Opioid use disorder is a terrible disease that takes over people’s lives and leaves them overwhelmed, consumed by compulsions and cravings, and often alone. Over the past 10 years, opioid overdoses and deaths have continued to climb in Ontario, now surpassing the annual death toll from road traffic accidents. It’s only natural for healthcare providers to feel frustrated and helpless as we try to help those whose disease has rendered them defenceless, and seemingly incapable of helping themselves. Our role as health care providers repeatedly immerses us in the painful circumstances of the most unstable of patients. We don’t often see those in recovery, who’ve found stability, and had an organized life returned to them. It is important to know that safer practices and effective treatments are available, and recovery is possible. For more than a decade, paramedics have been on the front lines of an ongoing battle with accidental opioid overdose and death. This article will outline strategies that paramedics can employ to assist some of the sickest patients in our 911 system with their disease and recovery.
Approach to Acute Opioid Toxicity
Opioids act on opioid receptors in the body to relieve pain and dyspnea and suppress coughing. These therapeutic effects can be highly desirable in appropriate patients. In toxicity, opioids can cause drowsiness, respiratory depression, unconsciousness and apnea. Hypoxemia and bradycardiac cardiac arrest ensue if oxygen is not effectively delivered. The mainstay of treatment is opening the airway, stimulating the patient to take breaths, and breathing for them with a BVM if they are not ventilating adequately despite the previous two interventions. If the patient can be adequately ventilated and oxygenated, the immediate crisis has been addressed.
Naloxone is an opioid antagonist that has a high affinity for opioid receptors. It outcompetes opioids at the receptor and reverse the effects of the opioid.
In patients who regularly use opioids, opioid antagonism can precipitate opioid withdrawal, which is an incredibly uncomfortable experience. Patients in withdrawal experience anxiety, restlessness, diffuse pain, gastrointestinal distress, and opioid cravings. Naloxone-precipitated opioid withdrawal is not only uncomfortable, but it reduces the likelihood that patients will come to hospital or engage in a discussion with healthcare providers about their condition, accept advices, and hear about treatment options, as this uncomfortable experience overwhelms the ability to consider or accept advice.
Patients with opioid toxicity don’t die from lack of naloxone, they die from lack of oxygen. Therefore, if naloxone is required, it is recommended to use the lowest dose required, titrated to breathing and oxygenation. The goal is not full reversal and alertness. An effective approach is to start an IV and provide naloxone 0.04mg q 5 minutes titrated to the desired effect. The benefit of this approach is that the patient survives their overdose, remains comfortable, is transported to hospital, wakes up comfortably, and is more likely to engage in a discussion with healthcare providers about their goals of care, including options for treatment and recovery.
“Patients with opioid toxicity don’t die from lack of naloxone, they die from lack of oxygen.”
It’s important to note that the current street supply of opioids largely consists of fentanyl and mixtures of other contaminants that can have pharmacological effects. Benzodiazepine, the tranquilizer Xylazine (check-out an awesome post the Xylazine crisis HERE), and other sedtives like medetomidine, have been found in street drugs and can complicate the resuscitation process.
Most notably, these drugs cause sedation but do not respond to naloxone.
This emphasizes the importance of supportive care as the mainstay of treatment for most cases of drug toxicity. As paramedics, you are experts in airway management. Creating the conditions for a patent airway, providing adequate oxygenation, and supporting hemodynamics are most important than identifying exactly what specific drugs are a factor. The reality is that in most cases the paramedic (and emergency department team) will not know what drugs were consumed, and it does not change management.
“A patent airway, adequate oxygenation, and supporting hemodynamics are more important than identifying exactly what specific drugs are a factor”
The Important of a Thorough Medical Assessment
Patients with opioid use disorder are at risk of serious traumatic and medical complications. Patients found with altered level of consciousness, especially in uncontrolled environments or without a detailed history for what happened, must be examined for signs of injury, stroke, CNS infection, seizure, hypoglycemia, hypoxemia, and shock, to name a few.
