This study observed a greater proportion of opioid-related overdoses involving pharmaceutical opioids as compared to heroin. Mixed drug overdoses involving non-opioids were more frequent than opioid only overdoses. This finding was more pronounced during March to August 2020 as compared to the same period in 2019 (pre-COVID-19), and for those presenting with intentional overdoses. A reduction in the number of patients presenting with opioid-related overdoses between 2019 and 2020 was evident, which may be attributed to the COVID-19 pandemic. Mental health comorbidities were prominent amongst the patient population, especially depression and anxiety. As part of the post-discharge plan for patients presenting with opioid-related overdose, several strategies were documented including psychiatry follow-up and drug and alcohol services referral. However, no patients received THN. Barriers to the provision of THN in hospital EDs need to be addressed to complement and support wider efforts to promote THN access and prevent opioid-induced mortality.
To our knowledge, this is the first study examining the provision of THN and other interventions post-opioid overdose in Australian EDs. Providing and educating people on THN is an effective strategy to reverse opioid overdose and prevent mortality [16]. The 2020 Society of Hospital Pharmacists of Australia guidelines state that THN should be provided to patients presenting with opioid toxicity, those who inject opioids, use opioid substitution therapy or are prescribed opioids for chronic pain [25]. While THN is available free-of-charge from 225 community drug and alcohol services and pharmacies in the Australian state of Western Australia under the THN pilot, only 1 hospital is registered with this program and 2 other hospitals are supplying THN to ED patients according to anecdotal reports [28]. Equity of access and care needs to be addressed, as no hospitals outside of the inner city are currently providing THN. Internationally, the underutilisation of THN programs is attributed to multiple barriers, including lack of time, training and institutional support [21, 29]. Furthermore, some healthcare workers hold stigmatising and inaccurate assumptions about naloxone distribution [30, 31]. There is a need to improve understanding and shift attitudes regarding THN to ensure survivors of opioid overdose, and those at risk of overdose from pharmaceutical and non-pharmaceutical drug use, have access to this life-saving intervention from the ED [25].
An expected finding of this study was the significant proportion of patients with comorbid mental health conditions. This was evident for those who intentionally overdosed (75%), as well as those who unintentionally overdosed (51.4%), which reflects a well-established relationship between SUDs and mental health conditions [32–34]. Those who intentionally overdosed were less likely to be given naloxone than those who unintentionally overdosed (p<0.001). This may indicate intentional overdoses were less severe or opioids contributed to a lesser extent. Consistent with the latter, those who intentionally overdosed were significantly more likely to present with mixed drug overdoses (p<0.05). Psychiatric team follow-up was more commonly documented in the post-discharge plan of those who intentionally overdosed than those who unintentionally overdosed (p<0.05). However, referral rates could be improved. Addressing the circumstances surrounding patients’ intentional overdoses and implementing treatment strategies is crucial to preventing self-harm [35].
A significant number of patients were referred to outpatient drug and alcohol services. However, outpatient referrals often indicated the provision of contact numbers and relied on patients to organise appointments. This is inconsistent with an ideal continuity of care approach where, for example, a clinical handover is conducted between healthcare providers with patient involvement or peer recovery coaches conduct motivational interviewing and facilitate referrals [15, 36]. A complicating factor with regards to organising referrals may be patients’ lack of motivation to change their drug use behaviours [37]. Requesting discharge and declining services was a common occurrence amongst the patient population, which may demotivate healthcare professionals to encourage patient change. The drug and alcohol team (at this hospital) extended their hours of operation considerably from 2019 to 2020, which was accompanied by a 30% increase in referral rates. Positive changes such as this are required to address the disconnect between EDs and community drug and alcohol services and optimise patient engagement in outpatient services following ED overdose presentations.
Pharmaceutical opioids were implicated in the majority of opioid-related overdoses included in this audit (72.1%). Comparatively, the Australian Institute of Health and Welfare reported the annual hospitalisation rate for overdoses involving pharmaceutical opioids was more than double that of overdoses involving heroin or opium (9.1 vs. 3.4 per 100,000 population) [38]. This is consistent with US trends, where in 2018 9.9 million people reported past-year use of prescription opioids for non-medical purposes and 800,000 reported heroin use [1]. In the current audit, pharmaceutical opioids prescribed for the patient were implicated in a substantial number of cases (N= 24). In recognition of the harm attributed to pharmaceutical opioids, the Therapeutic Goods Administration of Australia has established the Opioid Regulatory Advisory Group to alter opioid prescribing and dispensing practices [39]. For example, smaller pack sizes for immediate-release prescription opioid medications have become available to allow dispensing of the quantity required for the patient. This prevents surplus opioids circulating within the community that may cause inadvertent or deliberate harm [39]. Continual review of opioid use is required to lessen the burden of opioid-related harm.
A significant reduction in the number of ED presentations for opioid-related overdose was seen between 2019 and 2020 (N= 42 vs. 26, respectively). This finding correlates with anecdotal reports from healthcare workers at the hospital of fewer overdose presentations with the COVID-19 pandemic onset. In contrast, US studies have observed an increase in opioid overdose presentations from March 2020 [4, 7]. There are a number of possible explanations for the decline observed in this audit including (1) changes in drug access with border closures, (2) comparatively fewer well-meaning bystanders available to phone ambulances during isolation periods imposed in Australia, (3) increased fatalities (4) community expansion of the Australian THN pilot [20], and (4) a small sample size. To support the second of these hypotheses, patients were more likely to present by means other than ambulance transport during 2020 than 2019 (30.8% vs. 11.9%). While there was no significant difference in the proportion of overdoses involving pharmaceutical and non-pharmaceutical opioids, mixed drug overdoses involving non-opioids were more frequent in 2020 than 2019 (80.8% vs. 57.1%), as well as overdoses involving between 4 and 7 drugs (42.3% vs. 19.0%). These trends provide preliminary evidence to suggest a shift in drug use behaviours during 2020 as compared with 2019.
The findings of this study are subject to a number of limitations. As a small sample size, single centre study was conducted the outcomes cannot be generalised to other hospital EDs. However, results regarding characteristics of overdose presentations are consistent with current literature.1,38 Selecting the patient population using ICD-10-AM codes may have excluded eligible patients, but we included a large number of codes to capture the majority of presentations. Furthermore, this retrospective audit relied on documentation of patient characteristics, their overdose presentations and interventions delivered, which may be inaccurate or incomplete. For example, patients may not have been forthcoming with their comorbidities or healthcare workers may not have documented if they provided harm-minimisation education. To minimise the possibility of incomplete data we reviewed all available sources of information. Multi-centre, large-scale studies are required to further investigate ED opioid overdose presentations and the subsequent delivery of interventions.