Pandemic meets epidemic: COVID-19 impacts on opioid overdose patients
Evidence-based naloxone administration recommendations to minimize risk of COVID-19 exposure and alleviate provider fear
Prior to the COVID-19 pandemic, much of the country was already locked in a long-running struggle with an opioid epidemic. Like COVID-19, the burden for overdose care weighed heavily on EMS agencies and emergency departments across the country.
In 2018, we finally saw a slight decrease in opioid overdoses, however, provisional 2019 overdose data, released quietly as providers were fully engaged in fighting COVID-19, reveals a record-breaking 50,042 opioid overdose deaths, a whopping 7% increase from 2018.
Though any potential impact that the pandemic has had on the course of the opioid epidemic has yet to be exhaustively investigated, there’s some published data showing that it’s resulting in an even higher prevalence of opioid overdose. For example, Kentucky alone has a 17% increase in the number of EMS opioid overdose runs with transportation to an emergency department (ED), a 71% increase in runs with refused transportation, and a 50% increase in runs for suspected opioid overdoses with deaths at the scene. The American Medical Association (see below) has already expressed concern given reports of increasing opioid-related deaths from several states as well as reports in the popular press.
There are a number of factors driving the overdose increase, including: social isolation, interruptions in outpatient treatment of patients diagnosed with opioid use disorders, and the increasing presence of fentanyl in the nation’s illicit drug supply. Fentanyl and fentanyl analogues already taint much of the nation’s heroin supply and is increasingly being seen in other drugs, like cocaine, methamphetamine and illicit substances masquerading as pharmaceuticals, such as Xanax or OxyContin.
Don’t withhold naloxone
There are a handful of disturbing reports coming from both the U.S. and Canada of first responders withholding naloxone, citing the threat of contracting COVID-19. The Substance Abuse and Mental Health Services Administration likens the withholding of naloxone to withholding CPR, a situation where coronavirus transmission risk is low and mortality from such an event even lower.
Researchers from the University of Toronto as well as SAMHSA have developed evidence-based recommendations for naloxone administration that can help minimize risk and alleviate provider fear:
- If possible, switch from intranasal (IN) naloxone to less risky administration via IM or IV. In some areas, EMTs may not be able to make the switch from IN to IM/IV delivery due to scope of practice limitations, but risks can be minimized using appropriate PPE.
- Commercially available Narcan Nasal Spray may result in a decreased risk of aerosolized particles than intranasal delivery using a mucosal atomization device.
- Apply a surgical mask to patients after naloxone administration. This is particularly important if continuing administration of IN naloxone. In a simulated sneeze event, aerosol generation can extend up to 66 cm but can be eliminated by a surgical mask.
- Wear appropriate PPE at all times, including gloves, face protections, and if possible, a surgical gown.
Definitive care for opioid use disorder
An uptick in opioid overdoses could prove counterproductive to protecting EMS and ED resources – something that regional health systems are looking at closely in case of a surge in COVID-19 patients. This is especially true for two reasons. The first is that a person who has previously experienced a non-fatal opioid overdose is more likely to experience an overdose again. A recent study looking at EMS and ED opioid overdoses in Indiana found that nearly 11% of non-fatal overdose patients experienced a repeat non-fatal overdose; in other words, the mere occurrence of an overdose itself could almost guarantee additional overdose cases in the future. The second reason is that individuals using opioids are at an elevated risk for complications of COVID-19, including worsened hypoxemia, which could increase the likelihood of overdose development.
It’s important to remember that opioid use disorder (OUD), like diabetes and COPD, is a chronic illness. Although naloxone reverses the physiological effects of an opioid overdose, it does nothing to treat the disease of OUD. Evidence-based treatment for opioid use disorder is effective and typically includes both pharmacological (e.g., opioid maintenance medication) and behavioral therapy approaches (e.g., rehab).
Opioid maintenance therapy alone (i.e., buprenorphine or methadone) is associated with reduced risk of use of illicit opioids as well as reduced risk of overdose death. The sad fact, however, is that the vast majority of nonfatal opioid overdose patients do not receive treatment.
A study published this past May looking at six years of data from a commercially insured database of 15 million participants found that only 16.6% of patients who had an ED visit for opioid overdose had any claims for treatment at 3 months. If one takes into account non-fatal opioid overdoses who refuse EMS transport, that percentage is likely to lower considerably.
There’s been little effort to reverse this trend, and more than 5% of patients discharged from the ED alive after an opioid overdose die within 1 year. A referral to go get primary care isn’t doing enough for patients with OUD. Prior to the COVID-19 pandemic, a handful of EDs began initiating patients into opioid maintenance therapy using buprenorphine while at the same time navigating patients to continue treatment in a primary care setting.
Advancements in combatting the opioid epidemic
Initiating a patient on opioid maintenance therapy has become somewhat more feasible during COVID-19, and is likely to remain so in the foreseeable future. In March, the Drug Enforcement Administration expanded access to opioid-associated services through telehealth, including initial prescribing by a new clinician. The flexibility afforded by the DEA, as well as SAMHSA, prescribing buprenorphine is welcome news for health systems willing to work together by taking an integrated healthcare approach.
For EMS agencies with strong mobile integrated healthcare programs and partners, adding OUD to the list of chronic illnesses you help the health system in supporting is not only a possibility, it becomes an imperative.