Naloxone distribution and administration in hospital emergency departments

• Author / Creator

  O'Brien, Daniel

• The opioid crisis continues to worsen throughout North America. Alberta has been particularly impacted, with approximately two Albertans dying of an opioid overdose every day. Opioid overdose deaths can be prevented with the timely administration of naloxone, an opioid antagonist that reverses the potentially life-threatening respiratory depression that occurs during an opioid overdose. Naloxone is used by Emergency Medical Services (EMS) and hospital emergency department (ED) providers to manage opioid overdoses. Additionally, take-home naloxone programs are public health interventions that prevent opioid-related mortality by distributing naloxone to non-medical personnel who may witness an opioid overdose, such as people who use opioids or their peers. In recent years, take home naloxone programs have been increasingly incorporated into hospital emergency departments in an effort to reach individuals who are at high risk of opioid overdose. It is particularly critical to provide naloxone kits to patients who present to the ED with an opioid overdose, since they are at high risk for future overdose death.
  This thesis contains two distinct studies. Both studies use data collected through a retrospective chart review of medical records from emergency department (ED) visits for opioid overdose at Edmonton’s Royal Alexandra Hospital between May 2016 and April 2017.
  
  Study 1: Factors associated with being offered take home naloxone in a busy, urban emergency department
  Objectives: I sought to evaluate the implementation of the ED-based take home naloxone program at the Royal Alexandra Hospital by i) determining the proportion of individuals who visit the ED for an overdose who are offered a naloxone kit, and ii) identifying whether certain patients were more likely to be offered naloxone kits than others.
  Methods: I used multivariate analyses to identify patient characteristics associated with being offered a take home naloxone kit after visiting the ED for an opioid overdose.
  Results: I found that 50% of patients who visited the ED for an opioid overdose were offered a naloxone kit before leaving the ED. Patients were more likely to be offered a kit if they overdosed on an illegal opioid, or if they had a severe overdose as measured by their level of consciousness upon EMS arrival. In contrast, patients were less likely to be offered take home naloxone if they had an active prescription for an opioid at the time of their ED visit, if they were admitted to the hospital, or if they left the ED unexpectedly.
  Conclusions: Only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for opioid mortality. I recommend that hospital EDs provide guidance to staff to ensure that all eligible patients at risk of overdose receive THN.

  Study 2: A comparison of naloxone administration between patients admitted to an Emergency Department for illegal and pharmaceutical opioid overdose

  Objectives: Previous studies have suggested that EMS may under-administer naloxone to patients who overdose on pharmaceutical opioids compared to heroin. I sought to assess how different factors may influence EMS providers’ decision to administer naloxone, and whether patients who do not receive naloxone from first responders (including EMS, fire rescue services, or bystanders with naloxone kits) are more likely to subsequently require naloxone in the ED.
  Methods: I used multivariate analyses to test whether patients who overdose on illegal opioids are more likely to received naloxone from i) EMS and ii) ED staff, controlling for potentially confounding variables such as route of administration, level of consciousness, and other patients characteristics.
  Results: Compared to patients who overdosed on a pharmaceutical opioid, patients who overdosed on an illegal opioid (heroin or illegally manufacture fentanyl) were more likely to receive pre-hospital naloxone from EMS, bystanders with naloxone kits, and fire rescue services, but less likely to receive naloxone in the ED. Whether patients received naloxone from these first responders was not associated ED naloxone administration.
  Conclusions: Although EMS were less likely to administer naloxone to patients who overdosed on pharmaceutical opioids, this did not appear to impact whether naloxone is needed in the ED. Further research is needed to determine why EMS appear to manage illegal and pharmaceutical opioid overdoses differently.

• Subjects / Keywords

  • Emergency Department
  • Opioid overdose
  • Substance use
  • Naloxone

• Graduation date

  Fall 2019

• Type of Item

  Thesis

• Degree

  Master of Science

• DOI

  https://doi.org/10.7939/r3-gbtt-jw32

• License

  Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. Where the thesis is converted to, or otherwise made available in digital form, the University of Alberta will advise potential users of the thesis of these terms. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.