Take-home naloxone

We thank Kumar and Rosenberg for enhancing care provider knowledge of treatments for opioid abuse and its consequences (1). However, we need to be more precise in how we talk about the opioid crisis: using the term "poisoning" instead of "overdose" would better reflect clinical reality and also change our subconscious thinking patterns to reduce the stigma faced by patients. We ought to be consistent and accurate in our portrayal of medical conditions as it affects public attitudes and support for health policies (2). In this context, we've heard many misconceptions about drug use and addictions, such as the idea that supervised injection sites promote substance abuse.

The term "overdose" connotes personal failure and responsibility, and is a remnant of the old psychosocial model of addiction. This term suggests that the patient a) knows the nature of the substance taken and b) has taken more than what she or he was tolerant to or intended to take (3). "Overdose" also implies that there is a correct dose when none exists for use of illicit formulations. In practice, opioid formulations sold in unregulated markets have variable and unknown potency, so dosing is impossible. In addition, people experience loss of tolerance due to inconsistent use and concurrent illness, so dosing is variable at the individual level. For this reason, we judiciously dose opioids in acute care settings, with careful monitoring.

Consequently, we suggest that the more precise terms "poisoning" or "intoxication" should be used. These terms accurately label the acute medical illness and are physiologically and medio-legally aligned, corresponding with the international standard disease classification system ICD-10 (4). Reorienting our language with regard to opioids is also compatible with public understanding regarding other substances: we say "alcohol poisoning" or "intoxication", and not "alcohol overdose".

With these more accurate terms, providers may be cued to consider and address the two separate health needs present: Acute poisoning or intoxication, and The contributory conditions: uncontrolled pain, mental illness, drug dependence or addiction etc.

As we update our understanding of substance use disorders from a psychosocial to a comprehensive medical model, it is imperative that we also update the language we use to accurately reflect the medical process in place. For the public, this can avoid moral judgements and confusion. Our hope is that using the right words can lead to more effective management of the opioid crisis as a public health emergency.

Edward Xie MD, CCFP(EM), DTM&H Emergency Physician, University Health Network Clinical Lecturer, University of Toronto

Samantha Green MD, CCFP DFCM, University of Toronto

Nitasha Puri MD CCFP dipABAM

Hasan Sheikh, BSc., M.D. CCFP(EM) ED physician, University Health Network

References

1. Kumar T and Rosenberg H. Five Things to Know About Take-home naloxone. CMAJ. 2017; 189:E1192.

2. Kelly J.F., Saitz R., Wakeman S. Language, Substance Use Disorders, and Policy: The Need to Reach Consensus on an "Addictionary". Alcoholism Treatment Quarterly. 2016; 34(1): 116-123.

3. Behar E, Rowe C, Santos GM, Murphy S, Coffin PO. Primary Care Patient Experience with Naloxone Prescription. Ann Fam Med. 2016 Sep;14(5):431-6

4. Canadian Institute for Health Information. International Statistical Classification of Diseases and Related Health Problems, 10th revision, Canada. Canadian Institute for Health Information. Ottawa, Canada. 2009.

Conflict of Interest:

None declared