Important Health Advisory: Emergency Department Interventions to Prevent Opioid Overdose
People who have a nonfatal drug overdose are at very high risk for another one.1 Emergency Departments (ED's) have a unique opportunity to save lives by preventing future overdose among patients who have experienced opioid overdoses and among patients at risk of an initial overdose (e.g. frequent ED visits for substance use-related reasons or for pain medicine). Providing optimal care to patients who have overdosed and use of community programs contributes to effective use of the ED.
Recommendations from the NYS Department of Health (NYSDOH) and NYS Office of Alcoholism and Substance Abuse Services (OASAS)
- Recognize a previous overdose as a risk factor for and a predictor of a future opioid overdose(s).
- Counsel patients about the risks of overdose and how it may be prevented.
- Ask about current and past substance use, including use of heroin and prescription opioids.
- Recommend disposal of any remaining opioids if not obtained pursuant to a prescription.
- Recommend substance abuse treatment options (e.g. methadone and buprenorphine maintenance) and provide referrals and assistance to obtain treatment through clinics and physicians who prescribe buprenorphine.
- Provide harm reduction referrals for patients not willing or ready to abstain from substance use.
- Instruct individuals and their friends and family on how to recognize and respond to an overdose, including use of rescue breathing and possibly with naloxone.
- Provide take-home naloxone (see below for information on how to register to do so).
- Refer individuals, friends and family to Opioid Overdose Prevention Programs, if one is in your area.
- Educate patients about safe use, storage and disposal of prescription opioids.
- Review and update, as appropriate, existing opioid overdose-related ED policies and procedures.
Nationally, the rates of unintentional poisoning deaths increased 64% from 1999-2004 with nearly all attributed to drugs.2 The Centers for Disease Control and Prevention (CDC) found a 91.2% increase of poisonings from opioid analgesics from 1999 to 2002. During the same period, deaths related to heroin and cocaine increased 12.4% and 22.8% respectively.3 In NYS, in 2007 there were 8,756 opioid-related ED visits that did not result in hospital admission and 22,001 opioid-related hospital admissions. The OASAS identified a four-fold increase in admissions to crisis services for opioids other than heroin (e.g. pain medications) from 1997-2007 and a six-fold increase in non-crisis treatment admissions for opioids other than heroin.4
Referral Resources, Programs and Services
Opioid Overdose Prevention Programs
Opioid Overdose Prevention Programs registered with the NYSDOH train lay persons how to respond to and reverse potentially fatal opioid overdoses. Trained individuals may legally be provided with and administer naloxone.5 A list of programs is available.
If there are no Opioid Overdose Prevention Programs in your area and you see many high risk patients, consider becoming an Opioid Overdose Prevention Program. An Emergency Department or other provider that wishes to operate an Opioid Overdose Prevention Program needs to register with the NYSDOH. Registration information is available online.
Treatment for Opioid Dependence
OASAS certified providers form an extensive addiction treatment system including inpatient rehabilitation services and community-based chemical dependence treatment programs. Services for patients who have had an opioid overdose include counseling, methadone maintenance, buprenorphine treatment and naltrexone treatment. An on-line Treatment Provider Search and Directory is provided. The Addiction Medicine Web Site offers links to a wealth of information on topics including Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy, Methadone Dosing and an Opiates and Addiction Medicine Workbook.
Physicians outside of treatment settings may also prescribe buprenorphine, an alternative to methadone. A buprenorphine physician and provider locater is on-line.
For Treating Patients with HIV/AIDS
"Substance Use in Patients with HIV/AIDS: HIV Clinical Guidelines for the Primary Care Practitioner" (DOH publication #9600) contains guidance on overdose prevention. It may be ordered on the HIV Clinical Resource web site.
Harm Reduction/Syringe Exchange Programs
Harm Reduction/Syringe Exchange Programs offer a variety of services within a comprehensive model. In addition to provision of sterile injection equipment, services include outreach, risk reduction education, provision of harm reduction supplies, supportive services, HIV counseling and testing, partner notification assistance, case management, health care, legal, and housing services. PRograms provide referrals for services that they are unable to provide directly, including to detoxification and substance abuse treatment. A listing is available on-line and the AIDS Institute's Harm Reduction Unit can be reached at (212) 417-4661.
Syringe Access and Safe Disposal
Through the Expanded Syringe Access Program (ESAP), up to 10 syringes may be sold or furnished to persons 18 years of age or older without a prescription by pharmacists, health care facilities, and health care practitioners registered with the NYSDOH. The NYSDOH web site provides a directory of ESAP providers and a listing of community-based disposal sites.
Opioid Overdose Prevention Programs
- NYSDOH AIDS Institute at (212) 417-4770 or via e-mail: email@example.com
- OASAS Addiction Medicine Unit at (518) 457-1349 or via e-mail: AddictionMedicine@oasas.state.ny.us
Controlled Substances or Prescribing controlled substances
- NYSDOH Bureau of Narcotic Enforcement at 1-866-811-7957 (select option 2) or via e-mail: firstname.lastname@example.org
- Coffin PO, Tracy M, Bucciarelli A, Ompad D, Vlahov D, Galea S. Identifying injection drug users at risk of nonfatal overdose. Acad Emerg Med. 2007; 14: 616-623.
- CDC. Unintentional Poisoning Deaths - United States, 1999-2004. MMWR. 2007. 56(05): 3-96.
- Paulozzi LJ, Budnitz DS, Yongli Xi. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006; 15: 618-627.
- NYS OASAS. Unpublished draft: Trends in Primary Problem Substances for Admissions to Chemical Dependence Crisis and Non-crisis Services, 1997 to 2007. April 8, 2009.
- Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: Options for critical response to the epidemic of opioid overdose mortality. AJPH. 2009; 99(3): 402-407.