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.
Explore This IssueACEP Now: Vol 38 – No 01 – January 2019
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.
- Overdose death rates. National Institute on Drug Abuse website. Accessed Dec. 19, 2018.
- Annual surveillance report of drug-related risks and outcomes—United States, 2017. Centers for Disease Control and Prevention website. Accessed Dec. 19, 2018.
- Vivolo-Kantor AM, Seth P, Gladden RM, et al. Vital signs: trends in emergency department visits for suspected opioid overdoses—United States, July 2016–September 2017. MMWR Morb Mortal Wkly Rep. 2018;67(9):279-285.
- D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.
- Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017;357:j1550.
- Molero Y, Zetterqvist J, Binswanger IA, et al. Medications for alcohol and opioid use disorders and risk of suicidal behavior, accidental overdoses, and crime. Am J Psychiatry. 2018;175(10): 970-978.
- Mattick RP, Breen C, Kimber J, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207.
- Olson PC, Agarwal V, Lafferty JC, et al. Takotsubo cardiomyopathy precipitated by opiate withdrawal. Heart Lung. 2018;47(1):73-75.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: 2013.
- Hesse M. The Readiness Ruler as a measure of readiness to change poly-drug use in drug abusers. Harm Reduct J. 2006;3:3.
- Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003; 35(2):253-259.
- Madras BK, Compton WM, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99(1-3):280-295.