Step 5: Counsel and Arrange Appropriate Follow-up

Screening, Brief Intervention and Referral to Treatment (SBIRT) is a valuable tool to start patients on the path to recovery. In one study, 37 to 45 percent of patients who underwent SBIRT in the emergency department engaged with treatment at 30 days.¹² Ask for permission to discuss substance use and overdose, discuss goals, and express your concerns with their current use. Screen for other substance use.

Screen for safety as well. The opioid overdose could represent a suicide attempt. Assess the patient’s goals and stage of change. Offer referral to resources in the community or hospital, based around goals (eg, housing, detox, addiction medicine clinic, family doctor services, safe injection facilities, etc.). Discuss and offer naloxone kits and clean injection supplies. Counsel patients around the high risk of accidental overdose given withdrawal and/or decrease in tolerance.

Finally, arrange rapid follow-up in an addiction medicine clinic or similar community clinic in one to two days if possible. Provide a prescription for daily observed dosing at a pharmacy at the appropriate dose up to 16 mg SL per day until follow-up.

All patients are more than their addiction. We have a significant opportunity to improve the lives of patients with opioid use disorders in the long run.

Special thanks to Dr. Aaron Orkin, Dr. Michelle Klaiman, and Dr. Kathryn Dong for their contributions to the EM Cases podcast that inspired this article and to Dr. Taryn Lloyd for the creation of the opioid withdrawal management algorithm diagram used in this article.

References

1. Overdose death rates. National Institute on Drug Abuse website. Accessed Dec. 19, 2018.
2. Annual surveillance report of drug-related risks and outcomes—United States, 2017. Centers for Disease Control and Prevention website. Accessed Dec. 19, 2018.
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8. Olson PC, Agarwal V, Lafferty JC, et al. Takotsubo cardiomyopathy precipitated by opiate withdrawal. Heart Lung. 2018;47(1):73-75.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: 2013.
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