COVID‐19: A new barrier to treatment for opioid use disorder in the emergency department – Grunvald – 2021 – Journal of the American College of Emergency Physicians Open

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1 INTRODUCTION

1.1 Background

Since coronavirus illness 2019 (COVID‐19) was declared a pandemic, the USA, already within the midst of a devastating opioid epidemic, has seen a rise in deadly opioid‐associated overdoses.1 Explanations for the connection between COVID‐19 and the elevated charges of opioid‐associated fatalities embody social isolation, disruptions in medicine for opioid use dysfunction, lack of entry to psychological well being care companies, improve in relapse, lack of entry to hurt discount or well being care companies, elevated homelessness and incarceration, and concurrent COVID‐19 an infection.2 Emergency departments (EDs) are uniquely positioned to establish and provoke remedy for sufferers with opioid use dysfunction. Many EDs have applied applications that provoke medicine for opioid use dysfunction, constantly demonstrating that offering entry to buprenorphine/naloxone results in elevated enrollment and upkeep in outpatient remedy applications.3 Begin Remedy and Get well (STAR), a program initiated in February 2019 on the College of Vermont Medical Heart (UVMMC) ED, expands entry to medicine for opioid use dysfunction by figuring out sufferers assembly the standards for opioid use dysfunction and providing ED‐initiated medicine for opioid use dysfunction with buprenorphine/naloxone and speedy entry to an outpatient dependancy remedy program inside 72 hours.

1.2 Significance

Opioid use dysfunction is a posh illness, and combatting opioid use dysfunction efficiently requires a multisystem strategy with vital time and useful resource allocation. The COVID‐19 pandemic has disturbed this technique and thus is having a detrimental affect on sufferers with opioid use dysfunction.

1.3 Targets of this investigation

The aim of this text is to explain the affect of COVID‐19 on STAR and on sufferers with opioid use dysfunction who current to the ED.

2 METHODS

2.1 Research design and setting

A retrospective assessment of data was performed evaluating 2 intervals: pre‐pandemic and pandemic. The pre‐pandemic interval was outlined as February 1, 2019 to February 29, 2020; whereas, the pandemic interval was outlined as March 1, 2020 to Could 31, 2020. The COVID‐19 pandemic was declared a nationwide emergency on March 13, 2020. The beginning of the pandemic interval was chosen as March 1 as we imagine impacts from COVID‐19 to the ED realistically predated the emergency declaration. This analysis was reviewed and authorized by the College of Vermont Institutional Evaluate Board.

The Backside Line

Through the COVID‐19 pandemic, the charges of opioid‐associated fatalities have elevated. On this research evaluating pandemic and pre‐pandemic intervals at an city tutorial emergency division, though the share of sufferers presenting with opioid use problems or overdoses remained fixed, there was a 90% decline in enrollments in ED‐initiated medicines for opioid use dysfunction and a rise in statewide month-to-month opioid‐associated fatalities. These outcomes spotlight the necessity for extra concentrate on entry to opioid use dysfunction remedy through the ongoing pandemic.

2.2 STAR affected person enrollment and remedy

Analysis coordinators screened the medical data of each affected person presenting to the ED for indicators of opioid use dysfunction, together with prescribed or illicit use of oral opioids and/or buprenorphine/naloxone, identified historical past of opioid use dysfunction, intravenous drug use, withdrawal, or referral. Screening began in February 2019 and was carried out 21 hours per day till March 31, 2020, at which level analysis hours have been briefly decreased to 12 hours per day due to the restraints related to COVID‐19. Through the decreased staffing hours, analysis workers continued to be obtainable on‐name for distant enrollments 24 hours a day/7 days per week. Sufferers who have been aged < 18 years have been excluded, whereas these aged  > 65 years have been initially excluded from the research, however have been included as of July 24, 2019. When a possible research topic was recognized, a analysis coordinator consulted with the affected person’s ED doctor to verify enrollment eligibility. Exclusion standards included present use of medicine for opioid use dysfunction, altered psychological standing, medical extremis, incarceration, suboxone injection inside 1 yr, hepatic impairment, suicidality, opioid use dysfunction in remission, doctor discretion, deliberate admission, or earlier enrollment in STAR.

