Jan Deol wonders what happened to the other brother.
An emergency physician at Grey Nuns Community Hospital, Jan helped two brothers who were brought in by EMS for an accidental fentanyl overdose about a year ago. Because he had experience in the field of opioid use disorder (OUD), Jan was able to start them on Suboxone, a medication that counters opioids, and refer them to a treatment clinic. One brother never followed up, but the other did.
“He’s on a stable dose of Suboxone,” says Jan. “He’s socially productive in the sense that he has a full-time job and is engaged with his friends and family.”
“He looks like a different person.”
Jan’s experience and training with opioid treatment means he can provide Suboxone immediately. Now, Jan is part of a pilot project at the Grey Nuns Emergency department to test-drive that approach on a bigger scale before it gets rolled out across the province.
The Suboxone project is one of the newest tactics in addressing a major public health crisis. In 2017, 733 people in Alberta died from apparent accidental opioid overdoses, the vast majority of them fentanyl-related. In the first nine months of 2017, 17 per cent of patients who died from an apparent accidental fentanyl overdose had made an opioid or other substance-related emergency department visit in the previous 30 days.
“It’s killing people,” says Darla Reynolds, Program Manager at the Grey Nuns Emergency. “It’s killing more people than car accidents are.”
When a patient with OUD comes into the Grey Nuns Emergency, a physician can screen and start the person on Suboxone, as long as the patient is over 18, has a suspected opioid use disorder and wants to stop using opioids.
“Patients need to be in withdrawal to take their first dose in the department, or they can be sent home with doses and instructions if they have not started withdrawing yet. They need to want to stop using,” says Andrea Michael, Clinic Nurse Educator at the Grey Nuns Emergency.
“It’s not going to remove all the symptoms but it’s going to make it manageable,” she adds.
The opioid dependency program clinic reserves daily slots for the hospital so patients are often able to get in the morning after their hospital visit.
The strength of this approach lies in bridging the gap between the ED visit and treatment, without leaving patients to search for treatment on their own while dealing with “very uncomfortable” withdrawal symptoms, says Darla.
“Oftentimes the emergency department is the only touch point these patients have with the healthcare system,” says Jan, who also works at the Royal Alexandra Hospital and Metro City Medical Clinic, which specializes in opioid addiction treatment. “These aren’t the patients that are going for annual physical checkups with their family physician. If their only touch point with health care is the emergency department, then we need to use the opportunity to link these patients with evidence-based treatment in the community.”
Grey Nuns volunteered to be one of two Edmonton pilot sites, with one more in Calgary. There is a plan to expand the Suboxone project to emergency departments across the province by 2020. Grey Nuns is seventh in the province for overdose visits to the ER, encountering approximately one overdose a day.
Stigma and misconceptions still surround opioid dependency.
“It could be your neighbour, it could be the homeless person downtown, it could be the executive downtown. It really doesn’t have a profile, and that’s the thing about opioid dependency—it seems to be becoming quite alarmingly common,” says Darla.
Patients who try to wean themselves off of opioids are especially vulnerable. If they try to quit cold turkey and begin retaking opioids, there’s an increased risk of overdosing, says Andrea. That’s why it’s important to provide Suboxone, followed by an immediate appointment to plan treatment.
Compassion is critical, says Jan.
“We’re talking about a lot of patients who are socially unstable, who have no other options in terms of health care or even social supports. When they come to the Grey Nuns Hospital, they will be greeted by nursing staff, physicians and an environment that shows compassion and is empathetic to their illness. This attitude is necessary for this pathway to work and for our patients to improve. I think it's the just thing to do.”