harms historically associated with diversion of full opioid agonists. Buprenorphine use is associated with positive health outcomes even for those who are continuing to use substances3.
What do we know about harm reduction for opioid use disorder? Simply put, it works.
How do we encourage and implement harm reduction from the emergency department (ED)? There are several simple, tangible ways we can promote decreased morbidity and mortality for our ED patients with OUD:
Non-stigmatizing language: Utilize non-stigmatizing language
in documentation, in communication with patients, and in communication with other healthcare professionals. The National Institute on Drug Abuse (NIDA) has a helpful, easy-to-use webpage describing preferred language when discussing substance use disorders.5 Language is one of the simplest ways we can help to reduce the stigmas that come with substance use disorders, and thus help promote more equitable medical care.6 Naloxone prescribing and dispensing: Naloxone distribu-
tion is associated with decreased fatal opioid overdoses as well as reductions in opioid-related ED visits.7,8 It has also shown to be cost effective.9 Have a low threshold to prescribe it. It is even better if you can provide it directly to the patient in the ED (“naloxone dispensing”), as prescription fill rates have been historically very low for a variety of reasons, including cost and stigma. Counsel patients and families on how to use it. While patients cannot administer naloxone to themselves while experiencing
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Controlling pain and withdrawal: Uncontrolled pain and
withdrawal are some of the most commonly cited reasons why patients cannot tolerate hospitalization for necessary medical care.18 Even if a patient is not currently taking MOUD, allowing them to continue treatment for their potentially life-threatening medical condition (for example, IV antibiotics for endocarditis) is critical. Remember that patients who use opioids typically have significant opioid tolerance and dependence and will need higher doses of opioids than an opioid-naive patient to achieve control of symptoms. >>