If the affected person met the eligibility standards, analysis workers defined the research and enrollment process to the affected person. This course of occurred in individual till March 16, 2020, at which level analysis workers have been required to perform remotely by cellphone. For sufferers involved in participation, analysis workers obtained consent and picked up contact info and enrollment questionnaires. Sufferers have been evaluated by an ED doctor and scored by way of the Medical Opioid Withdrawal Rating (COWS) to find out withdrawal severity. A starter package containing twelve 2 mg sublingual movie strips of buprenorphine/naloxone with dwelling induction directions and a assured appointment with the UVMMC Habit Remedy Program inside 72 hours have been offered. Sufferers manifesting withdrawal with a COWS rating ≥ 8 have been administered a right away 4 mg dose from the starter pack earlier than discharge from the ED.

2.3 Measurements

For every interval, we assessed the ED census, proportion of sufferers screened optimistic for opioid use dysfunction, variety of sufferers who offered with overdose, proportion of ED census with overdose, variety of sufferers who screened optimistic for opioid use dysfunction, variety of sufferers deemed eligible for STAR, and the variety of sufferers enrolled in STAR by month. These information have been obtained from UVMMC ED digital medical data and the STAR program registry. For extra context, we additionally examined the statewide and native county opioid fatalities throughout every interval. These information have been obtained from the Vermont Division of Well being important data.

2.4 Outcomes

ED census, proportion of census screening optimistic for opioid use dysfunction, and variety of ED overdose visits have been used to evaluate for enrollment potential. STAR enrollments (major end result) have been measured to gauge curiosity in participating with medicine for opioid use dysfunction. Chittenden County and statewide opioid‐associated fatalities have been included to establish patterns of opioid use in the local people and bigger statewide tendencies.

2.5 Evaluation

Variables have been in contrast between the pre‐pandemic and pandemic intervals. All analyses have been performed utilizing a 2‐pattern t assessments utilizing Stata (model 16; StataCorp, Faculty Station, TX) to find out means and 95% confidence intervals (CIs). Variance ratio testing was carried out to find out if the t assessments must be performed with equal or unequal variances.

3 RESULTS

3.1 Affected person screening and enrollment

From a complete of 54,354 sufferers screened for opioid use dysfunction within the ED, 47,706 have been screened within the pre‐pandemic interval and 6648 within the pandemic interval. Within the pre‐pandemic interval, 1911 people screened optimistic for opioid use dysfunction, 156 of them have been eligible for enrollment after the applying of the exclusion standards, and 126 of them consented to STAR enrollment. Through the pandemic interval, 308 people screened optimistic for opioid use dysfunction, 8 of them have been eligible for enrollment after the applying of the exclusion standards, and 4 of them consented to STAR enrollment (Determine 1).

image

Flowchart of affected person screening and enrollment into STAR throughout pre‐pandemic and pandemic intervals. bup/nal, buprenorphine/naloxone; ED, emergency division; EMS, emergency medical companies; IV; intravenous; OUD, opioid use dysfunction; STAR, Begin Remedy and Get well

3.2 ED information

The month-to-month common variety of ED visits decreased considerably from 5126.9 to 3306.7 between the pre‐pandemic and pandemic intervals (distinction = −1820.3; 95% CI, −3406.3 to −234.2). The month-to-month common proportion of sufferers screening optimistic for opioid use dysfunction elevated barely from 4.3 to 4.6 (distinction = 0.3; 95% CI, −0.4 to 1.0), and the common variety of month-to-month ED visits for overdose elevated barely from 17.7 to twenty.3 between the pre‐pandemic and pandemic intervals (distinction = 2.6; 95% CI, −4.8 to 10.1). The common month-to-month proportion of ED visits for overdose additionally elevated between the pre‐pandemic and pandemic intervals, though this was not statistically vital: 0.4% versus 0.7% (distinction = 0.3; 95% CI, −0.3 to 0.9). The month-to-month common variety of STAR enrollments dropped considerably from 9.7 to 1.3 (distinction = −8.4; 95% CI, −12.8 to −4.0; Desk 1, Determine 2).

TABLE 1.
Imply month-to-month traits and end result measures of sufferers presenting to the emergency division through the pre‐pandemic (February 1, 2019–February 29, 2020) and pandemic (March 1, 2020–Could 31, 2020) intervals of the research
Variable Pre‐pandemic imply month-to-month Pandemic imply month-to-month Distinction imply (95% CI)
ED census, n 5126.9 3306.7 −1820.3 (−3406.3 to −234.2)
Opioid use dysfunction of census, % 4.3 4.6 0.3 (−0.4 to 1.0)
ED overdose, n 17.7 20.3 2.6 (−4.8 to 10.1)
ED overdose of census, % 0.4 0.7 0.3 (−0.3 to 0.9)
STAR enrollments, n 9.7 1.3 −8.4 (−12.8 to −4.0)
State overdose fatalities, n 9.4 15.3 5.9 (0.8 to 11.1)
Chittenden County, VT, overdose fatalities, n 1.5 2.3 0.8 (−0.7 to 2.3)
  • CI, confidence interval; ED, emergency division; STAR, Begin Remedy and Get well.
image

