A 33-year-old male with a history of opioid overdose and opioid use disorder is admitted with IV heroin use complicated by injection site cellulitis. He is started on antibiotics with improvement in his cellulitis; however, his hospitalization is complicated by acute opioid withdrawal. Despite his history of opioid overdose and opioid use disorder, he has never seen a substance use disorder specialist nor received any education or treatment for his addiction. He reports that he will stop using illicit drugs but declines any further addiction treatment.
What strategies can be employed to reduce his risk of future harm from opioid misuse?
Over the past decade, the U.S. has experienced a rapid increase in the rates of opioid prescriptions and opioid misuse.1 Consequently, the number of ED visits and hospitalizations for opioid-related complications has also increased.2 Many complications result from the practice of injection drug use (IDU), which predisposes individuals to serious blood-borne viral infections such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) as well as bacterial infections such as infective endocarditis. In addition, individuals who misuse opioids are at risk of death related to opioid overdose. In 2013, there were more than 24,000 deaths in the U.S. due to opioid overdose (see Figure 1).3
In response to the opioid epidemic, there have been a number of local, state, and federal public health initiatives to monitor and secure the opioid drug supply, improve treatment resources, and promulgate harm-reduction interventions. At a more individual level, hospitalists have an important role to play in combating the opioid epidemic. As frontline providers, hospitalists have access to hospitalized individuals with opioid misuse who may not otherwise be exposed to the healthcare system. Therefore, inpatient hospitalizations serve as a unique and important opportunity to engage individuals in the management of their addiction.
There are a number of interventions that hospitalists and substance use disorder specialists can pursue. Psychiatric evaluation and initiation of medication-assisted treatment often aim to aid patients in abstaining from further opioid misuse. However, many individuals with opioid use disorder are not ready for treatment or experience relapses of opioid misuse despite treatment. Given this, a secondary goal is to reduce any harm that may result from opioid misuse. This is done through the implementation of harm-reduction strategies. These strategies include teaching safe injection practices, facilitating the use of syringe exchange programs, and providing opioid overdose education and naloxone distribution.
Overview of Data
Safe Injection Education. People who inject drugs are at risk for viral, bacterial, and fungal infections. These infections are often the result of nonsterile injection and may be minimized by the utilization of safe injection practices. In order to educate people who inject drugs on safe injection practices, the hospitalist must first understand the process involved in injecting drugs. In Table 1, the process of injecting heroin is outlined (of note, other illicit drugs can be injected, and processes may vary).4
As evidenced by Table 1, the process of sterile injection can be complicated, especially for an individual who may be withdrawing from opioids. Table 1 is also optimistic in that it recommends new and sterile products be used with every injection. If new and sterile equipment is not available, another option is to clean the equipment after every use, which can be done by using bleach and water. This may mitigate the risk of viral, bacterial, and fungal infections. However, the risk is still present, so users should not share or use another individual’s equipment even if it has been cleaned. Due to the risk of viral, bacterial, and fungal infections, all hospitalized individuals who inject drugs should receive education on safe injection practices.
Syringe Exchange Programs. IDU accounts for up to 15% of all new HIV infections and is the primary risk factor for the transmission of HCV.5 These infections occur when people inject using equipment contaminated with blood that contains HIV and/or HCV. Given this, if people who inject drugs could access and consistently use sterile syringes and other injection paraphernalia, the risk of transmitting blood-borne infections would be dramatically reduced. This is the concept behind syringe exchange programs (also known as needle exchange programs), which serve to increase access to sterile syringes while removing contaminated or used syringes from the community.
There is compelling evidence that syringe exchange programs decrease the rate of HIV transmission and likely reduce the rate of HCV transmission as well.6 In addition, syringe exchange programs often provide other beneficial services, such as counseling, testing, and prevention efforts for HIV, HCV, and sexually transmitted infections; distribution of condoms; and referrals to treatment services for substance use disorder.5
Unfortunately, in the U.S., restrictive state laws and lack of funding limit the number of established syringe exchange programs. According to the North American Syringe Exchange Network, there are only 226 programs in 33 states and the District of Columbia. Hospitalists and social workers should be aware of available local resources, including syringe exchange programs, and distribute this information to hospitalized individuals who inject drugs.
