(15) Improving Intranasal Naloxone Distribution for Harm Reduction in Emergency Departments

Background:
The COVID19 pandemic has exacerbated the opioid epidemic in Ohio, with increased numbers of opioid overdoses recently recorded. Emergency departments (EDs) commonly serve as a first point of medical contact for those with opioid overdose and those at risk for overdose. Access to addiction treatment and harm reduction resources within EDs is critical in preventing opioid overdoses and related deaths. Nationwide efforts to increase medication for opioid use disorder (MOUD) access have been underway largely through the use of buprenorphine-based medications; other strategies such as distribution of intranasal naloxone kits (i.e. Narcan) in the ED have not received as much attention.
Since 2015, The Ohio State University Wexner Medical Center (OSU) at both its community and main campus hospitals has sought to increase the distribution of intranasal naloxone kits to those at risk of opioid overdose. Due to low distribution rates at these sites, in 2019 these kits were provided free-of-charge through the Ohio Department of Health “Project DAWN” (Deaths Avoided with Naloxone) initiative. Despite education efforts and staff training, these resources remain severely underutilized, with the community hospital outperforming the main hospital.

Methods:
In a medical student driven project, the frequency of intranasal naloxone distribution to qualifying patients was tracked over a six-month period from January to June 2021. Inclusion criteria for eligible patients included those presenting with a chief complaint of opioid overdose, withdrawal, or those with history of OUD. In an effort to determine why distribution remains underutilized, a qualitative internet-based survey was deployed to nursing staff and prescribers (advanced practice practitioners, resident and attending physicians). To determine the perception of intranasal naloxone use for harm reduction and barriers to distribution, the survey queried the importance, perceived need, indications, and ability to distribute intranasal naloxone in a combination of “yes”/”no” and free-text responses.

Results:
Over the six-month study period, < 10% of more than 500 eligible patients received intranasal naloxone kits at both campuses. In total, 72 providers were interviewed, 27 of whom were prescribers and 45 were nurses. All participants completed the survey in its entirety. Survey results indicated that despite an adequate knowledge base, significant logistical barriers to distribution remained. This included not knowing the process required to order and dispense kits, a lack of clearly defined roles in the distribution process, and logistical issues in the physical location of kits throughout the ED.

Conclusions:
Despite willing and knowledgeable providers, logistical issues slowed intranasal naloxone distribution in a patient population more likely to leave against medical advice and less likely to interact with medical providers. This implies that even for those for whom a kit is ordered they may not have it in hand when leaving the ED, missing a rare opportunity to provide harm reduction devices to those most in need. Efforts are underway to improve distribution of the intranasal naloxone kits, including additional orientation for off-service interns, the development of a best practice advisory, and the utilization of standing orders.

References: 1. Soares WE 3rd, Melnick ER, Nath B, et al. Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems. Annals of emergency medicine. Published online March 2021. doi:10.1016/j.annemergmed.2021.03.013
2. D’Onofrio G, O’Connor PG, Pantalon M v., et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA - Journal of the American Medical Association. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
3. Schoenfeld EM, Westafer LM, Soares WE 3rd. Missed Opportunities to Save Lives-Treatments for Opioid Use Disorder After Overdose. JAMA network open. 2020;3(5):e206369. doi:10.1001/jamanetworkopen.2020.6369
4. Snyder H, Kalmin MM, Moulin A, et al. Rapid Adoption of Low-Threshold Buprenorphine Treatment at California Emergency Departments Participating in the CA Bridge Program. Annals of emergency medicine. Published online August 2021. doi:10.1016/j.annemergmed.2021.05.024
5. Ti L, Ti L. Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systematic Review. American journal of public health. 2015;105(12):e53-9. doi:10.2105/AJPH.2015.302885

Diversity, Equity, and Inclusion: Those with opioid use disorder (OUD) and other substance use disorders are less likely to interact regularly with the medical system. This makes engagement within the emergency department an important point of contact to initiate preventative and harm reduction measures, including the distribution of intranasal naloxone to prevent overdose deaths. The emergency departments examined in this study provide intranasal naloxone to any qualifying patient free of charge. They also provide additional treatment resources and screenings to any patient wanting help. Current study findings reveal potential barriers in the distribution of harm reduction resources for OUD and may assist other emergency departments looking to do the same.