A leading-edge project in the St. Paul’s Hospital (SPH) Emergency Department (ED), in collaboration with the VCH Regional Addiction Program, is being piloted (initially launched December 11th 2018) to provide opioid overdose patients with to-go kits of buprenorphine-naloxone (suboxone) treatment upon discharge.
Suboxone is a brand name combination pill of two active ingredients – buprenorphine and naloxone – which can treat opioid addiction by stopping cravings and withdrawal symptoms, and it can also prevent overdose deaths. In addition, the medication has a much better safety profile compared to methadone and is recommended as the preferred first line of treatment by the BC Centre on Substance Use.
The pilot project at SPH is based on a similar study in the USA where results showed 75% of people who took home suboxone were retained in addiction treatment 2 months later. The program is a first in Canada in terms of its low-barrier approach, with an emphasis on pre-prepared, to-go packs, easy-to-understand instructions, and a well-defined follow-up care plan. SPH is handing out the to-go kits along with instructions on how to begin the medication - click the image at the end of the article for the draft version of these instructions.
This is a nurse led initiative and nurses are onsite 7 days a week 8am-6pm identifying clients, collaborating with prescribers and dispensing kits. Nurses are creating follow-up plans with patients to reduce barriers to ongoing care. St. Paul’s Hospital sees the vast majority of overdoses in Vancouver Coastal Health region, almost 10 times more than other hospitals. With this new protocol, patients with opioid use disorder who are being treated for an opioid overdose in the ED will receive a three-day supply of Suboxone from a specially-trained addiction nurse after seeing an ED physician. Detailed information on follow-up treatment and community resources will be provided as well, which will include the Rapid Access Addiction Clinic(RAAC) at St. Paul’s, which is open every day, DTES Connections, the Overdose Outreach Team and the ED at St. Paul’s is provided..
By providing these patients with a take-home supply of Suboxone right out of the ED, project co-lead and St. Paul’s Hospital addiction physician Dr. Keith Ahamad hopes this innovative approach will ultimately save lives.
8 kits have been handed out since December 2018 and the clients have been mainly young women. 3/8 are still on suboxone treatment one month later. There was 1 case of precipitated withdrawal possibly due to housing staff instructing the client to take too high a dose initially; this is uncomfortable and can result in disengagement from treatment so Nurse Emma Garrod at SPH, stresses that people need to please follow the instructions! To start suboxone you need at minimum 12-15 hours of withdrawal from your last opioid use, and often longer if you have been using fentanyl.
The pilot, which will run for the next two years, will be evaluated by the BCCSU to assess the impact on overdoses, hospital visits, mortality, and engagement in care. If the St. Paul’s project proves successful, it could be expanded to include other patients in the ED identified with opioid use disorder. Eventually, this model could be adopted by all emergency departments in the province.
Please see below the 'Suboxone To-Go' step by step instructions (Please be aware this is a draft pamphlet and is subject to updates). Click here to bring up the document in full.