Emergency Naloxone: What Next?

The next step for providers after naloxone resuscitation.

Treatment Context

The opioid epidemic hits hardest for healthcare professionals in emergency treatment — paramedics and emergency room doctors and nurses. In emergency treatment settings, providers are treating people for overdoses who then very often go back to using substances after discharge. This can be disheartening for providers who have dedicated themselves to saving lives, not enabling harmful behaviors.

Let’s look at the context, though. A person, addicted to opiates, is treated in an emergency room for an overdose. While in the emergency room, the healthcare providers give the person the “come to Jesus” talk. That is, they tell the person flat out that their addiction will kill them. They tell the person that s/he must stop using. The person responds with hostility, sometimes aggression, excuses, minimizing, or plain indifference. The person is discharged and goes back to their previous substance use pattern.

Why can’t we get through to these patients? Perhaps because we have little insight into how difficult the situation is, physically and mentally, for people with opioid use disorder.

Physiology of Naloxone Withdrawal

Naloxone Molecule from PubChem

Withdrawal by naloxone is a very stressful experience for a client. In rats, even low doses of naloxone-induced withdrawal produces anxiogenic-like effects similar to spontaneous discontinuation of morphine (Schulteis, Yackey, Risbrough, & Koob, 1998). Additionally, from a motivation standpoint, evidence indicates that some of the opiate-dependent population exhibit rapid neuroadaptation in which naloxone treatment and the context of the treatment can alter the reward response (Liu & Schulteis, 2004). In plain language, naloxone administration can create barriers to addiction treatment in addition to the typical resistance seen in people considering change.

Motivational Interviewing in Emergencies

Motivational Interviewing is a type of therapy practice that harnesses a person’s internal motivation for change. The key communication techniques in Motivational Interviewing are:

  • (Asking) Open-ended questions
  • Affirming positive behaviors (including seeking emergency treatment)
  • Reflecting
  • Summarizing

(Miller & Rollnick, 2013)

Advice and information is given with the person’s permission. This is where healthcare providers usually get things wrong. They are used to being asked for advice and treatment information by patients. They are not used to letting patients make their own treatment decisions.

But, after a person has been resuscitated, they are no longer your patient. They no longer require or want someone to make decisions for them. Instead, they become a person with autonomy and their own personal history, which will drive their health behaviors.

In motivational interviewing, one of the key interventions is “rolling with resistance.” That is, when a client exhibits signs of resisting change or treatment, the provider meets it with reflection rather than confrontation (Moyers & Rollnick, 2013). Obviously, in emergency rooms this is a difficult concept to apply.

At the point of emergency resuscitation with naloxone, there is usually not a lot of productive psychotherapy work going on. How providers handle this interaction can be destructive to the relationship between a person and a provider or institution.

I would not expect a client, when ready to consider changing their substance use behaviors, to come back to the facility where he did not feel heard or respected. The first thing I might recommend for the provider is to implement motivational interviewing — reflecting back the client’s resistance to treatment. At least this lets the client know that he’s being heard, and the decision for change falls back to him. If he fights against getting sober, he’s only fighting with himself. This makes the provider an ally, not an adversary, in the fight for change.

Harm Reduction with Non-Prescription Naloxone

Another perspective I would take, that allows for individualized treatment of clients, is one of harm reduction. The New York State Psychiatric Institute’s (2016) position on harm reduction is that improves client’s overall engagement in treatment, as ultimatums (e.g., either you stop using or you don’t get treatment) will alienate clients. This goes hand-in-hand with motivational interviewing, as it allows clients to make small changes to their behavior (New York State Psychiatric Institute, 2016). In this case, the client can continue to use opiates, but change the risk it poses to his life.

One of the ways that New York State has supported this philosophy is by making naloxone available without a prescription (New York State Department of Health, 2016). I received free training from a local provider on opiate overdosing and was supplied a single dose of intranasal naloxone to carry with me. Getting the client to prevent his or someone else’s death may be the best outcome we can achieve at that time — at least then they will have another opportunity to make a decision.

References

Liu, J., & Schulteis, G. (2004). Brain reward deficits accompany naloxone-precipitated withdrawal from acute opioid dependence. Pharmacology Biochemistry and Behavior, 79(1), 101–108.

Miller, J., & Rollnick, S. (2013). Core Motivational Interviewing skills: OARS. Retrieved from https://ytp.uoregon.edu/content/core-motivational-interviewing-skills-oars

New York State Department of Health. (2016). New York State’s opiod overdose prevention program. Retrieved from http://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/

New York State Psychiatric Institute. (2016). Motivational interviewing. Retrieved from http://practiceinnovations.org/Consumers/Motivational-Interviewing

Schulteis, G., Yackey, M., Risbrough, V., Koob, G. F. (1998). Anxiogenic-like effects of spontaneous and naloxone-precipitated opiate withdrawal in the elevated plus-maze. Pharmacology Biochemistry and Behavior, 60(3), 727–731.