INTRODUCTION

Deaths due to opioid overdose have reached unprecedented levels in Canada; over 12,800 opioid-related deaths occurred between January 2016 and March 2019, and overdose death rates increased by approximately 50% from 2016 to 2018.¹ In 2016, Health Canada declared the opioid epidemic a national public health crisis,² and life expectancy increases have halted in Canada for the first time in decades.³ Children are not exempt from this crisis, and the Chief Public Health Officer of Canada has recently prioritized the prevention of problematic substance use among Canadian youth.^{Reference Tam4}

In 2014, the overall health care costs of substance use in Canada were estimated to be $11.1 billion, of which 2.8% ($0.3 billion) were attributed to opioids.⁵ Since then, health care use resulting from opioid use has increased dramatically. Opioid-related hospitalizations increased by 27% between 2013 and 2017.⁶ From 2016 to 2017, emergency department (ED) visits due to opioids increased by 73% in Ontario, and 23% in Alberta.⁶ Furthermore, youth aged 15 to 24 years have the highest and fastest-growing rates of ED visits related to opioids, tripling over the past 5 years.⁶

EDs are often the main source of health care for patients with substance use disorders.^{Reference Hawk and D'Onofrio7} ED visits are crucial opportunities to identify and address the complex needs of patients who are socially and medically marginalized.^{Reference Kahan, Poremski and Wise-Harris8} Those who visit the ED frequently are at significant risk of subsequent overdose.^{Reference Brady, DiMaggio, Keyes, Doyle, Richardson and Li9} People who overdose are more likely to have visited an ED in the preceding year, and are more likely than the average patient to have left without being seen or against medical advice.^{Reference Otterstatter, Crabtree and Dobrer10}

In the context of a national opioid crisis, there is a professional imperative for emergency providers to take evidence-based steps to prevent future morbidity and mortality resulting from opioid use and from common presentations of opioid-related illness in ED settings. Nonfatal opioid overdose, rapid opioid tapering, and opioid withdrawal are significant risk factors for subsequent death due to opioid overdose.^{Reference Caudarella, Dong, Milloy, Kerr, Wood and Hayashi11,Reference Wines, Saitz, Horton, Lloyd-Travaglini and Samet12} In Canada, ED-based interventions for opioid use disorder have been shown to be effective and acceptable to patients.^{Reference Hu, Snider-Adler, Nijmeh and Pyle13-Reference Kestler, Giesler and Buxton16}

CAEP supports a broad and multi-faceted public health approach to addressing this complex health crisis and embraces an evidence-based harm reduction approach to substance use, which aims to reduce the harms of substance use without mandating abstinence.^{Reference Hawk, Coulter and Egan17,18} This position statement offers recommendations designed to position emergency medicine, emergency health care providers, and EDs as key partners in a broad and intersectoral strategy to address Canada's opioid crisis for Canadians of all ages.

The scope of this position statement is limited to clinical practice in the ED. The recommendations in this position statement are applicable and adaptable across urban, suburban, and rural practice environments nationwide, although reasonable modifications may be required to suit local patient needs, demographics, and epidemiology. These recommendations were not developed according to systematic review or guideline methodologies and should not be interpreted as a clinical practice guideline. This position statement is intended to advance common practice, and not to establish a standard of care.