Those who use intravenous drugs experience some of the rarest and most unusual medical complications that would be entirely unexpected in others their age. When this is combined with the fact that these patients are often alone, marginalized, and not trusting of a system that stigmatizes many of them, every interaction with a healthcare provider is an opportunity to assess for and detect a serious condition that will benefit from time-sensitive treatment. For example, patients who inject drugs intravenously are at risk for dangerous infectious complications like infectious endocarditis of the heart (chest pain, loud murmur and CHF), spinal epidural abscesses (back pain and leg weakness), and septic joints (joint pain and swelling), all of which can cause fever with no clear focus otherwise.
Paramedics must keep an open mind to the potential for such complications, even if the patient presents with a classic opioid toxidrome and responds to naloxone. Be deliberate with your questioning, examine patients with intent to discover complications discussed above, do not dismiss abnormal vital signs (especially a fever), and a counsel patients accordingly. Online medical consultation (OMC) is always an option if you have questions about a patient’s condition and how to counsel them about your concerns.
Paramedics as Valuable and Trusted Healthcare Professionals in this Crisis
Opioid use disorder impacts people from a large cross-sectional swath of society. However, many people with this condition are marginalized, feel stigmatized, and rarely see healthcare providers.
Many patients are not transported to hospital after an opioid overdose. This leaves a significant number of people with this deadly condition under-exposed to the advice, harm reduction strategies, and treatment options of a qualified healthcare provider.
The acute opioid overdose that triggers a 911 call can afford a rare moment of exposure to a healthcare provider (you!) who can provide a thorough medical assessment, advice, referral, and discuss treatment options. This should be seen not only as an opportunity to manage an opioid overdose and save a life in that moment, but also as an opportunity to identify underlying medical complications and introduce the patient to the harm reduction and treatment options available for their condition.
Given the potency and unpredictability of the current street supply, this opportunity may be the last one this person gets.
How Do We Optimize Our Approach for Those with Opiate Use Disorder?
Harm Reduction
Shortly, we will discuss effective treatment strategies for opioid use disorder. But, to benefit from these options, patients must survive to make the connection.
The addicted brain can cause cravings and compulsions to seek and use drugs that no person can resist. With the unpredictability of the potency and content of the current street supply, each use brings the potential for accidental death. Understanding that opioid use will continue despite its harms, and taking steps to mitigate the risk with each use, is the mainstay of harm reduction strategies.
Paramedics should be knowledgeable about harm reduction strategies, and feel comfortable counseling patients with opioid use disorder on the importance of never using alone (or simultaneously with companions), keeping naloxone close and ensuring they know when and how to use it, taking test doses first, safer use/safer supply options, and calling 911 in the event of overdose. These discussions should be had not only with the patient, but their companions, friends, families and anyone who will listen, as many times as they will listen.
Do not underestimate the trust and authority paramedics bring to the scene of a medical condition, particularly at the time of emergency and distress. Even when it seems that you are not being heard, windows of opportunity do open and it is not always apparent when it happens. At the very least, people will hear that you value whether they live or die, and that may not be something they have heard from anyone in a long while.
For those paramedic services who offer it, distribution of naloxone kits should be undertaken in accordance with local practice in addition to the risk reduction strategies above.
Opioids Are the Most Effective Treatment for Opioid Use Disorder
Cravings and compulsions associated with opioid withdrawal cause opioid seeking behaviour that consumes the life of individuals with opioid use disorder. Acquiring the drug becomes a priority, often to the exclusion of personal health, vocation, relationships and responsibilities. The most effective treatment for the dangerous spiral induced by opioid withdrawal/craving is the prescription of opioid agonists. Long-acting opioids like methadone, buprenorphine, and slow-release oral morphine work by preventing opioid withdrawal, break the cycle of highs and lows, are safe if used as prescribed, and are often covered by drug plans.
Many people who use drugs also consider prescription opioids as a safer alternative to unregulated street drugs. Prescribed opioids have been shown to reduce street drug use, increase engagement in treatment, and reduce mortality. The sense of normalcy that opioid agonist therapy brings these patients affords the opportunity for stability. Many patients on opioid agonist therapy abstain from street drug use, re-establish relationships with friends and family, acquire stable housing, engage in meaningful work, and contribute positively to their communities once again.
“Do not underestimate the trust and authority paramedics bring to the scene of a medical condition, particularly at the time of emergency and distress”
The effectiveness of these therapies has caused opioid use disorder clinics to be made available in many communities in Ontario. Many emergency departments and family physicians are comfortable providing buprenorphine.