(A) Month-to-month UVMMC ED census and proportion of month-to-month census screening optimistic for opioid use dysfunction amongst sufferers presenting to the ED through the pre‐pandemic (February 1, 2019–February 29, 2020) and pandemic (March 1, 2020–Could 31, 2020) intervals of the research. (B) Variety of enrollments in STAR, variety of overdose deaths in Vermont, and variety of visits to the ED with drug overdose as chief criticism by month amongst sufferers presenting to the ED through the pre‐pandemic (February 1, 2019–February 29, 2020) and pandemic (March 1, 2020–Could 31, 2020) intervals of the research. Vertical line represents the start of the pandemic interval. ED, emergency division; OUD, opioid use dysfunction; STAR, Begin Remedy and Get well; UVMMC, College of Vermont Medical Heart

3.3 State and county overdose fatality information

Imply month-to-month statewide overdose‐associated fatalities elevated considerably from 9.4 to fifteen.3 (distinction = 5.9; 95% CI, 0.8 to 11.1), whereas Chittenden County fatalities elevated barely from 1.5 to 2.3 (distinction = 0.8; 95% CI, −0.7 to 2.3; Desk 1, Determine 2).

3.4 Seasonal variation

To account for potential differences due to the season in opioid use, the evaluation was repeated utilizing pre‐pandemic information that have been restricted to the identical months of the pandemic (March–Could) in 2019 and located comparable outcomes. Through the seasonal interval of 2019, there have been 15 opioid‐associated fatalities in contrast with 45 with 1 case pending through the pandemic interval, representing a imply month-to-month improve between seasonal intervals from 5.0 to fifteen.3 (distinction = 10.3; 95% CI, 3.0 to 17.7; Desk 2).

TABLE 2.
Imply month-to-month traits and end result measures of sufferers presenting to the emergency division through the pandemic interval (March 1, 2020–Could 31, 2020) and the corresponding months of the pre‐pandemic interval (March 1, 2019–Could 31, 2019)
Variable Pre‐pandemic imply month-to-month Pandemic imply month-to-month Distinction imply (95% CI)
ED census, n 5073.3 3306.7 −1766.7 (−2857.3 to −676.0)
Opioid use dysfunction of census, % 4.5 4.6 0.1 (−1.2 to 1.4)
ED overdose, n 19.0 20.3 1.3 (−11.8 to 14.5)
ED overdose of census, % 0.4 0.6 0.3 (−0.2 to 0.7)
STAR enrollments, n 11.0 1.3 −9.7 (−15.7 to −3.6)
State overdose fatalities, n 5.0 15.3 10.3 (3.0 to 17.7)
Chittenden County, VT, overdose fatalities, n 0.3 2.3 2.0 (−0.6 to 4.6)
  • CI, confidence interval; ED, emergency division; STAR, Begin Remedy and Get well.

3.5 Limitations

A limitation of this research is the obtainable pattern dimension within the pandemic interval. Due to the scale of Vermont and the inhabitants that UVMMC serves, the pattern dimension of sufferers with opioid use dysfunction, overdose visits, and opioid‐associated fatalities have been small, which limits generalizability to different EDs. Nonetheless, UVMMC is typical of different neighborhood medical facilities that additionally perform as tutorial tertiary referral facilities serving a bigger rural inhabitants, which possible will face comparable challenges through the COVID‐19 pandemic. One other limitation was not accessing information on the precise medicine concerned within the ED overdoses; nonetheless, statewide information recommend that essentially the most predominant misused medicine are opioids.

4 DISCUSSION

Though the general variety of sufferers presenting to the UVMMC ED through the COVID‐19 pandemic decreased dramatically, the share of sufferers screening optimistic for opioid use dysfunction didn’t change. Furthermore, the variety of overdose visits remained the identical, resulting in overdose visits as a proportion of the month-to-month ED census nearly doubling. Regardless of these circumstances, there was a major 86.2% discount in STAR enrollment. This means that though the necessity for remedy was unchanged, fewer sufferers have been enrolled in STAR. This lower could have been attributed to a reluctance from sufferers or could mirror an obstacle on the ED to supply this service. COVID‐19 has created extra boundaries to care and has led to an surroundings with elevated dangers for sufferers with opioid use dysfunction.

