Opioid use disorder treatment disruptions during the early COVID-19 pandemic and other emergent disasters: a scoping review addressing dual public health emergencies.

BACKGROUND: During public health emergencies, people with opioid use disorder (PWOUD) may be particularly impacted. Emergent disasters such as the COVID-19 pandemic disrupt already-strained harm reduction efforts and treatment availability. This study aims to answer three research questions. How do public health emergencies impact PWOUD? How can health systems respond to novel public health emergencies to serve PWOUD? How can the results of this scoping review be contextualized to the province of Alberta to inform local stakeholder responses to the pandemic? METHODS: We conducted a scoping review using the 6-stage Arksey and O'Malley framework to analyse early-pandemic and pre-pandemic disaster literature. The results of the scoping review were contextualized to the local pandemic response, through a Nominal Group Technique (NGT) process with frontline providers and stakeholders in Alberta, Canada. RESULTS: Sixty one scientific journal articles and 72 grey literature resources were included after full-text screening. Forty sources pertained to early COVID-19 responses, and 21 focused on OUD treatment during other disasters. PWOUD may be more impacted than the general population by common COVID-19 stressors including loss of income, isolation, lack of rewarding activities, housing instability, as well as fear and anxiety. They may also face unique challenges including threats to drug supplies, stigma, difficulty accessing clean substance use supplies, and closure of substance use treatment centres. All of these impacts put PWOUD at risk of negative outcomes including fatal overdose. Two NGT groups were held. One group (n = 7) represented voices from urban services, and the other (n = 4) Indigenous contexts. Stakeholders suggested that simultaneous attention to multiple crises, with adequate resources to allow attention to both social and health systems issues, can prepare a system to serve PWOUD during disasters. CONCLUSION: This scoping review and NGT study uncovers how disasters impact PWOUD and offers suggestions for better serving PWOUD.

Rapid Micro-induction of Buprenorphine/Naloxone for Opioid Use Disorder in a Critically ill Intubated Patient: A Case Report.

BACKGROUND: Buprenorphine/naloxone has been shown to be an effective treatment of opioid use disorder. According to the Canadian National clinical practice guideline on the management of opioid use disorders, given the superior safety profile of buprenorphine/naloxone and its potential for flexible take-home dosing in comparison to other opioid agonist medication it is strongly recommended to initiate opioid agonist treatment with buprenorphine/naloxone as the preferred first-line treatment when possible. Due to its pharmacological properties induction can be challenging, requiring the cessation of all opioids for a certain amount of time to avoid the risk of precipitated withdrawal symptoms. For this reason, buprenorphine/naloxone is not initiated for the treatment of opioid use disorder in critically ill patients where continuous infusion of opioids are required for maintenance of sedation resulting in a missed opportunity for first line treatment of that patient's opioid use disorder. CASE SUMMARY: We present a case of a 29-year-old female with opioid use disorder admitted for infective endocarditis and septic shock requiring intubation for hypoxic respiratory failure secondary to bilateral lung septic emboli with a high opioid debt requiring higher than typical doses of fentanyl and dexmedetomidine infusions to maintain sedation with clinical objective sign of inadequate treatment of her pain and opioid withdrawal. She was successfully started on buprenorphine/naloxone using a rapid micro-induction technique that did not cause precipitated withdrawal or require cessation of her fentanyl infusion. CONCLUSION: This case illustrates a new method for starting buprenorphine/naloxone in a critically ill intubated patient, where buprenorphine/naloxone was never a consideration in this specific patient population. SCIENTIFIC SIGNIFICANCE: This method can be used to minimize barriers to opioid agonist therapy in intubated patients.

Identification of emergency department patients for referral to rapid-access addiction services.

OBJECTIVES: Substance-related emergency department (ED) visits are rapidly increasing. Despite this finding, many EDs do not have access to on-site addiction services. This study characterized substance-related ED presentations and assessed the ED health care team's perceived need for an on-site rapid-access addiction clinic for direct patient referral from the ED. METHODS: This prospectively enrolled cohort study was conducted at an urban tertiary care ED from June to August 2018. Adult ED patients with problematic or high-risk substance use were enrolled by ED staff using a one-page form. The electronic and paper records from the index ED visit were reviewed. The primary outcome evaluated whether the ED health care team would have referred the patient to an on-site rapid-access addiction clinic, if one were available. RESULTS: We received 557 enrolment forms and 458 were included in the analysis. Median age was 35 years, and 64% of included patients were male. Alcohol was the most commonly reported substance of problematic or high-risk use (60%). Previous ED visits within 7 days of the index visit were made by 28% of patients. The ED health care team indicated "Yes" for rapid-access addiction clinic referral from the ED for 66% of patients, with a mean of 4.3 patients referred per day during the study period. CONCLUSIONS: At least four patients per day would have been referred to an on-site rapid-access addiction clinic from the ED, had one been available. This indicates a gap in care and collaborating with other sites that have successfully implemented this clinic model is an important next step.

Rapid Induction of Buprenorphine/Naloxone for Chronic Pain Using a Microdosing Regimen: A Case Report.

Buprenorphine is an effective treatment for chronic pain and may reduce opioid-induced hyperalgesia. However, its pharmacological properties make its induction challenging, time-consuming, and can precipitate opioid withdrawal. We present the case of a 66-year-old woman with inadequately controlled postoperative pain despite escalating doses of oxycodone and methadone, who was successfully transitioned to buprenorphine/naloxone using a rapid microinduction technique without precipitating opioid withdrawal. Rapid induction provides an alternative method for transitioning patients from other opioids to buprenorphine/naloxone and facilitates transition of patients with chronic pain to buprenorphine therapy within a shorter window compared to currently existing protocols.