It is important for paramedics to understand what options are available in their community, and how to connect patients with providers. Find out what pathways exist in your community, and how to make the connections. If your service does not have these connections yet, inquire how to develop one.
Every paramedic encounter with a patient with opioid use disorder should cause inquiry into treatments that have been tried, what they are prescribed currently, and exploring the patient’s knowledge of treatment options. Every patient should be informed that prescribed opioids like buprenorphine, methadone, and/or morphine can and will be offered, and how they can connect with their local opioid use disorder clinic. Ideally this information is provided to patients verbally and in writing. This should hold true no matter what the outcome of the encounter – whether the patient is transported to hospital, discharged from paramedic care under a new patient care model, or refuses transportation. Every paramedic should be comfortable having this conversation with patients.
You will all be familiar with patients who do not seem interested in the prescribed opioids or treatment options. If they are willing to listen, discuss it with them anyways. Discuss it with them, their companions, friends, loved ones, and anyone who will listen. The more they hear about the options, the more likely they are to take advantage of one if a narrow window of opportunity arises. Prescribed opioids are effective, available and accessible.
Paramedic Administration of Buprenorphine
Bystander and first responder naloxone programs have been successfully implemented as a key tenet of harm reduction from acute opioid toxicity.
One of the consequences of liberal use of naloxone in the community is that paramedics frequently encounter patients with naloxone- precipitated opioid withdrawal. This is a very uncomfortable condition. Many of these patients are in no condition to discuss harm reduction and treatment options, and many will refuse transportation to the hospital. Many disappear before the ambulance arrives. They rightfully know that the treatment for their condition is opioids, and many will resort to the street supply immediately after naloxone reversal to treat their symptoms. This puts them at risk of repeat overdose, often within minutes or hours of a 911 call.
For properly selected patients with naloxone- precipitated opioid withdrawal, treatment with buprenorphine/naloxone (Suboxone – click here for a guide on use) relieves the withdrawal symptoms. Patients feel better, are more comfortable, are more likely to develop a sense of trust in the healthcare provider who has treated them, and are more amenable to discussions about their condition, and the treatment options available (they have just experienced one successfully). It is conceivable that they are more likely to accept transportation to hospital or an addictions clinic once their symptoms are effectively treated, they are more likely to engage in outpatient follow-up, they are likely protected from acute opioid toxicity in the short term, given the pharmacology of buprenorphine (high binding affinity to opioid receptors, only partial agonism), and at the very least their symptoms are effectively treated which is more humane.
Plans are currently underway in the RPPEO region to implement paramedic administration of buprenorphine for patients with naloxone- precipitated opioid withdrawal. This implementation will be part of a broader comprehensive strategy, as discussed in this article, to encourage and empower paramedics to exercise a range of strategies to assist in the treatment of patients with this devastating but treatable condition.
Treatment of Acute Pain in Patients with Opioid Use Disorder
Paramedics will encounter and treat patients with opioid use disorder who are experiencing acute painful conditions. There can understandably be reluctance and uncertainty from patients and health care providers about how to do this safely.
It is well known that acute pain in patients with opioid use disorder is commonly undertreated. This is a gap that is important to address. It is recommended that for patients with acute pain, their regular opioid agonists be continued at the usual daily dose, to avoid opioid withdrawal. Multimodal analgesia is encouraged, with co- administration of acetaminophen and NSAIDs if there are no contraindications. Additionally, short-acting opioids like morphine or fentanyl should be administered if indicated, just as they would be for patients without opioid use disorder. There is no evidence that exposure to short-acting opioids for the treatment of acute pain increases relapse rates, and there is some evidence that withholding adequate analgesia out of concern for relapse might in fact increase the risk. Patients may be hesitant to accept short-acting opioids given their past history, and this is their choice, but they can be counselled that the risk is low and should be offered effective treatment for their pain.
Conclusion
Opioid use disorder is a devastating but treatable disease that paramedics see the consequences of every day. The deadliness of the current street supply and the often- marginalized population it affects means paramedics are sometimes the only healthcare providers these patients will ever see. This opportunity can be leveraged to assist in mitigating the effects of the disease and improve patient outcomes. Many of us are close with someone struggling with addiction, and it is the compassionate, persistent, unrelenting care of trusted strangers such as yourselves that can make a difference in a life that feels lost and forgotten.
