The Emergency Department as an Opportunity for Naloxone Distribution

A Systematic Review

Alexander H. Gunn, MBS, EMT-B; Zachary P.W. Smothers, MBS, EMT-B; Nicole Schramm-Sapyta, PhD; Caroline E. Freiermuth, MD; Mark MacEachern, MLIS; Andrew J. Muzyk, PharmD, MHPE

Disclosures

Western J Emerg Med. 2018;19(6):1036-1042. 

In This Article

Introduction

In April 2018, the United States (U.S.) Office of the Surgeon General released a public health advisory urging communities to improve access to naloxone for those who are at risk for opioid overdose.[1] This recommendation is shared in the 2017 President's Commission on Combating Drug Addiction and the Opioid Crisis, and the World Health Organization's guidelines that recommend increased access to naloxone.[2,3]

These recommendations are supported by previous research, which demonstrated that community-based, take-home naloxone distribution is associated with reduced opioid-overdose death rates and is cost effective.[4–6] A national survey of community-based naloxone distribution programs found that from 1996 to 2014 152,284 individuals received naloxone from a community-based program, which resulted in the successful reversal of 26,463 overdoses.[4] Despite the high number of reversals, take-home naloxone programs are only present in 8% of U.S. counties overall and 12% of counties with the highest opioid-overdose rate.[7] To improve access to take-home naloxone, community distribution programs have expanded to include substance use treatment facilities, primary care clinics, and pharmacies.[4] The emergency department (ED) presents another opportunity to further expand access to take-home naloxone.

Over the last decade, the number of opioid-related ED visits has dramatically increased. From 2005 to 2014, these visits nearly doubled from 89.1 to 177.7 per 100,000 people, and more recent Centers for Disease Control and Prevention (CDC) estimates indicate an even sharper increase has occurred since 2015.[8,9] This rise in ED visits positions the ED as a powerful venue for identification of patients with substance use disorder (SUD) needs that, if unmet will result in higher hospital and ED admissions and healthcare costs.[10] This large pool of patients also provides an opportunity for healthcare workers to engage patients with opioid use disorder (OUD) and provide evidence-based interventions such as take-home naloxone.

Naloxone, a U.S. Food and Drug Administration-approved opioid overdose antidote, is a proven viable, safe, and effective intervention that can reduce opioid-overdose deaths in the community setting and be effectively administered by lay people. It has decreased ED visits when co-prescribed with opioid medications.[1,5,11,12] Pulmonary edema has been reported following the administration of naloxone; however, the best evidence has indicated these cases are multi-factorial and that naloxone is recommended in the case of opioid overdose.[13,14]

Previous research has demonstrated that an OUD intervention in the ED can reduce overdose risk and that ED providers are willing to prescribe take-home naloxone; however, they have low confidence in doing so.[15,16] Further, the majority of patients at risk for opioid overdose in the ED are willing to accept a take-home naloxone kit and believe that the ED is an appropriate venue.[17] Healthcare workers in the ED who want to implement a take-home naloxone program must be able to refer to the literature to understand the available evidence. The purpose of this systematic review was to identify, evaluate, and summarize available evidence regarding the distribution of take-home naloxone in the ED and identify the areas that require future research.

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