Q&A: Naloxone is not enough

By Mike Taigman and Silvia Verdugo MD, MPH

The death toll from opioid overdose continues to rise at a frightening pace. EMS has been really good at resuscitating people who have overdosed on opioids by giving naloxone for decades. Recently we have begun to distribute naloxone widely to opioid users, their friends and families. It saves lives, but it’s not enough.

As the country struggles to find a solution, a promising new approach to helping people quit using opioids, buprenorphine (BUP) treatment, has been implemented in a few hospital emergency departments. It’s something we think EMS could help provide.

Have you ever had the flu or a really bad hangover? Many people describe withdrawal from opioid use disorder as 10 times worse than the worst flu you can imagine. One young man said, “The worst part right now is just being so uncomfortable in my own skin. I toss and I fidget, I can’t stand my legs touching each other. It makes me angry and panicky when they do. The pain is coming through my shoulders and left arm, but also my skin just crawls all over my body. My nose is stuffed up and I’m coughing all the time.”

Some people start their path to opioid use disorder focused on getting high, while others are just trying to manage pain. Contrary to popular culture stereotypes of junkies shooting up in dark alleys, many people with opioid use disorder live lives that appear normal to the untrained eye.

Unlike people who use marijuana or cocaine to get high, opioid users progress to using the drug to just feel OK or not bad. Once they have become dependent, quitting puts them into an exceedingly uncomfortable withdrawal. Most seek out their next dose to relieve their suffering rather than for recreation. During a series of one-on-one interviews with opioid users, the most common answer to the questions about why they use is, “To be able to function as a person day to day.”

To learn more about treatment with buprenorphine in the emergency department and the potential for its use in EMS, we reached out to Gene Hern, M.D., M.S., EMS medical director at Berkeley Fire, Oakland Fire and AMR in Contra Costa County, California. Hern is also an emergency physician at Alameda Health System’s Highland Hospital part of the ED Bridge Program through the Substance Abuse and Mental Health Services Administration State Targeted Response to the Opioid Crisis Grant to the California Department of Health Care Services.

EMS1: Tell us about what inspired you to do this work?

Hern: Once I learned that last year’s deaths from opiates were higher than the peak years of GSW deaths and the peak year of HIV deaths combined, I was shocked. We have trauma receiving centers in EMS, but no opiate receiving centers, even though the problem is much more widespread and deadly.

Popular culture thinks that using opioids is about getting high. That may have been a component for some folks at the beginning of their addiction, but after a few weeks, the high is gone and people need the drug just to function. No one feels great as an addict. Self-loathing is a component for most people.

If a person overdoses on an opioid and is resuscitated with Narcan, they are 10 times more likely to die in the next year without treatment. Several good quality clinical trials show that buprenorphine treatment paired with counseling saves lives.

What is buprenorphine?

It’s a unique schedule III opioid used for the treatment of acute and chronic pain, opioid withdrawal and maintenance treatment of opioid addiction. It was used in the '70s as a long-acting block to the euphoric effects of heroin. It comes in various formulations. The one we use is sublingual, which takes about 15 minutes to take effect and an hour to reach full impact.

What are the clinical indications for buprenorphine?

People with opioid use disorder who inject heroin and abuse opioid pain medication who suffer withdrawal are the prime candidates. People who have overdosed and people who have had more than three emergency department visits or 911 calls in the last year are good candidates.

It’s important that people are actively in withdrawal before administering buprenorphine. If they are high, the administration can precipitate withdrawal. Also, people being treated with methadone should not be started on buprenorphine in the field or ED. They should consult with their methadone clinic if they would like to transition.

When you give someone a dose of sublingual buprenorphine, what usually happens?

The uncomfortable symptoms of withdrawal subside dramatically and within about 30 minutes. We usually give them a second dose before they are discharged to last them for a couple of days until they can see the folks in the drug addiction clinic we’ve paired them with.

How successful is buprenorphine treatment at getting people off of opioids for good?

Very few people establish a drug free life after their first ED treatment with buprenorphine. It’s common to see patients stop and start, but the more buprenorphine treated weeks we can string together, the more their mortality goes down and the percentage of people that stay clean increases. Unfortunately, the neural architecture of the brain is changed by addiction to opioids and it can take years to recover fully.

If you were going to design an EMS trial where buprenorphine treatment was started in the field, how would you design it?

We are exploring the possibility of starting a pilot program in one of the counties I work with. The inclusion criteria would be a person who has active withdrawal symptoms. We rate the severity of withdrawal using the Clinical Opiate Withdrawal Score (COWS), which evaluates:

• Pulse rate
• Sweating
• Restlessness
• Pupil size
• Bone or join aches
• Runny nose or tearing
• GI upset
• Tremor observation of outstretched hands
• Yawning
• Anxiety or irritability
• Gooseflesh skin

A COWS of 5 or greater indicates mild to moderate withdrawal.

A more controversial area requiring a lot of discussion would be treating over reversal or precipitated withdrawal caused by Narcan.

Any treatment with buprenorphine would need to be followed with public health, community paramedicine, street medicine follow-up until the patient can be seen in an out-patient buprenorphine clinic.

We would want to track safety, follow up compliance and retention in the treatment program.

Clinical Opiate Withdrawal Scale by Ed Praetorian on Scribd

About the author

Silvia Verdugo, M.D., M.P.H., is a clinical solutions specialist with FirstWatch. For the last several years, she’s been researching strategies for optimizing the use of pre-hospital EMS data to identify opioid overdose. Previously, she was the chief of HIV and STD prevention for the State Health Department of Baja California, Mexico, helping to make lives better for people suffering from drug abuse and living with HIV. 

This article was originally posted March 20, 2019. It has been updated.