Probably the most omnipresent barrier through the pandemic has been worry of contracting COVID‐19. Public messaging throughout this time was to “Keep Dwelling and Keep Protected,” which can have influenced sufferers to defer or refuse emergency care and account for a lower in ED census. General, visits to the UVMMC ED decreased by 35.5% through the pandemic. That is according to different analysis exhibiting the whole variety of US ED visits was 42% decrease than the identical interval a yr earlier,4 together with fewer visits for acute processes similar to stroke and acute coronary syndrome.5 Furthermore, sufferers with substance use problems typically expertise stigma that forestalls them from searching for care and interesting with medicine for opioid use dysfunction.6 Sufferers with opioid use dysfunction could decline emergency medical companies (EMS) transport to the ED after an overdose due to concern round this stigma and/or worry of COVID‐19 an infection. Analysis has proven each a rise in EMS requires opioid overdose and a major improve within the variety of sufferers who have been handled on scene and refused transport through the pandemic.7 A regarding sample within the police file administration system of Chittenden County discovered that 88% of overdose fatalities have been attributed to utilizing opioids in isolation.8 Statewide opioid‐associated fatalities in Vermont elevated by 63.4% through the pandemic interval. This means that COVID‐19 has pushed sufferers with opioid use dysfunction to riskier use, avoidance of remedy, and elevated mortality.

Different components could have contributed to the elevated charge of overdose and overdose deaths as COVID‐19 has additionally decreased entry to medicine for opioid use dysfunction in neighborhood outpatient settings. Though there have been regulatory modifications which have allowed medicine for opioid use dysfunction to be initiated and maintained by telehealth, many sufferers with opioid use dysfunction lack entry to the expertise wanted to make use of telehealth, whereas different sufferers with opioid use dysfunction could also be unwilling to interact on this new remedy modality. Furthermore, the transition away from in‐individual visits have led to issues within the distribution of hurt‐discount supplies. This consists of naloxone, fentanyl testing strips, and different secure injection provides. A scarcity of entry to naloxone and fentanyl testing strips may additionally have contributed to the rise in deadly and non‐deadly overdoses.9

Sufferers who do current to the ED through the pandemic could arrive with larger acuity and extra extreme illness. A case report illustrated this detailing a affected person who, due to worry of COVID‐19, didn’t search look after persistent chest ache for two days leading to “catastrophic issues” associated to their ST‐section elevation myocardial infarction.10 The affect of delaying care in sufferers with opioid use dysfunction could imply that individuals with opioid use dysfunction are usually not searching for emergency care till they’re being transported to the ED after an overdose or have developed extra extreme issues related to opioid use dysfunction. As soon as sufferers are within the ED, they face extra boundaries to enrolling in STAR. Analysis assistants have needed to function remotely through the pandemic, complicating the logistics of finishing an enrollment and prolonging the method. Having to enroll over the cellphone slightly than head to head could have additionally discouraged enrollment by the shortage of a private connection that an in‐individual interplay gives. Furthermore, having to attend an prolonged period within the ED after being medically cleared for discharge to finish the enrollment course of could have additional discouraged those that have been already anxious about coming to the ED due to fears of COVID‐19.

In abstract, the COVID‐19 pandemic is having a detrimental affect on sufferers with opioid use dysfunction presenting to the ED. Though total ED visits decreased through the preliminary months of the pandemic, the share of sufferers presenting with opioid use dysfunction or overdose‐associated visits remained fixed, but there was a major 86.2% lower within the variety of sufferers enrolling in ED‐initiated medicine for opioid use dysfunction. Allocation of healthcare assets and methods devised to mitigate hurt and keep remedy choices have to be applied for these scuffling with opioid use dysfunction through the ongoing pandemic.

CONFLICTS OF INTEREST

The authors declare no battle of curiosity.

AUTHOR CONTRIBUTIONS

Daniel Wolfson and Warren Grunvald conceived the research. Daniel Wolfson, Ramsey Herrington, Miles Lamberson, Roz King, Scott Mackey, and Sanchit Maruti supervised the conduct of the trial and information assortment. Daniel Wolfson, Roz King, Miles Lamberson managed the info, together with high quality management. Richard Rawson and Ramsey Herrington offered statistical recommendation on research design and analyzed the info. Warren Grunvald drafted the manuscript, and all authors contributed considerably to its revision. Daniel Wolfson takes accountability for the article as a complete.

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