Opioid Overdose Education and Naloxone Distribution. Syringe exchange programs and safe injection education aim to reduce harm by decreasing the transmission of infections; however, they do not address the problem of deaths related to opioid overdose. The primary harm-reduction strategy used to address deaths related to opioid overdose in the U.S is opioid overdose education and naloxone distribution (OEND). Naloxone is an opioid antagonist that reverses the respiratory depression and decreased consciousness caused by opioids. The OEND strategy involves educating first responders— including individuals and friends and family of individuals who use opioids—to recognize the signs of an opioid overdose, seek help, provide rescue breathing, administer naloxone, and stay with the individual until emergency medical services arrive.7 This strategy has been observed to decrease rates of death related to opioid overdose.7
Given the evolving opioid epidemic and effectiveness of the OEND strategy, it is not surprising that the number of local opioid overdose prevention programs adopting OEND has risen dramatically. As of 2014, there were 140 organizations, with 644 local sites providing naloxone in 29 states and the District of Columbia. These organizations have distributed 152,000 naloxone kits and have reported more than 26,000 reversals.8 Certainly, OEND has prevented morbidity and mortality in some of these patients.
The adoption of OEND can be performed by individual prescribers as well. Naloxone is U.S. FDA-approved for the treatment of opioid overdose, and thus the liability to prescribers is similar to that of other FDA-approved drugs. However, the distribution of naloxone to third parties, such as friends and family of individuals with opioid misuse, is more complex and regulated by state laws. Many states have created liability protection for naloxone prescription to third parties. Individual state laws and additional information can be found at prescribetoprevent.org.
Hospitalists should provide opioid overdose education to all individuals with opioid misuse and friends and family of individuals with opioid misuse. In addition, hospitalists should prescribe naloxone to individuals with opioid misuse and, in states where the law allows, distribute naloxone to friends and family of individuals with opioid misuse as well.
Controversies. In general, opioid use disorder treatment providers; public health officials; and local, state, and federal government agencies have increasingly embraced harm-reduction strategies. However, some feel that harm-reduction strategies are misguided or even detrimental due to concern that they implicitly condone or enable the use of illicit substances. There have been a number of studies to evaluate the potential unintended consequences of harm-reduction strategies, and overwhelmingly, these have been either neutral or have shown the benefit of harm-reduction interventions. At this point, there is no good evidence to prevent the widespread adoption of harm-reduction strategies for hospitalists.
Back to the Case
The case involves an individual who has already had at least two complications of his IV heroin use, including cellulitis and opioid overdose. Ideally, this individual would be willing to see an addiction specialist and start medication-assisted treatment. Unfortunately, he is unwilling to be further evaluated by a specialist at this time. Regardless, he remains at risk of future complications, and it is the hospitalist’s responsibility to intervene with a goal of reducing future harm that may result from his IV heroin use.
The hospitalist in this case advises the patient to abstain from heroin and IDU, encourages him to seek treatment for his opioid use disorder, and gives him resources for linkage to care if he becomes interested. In addition, the hospitalist educates the patient on safe injection practices and provides a list of local syringe exchange programs to decrease future risk of viral, bacterial, and fungal infections. Furthermore, the hospitalist provides opioid overdose education and distributes naloxone to the patient, along with friends and family of the patient, to reduce the risk of death related to opioid overdose.
Hospitalists should utilize harm-reduction interventions in individuals hospitalized with opioid misuse. TH
Dr. Theisen-Toupal is a hospitalist at the Veterans Affairs Medical Center and assistant professor of medicine at the George Washington University School of Medicine & Health Sciences, both in Washington, D.C.
- Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm. Published November 4, 2011.
- Drug abuse warning network, 2011: national estimates of drug-related emergency department visits. Substance Abuse and Mental Health Services Administration website. Available at: http://www.samhsa.gov/data/2k13/DAWN2k11ED/DAWN2k11ED.htm#5. Accessed July 29, 2015.
- Hedergaard H, Chen LH, Warner M. Drug-poisoning deaths involving heroin: United States, 2000–2013. National Center for Health Statistics Data Brief. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/nchs/data/databriefs/db190.htm. Published March 2015.
- Getting off right: a safety manual for injection drug users. Harm Reduction Coalition website. Available at: http://harmreduction.org/wp-content/uploads/2011/12/getting-off-right.pdf.
- Syringe exchange programs—United States, 2008. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5945a4.htm/Syringe-Exchange-P.... Published November 19, 2010.
- Wodak A, Conney A. Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users. World Health Organization website. Available at: http://apps.who.int/iris/bitstream/10665/43107/1/9241591641.pdf. Published 2004.
- Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174.
- Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Opioid overdose prevention programs providing naloxone to laypersons—United States, 2014. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm. Published June 19, 2015.