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

Discussion

On the basis of the evidence available, the ED represents a potential opportunity to engage patients at risk for overdose and distribute take-home naloxone for overdose reversal in the community. The reviewed work demonstrates that patients at risk of opioid overdose presenting to the ED are willing to accept take-home naloxone, which is consistent with previous related research.[17,19,20,23] While the evidence regarding the effectiveness of the intervention is poor, one study reported that16% of patients who received naloxone kits went on to use it in the rescue of an opioid overdose.23 Even with this potential for harm reduction and the acceptance among patients and providers, the practice of prescribing take-home naloxone was overall low.[20–23]

In addition to identifying the ED as an opportune setting to distribute naloxone, the included studies provide insight on the potential barriers and enabling factors for implementation as shown in Table 2. These considerations are continuing to change as the environment around naloxone distribution is developing. Many states have expanded naloxone-access laws, allowing a provider to write a standing order for an entire group of people, such as medical students, for example, to distribute naloxone kits. Additionally, private insurance companies are publicly making intranasal naloxone available with very little or no co-pay. The majority of the included studies as well as previous research has shown that providers are accepting of take-home naloxone programs and willing to prescribe.[15,19,21–23] In one study, however, physician resistance to prescribing naloxone was identified as the key barrier.20 The reasons for the experienced resistance are unclear and emphasize the importance of developing training to engage providers before initiating the intervention and identifying a program champion.

The included studies have low rates of patient follow-up, which limits our understanding of the effectiveness of take-home naloxone from the ED. The absence of this evidence may deter other EDs from attempting to implement such a program. This course of action would not be consistent with the recommendations of the authors in each of the included articles and the previous research that has shown community-based naloxone distributions are cost effective and decrease mortality.[5,6,19–23] While more research is needed to determine the best methods and to measure effectiveness of ED programs, the low rate of follow-up is likely the result of this difficult-to-track population, which is largely homeless and unemployed.[19] The ED can reach patients at risk for overdose who do not present to other healthcare venues. Thus, the potential for harm reduction signals the power of further engagement of patients at risk for overdose in the ED.

This review is the first to analyze previous research related to take-home naloxone distribution from the ED. While there are few studies published, the results show that such programs are feasible and could be an effective venue for harm-reduction strategies in the face of the rising number of opioid-related ED visits. Clinicians and hospital leadership should consider strategies to promote the distribution of naloxone to at-risk patients from the ED. Future work that examines the relative effectiveness of distributing take-home naloxone, motivational counseling, and connecting patients with evidence-based treatment could be vital in creating effective methods. Additionally, more research is needed to improve the real-time identification of at-risk patients and to understand which formulation of naloxone is most effective for take-home use.

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