After a naloxone revival, hospital protocol is to just let opioid addicts go

In a hospital emergency department, someone who has been revived from an opioid overdose using the reversal drug naloxone sometimes can be a relatively low-priority case.

The standard protocol is to stabilize and release: Help breathing and body functions regain rhythm, then provide referrals to addiction treatment and discharge.

“When somebody overdoses and goes into the emergency department, they are revived, they are medically stabilized, but then it usually stops there,” said Chelsea Laliberte, co-founder and executive director of Live4Lali, an anti-substance abuse organization in Arlington Heights. “There are no protocols for connecting the person to care.”

She's right, say doctors at Edward-Elmhurst Health in Naperville and the Cook County Health & Hospitals System in Chicago. There isn't yet a standard protocol for how to care for revived overdose patients, despite calls to begin treating them with medication-assisted therapy, which could help prevent future overdoses.

Medication-assisted treatment helps avoid withdrawal, which drives people to use again because it causes flu-like chills, sweats, pain and nausea when no opioid is present in the system.

“The risk we see is you'll go out and use again and kill yourself,” said Dr. Dipul Patadia, chairman of emergency medicine at Advocate Good Samaritan Hospital in Downers Grove. “It you don't get the help you need, you may potentially start to use again and come in as another opioid overdose — and this time not survive.”

Patadia said Good Samaritan is working on procedures to focus on providing referrals and have an addiction specialist consult with revived overdose patients in the emergency department. The goal is to get the patients connected to an outpatient clinic where they can begin medication-assisted treatment.

For now, Patadia said the hospital handles each revived overdose patient on a case-by-case basis. If space is available in the hospital's 10-bed detox unit, patients can be placed there. But the unit is typically full, and opioid withdrawal is not fatal. So, he said, patients often are discharged with a prescription for naloxone once they stabilize.

“If it's just an isolated opioid overdose, they can just be monitored and, if given referrals, can be sent out into the community to various places where they can seek help,” Patadia said.

But whether to seek help is up to the patient, and help can be hard to find. The strategy isn't exactly working.

“We see patients that have high recidivism,” Patadia said. “We definitely see a fair amount of patients that have gone through detox and have come again and used, despite our best efforts.”

Other hospitals are hesitant to introduce revived opioid users to medication-assisted treatment because the medications aren't easy to access.

The top three drugs used to treat opioid addiction are methadone, an opioid; buprenorphine, a partial opioid; and naltrexone, an opioid blocker. Methadone is dispensed only at select clinics, and doctors must have a special certification to give out buprenorphine, making these meds hard to get, said Dr. Aaron Weiner, director of addiction services for Linden Oaks Behavioral Health in Naperville.

“It's not necessarily helpful to them to get them on a drug that will not actually take them very far,” he said.

Buprenorphine, especially, could be a hard sell for emergency departments because of its misuse potential.

“It can be diverted on the street,” Weiner said.

The drug comes in filmy strips that dissolve under the tongue. But users can heat the strips into an injectable form to seek a high.

Along with doctors' hesitance to start medication-assisted treatment in the emergency department comes the problem of free will, says Dr. Steve Aks, an emergency physician for the Cook County Health & Hospitals System.

No matter the treatment offered, Aks said patients can refuse. And when a brain-altering disease such as addiction is involved, he said reason doesn't always reign and solutions are never simple.

“You have this idea that you just detox someone from heroin and then, bingo, you're done,” Aks said. “The reality is that it's a lifelong illness.”

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