One very common reason why patients seek medical care is for pain. Today, there are many ways to relieve pain, and one of them is with the use of opiates. Opiates have formally been approved for analgesia for close to 70 years, and for the most part, these drugs have been assumed to be relatively safe. However, in the last 2 decades, many reports have raised concern about the safety of these drugs. Cases of overdose and opiate toxicity are continually reported in all major cities in the United States. More notable is that the prescriptions for opiates have dramatically increased over the past 2 decades. This empirical prescription habit by healthcare workers has also led to an epidemic of an overdose outside the healthcare setting. Thus, for practicing healthcare workers, it is important to be aware of opiate toxicity in patients who are lethargic or unresponsive for no apparent reason (CDC, 2017).
Data released by the Drug Enforcement Agency (DEA) and the Centers for Disease Control and Prevention (CDC) indicate that from 2001 through 2010, the rate of opiate diversion, prescriptions for opiates, and opiate-related deaths have exponentially increased in the United States. The rates did plateau from 2011 through 2013 but again spiked from 2013 to 2014. Experts in pain management believe that the high number of opiate overdoses are not intentional but because patients may have been trying to manage unrelenting pain (CDC, 2016).
Opioid overdose occurs when a person has excessive unopposed stimulation of the opiate pathway. This can lead to decreased respiratory effort and possibly death. The frequency of opioid overdose is rapidly increasing. Drug overdose is the leading cause of accidental death in the United States, with opioids being the most common drug. The CDC currently estimates more than 1000 emergency department visits daily related to the misuse of opioids and about 91 opioid overdose deaths every day.
Prescriptions for opioid-containing medications quadrupled between 1999 and 2010. This paralleled a four-fold increase in overdose deaths due to opioids. The majority of the opioid deaths are attributable to the use of heroin and synthetic opiates other than methadone.
The issue with poorly treated pain has led medical professionals to use all types of short and long-acting opiates, and while this has made a difference in relieving pain, some patients often do not remain compliant with proper dosing. When the patient increases the dose or duration of opioids, then toxicity is a potential complication. Although annual rates of transition are low, this is commonly caused by individuals transitioning from the nonmedical use of prescription opioids to heroin.
Heroin, at about $2 a bag, is up to 10-fold cheaper and more readily available than prescription opioid medications for street purchase, which cost on average about a dollar per milligram. Additionally, there is an increasing trend of heroin mixed with fentanyl and other synthetic opioid compounds. This creates variable concentrations of opioid potency and a higher risk of overdose.
Adulterants: On the street, the majority of illicit drugs available are often contaminated with other substances. Sometimes to increase profits, sellers often add other agents to the formula without telling the end user. In many cases, these additives are pharmacologically active. Two decades ago in New York city, heroin had been adulterated with scopolamine, and this resulted in severe anticholinergic toxicity. Similarly, adulteration of cocaine is very common.
Most states have established prescription drug monitoring programs to counter the liberal prescription of opiates by healthcare workers (PDMP). In fact, in Kentucky, healthcare professionals must first consult with the state’s online drug database to determine which analgesic drug can be prescribed to patients. Such state enacted legislation has been developed to stop mass opiate prescription by healthcare workers. In addition, this also helps prevent diversion of legitimate opiate prescriptions (DEA, 2016).
Also, with the help of the Drug Enforcement Agency (DEA), there are now statewide registries of controlled substances that can assist healthcare providers to track usage patterns among patients in an effort to identify those individuals at high risk for opiate diversion or abuse. Even though the ready availability of opiates does play a role in opiate addiction, so far so no one has shown that there is a direct link between opiate abuse and legitimate use of these drugs for pain (DEA, 2016).
Causes of opioid overdose can include:
- Complications of substance abuse
- Unintentional overdose
- Intentional overdose
- Therapeutic drug error
Risk of opioid overdose increases in the following:
- Those that take escalating doses
- Return to use after cessation
- Those with severe medical and psychiatric conditions such as depression, HIV, and lung/liver disease
- Those that combine opioids and sedative medications
- Male gender
- Younger age (20 to 40 years)
- White non-Hispanic race
More than 1.5 million emergency department visits are related to opioid analgesics. Opioids are a common cause of death due to overdose.
Opiates are frequently prescribed for moderate to severe pain in the US. They are often prescribed alone or in combination with the non-steroidal anti-inflammatory drugs or muscle relaxants. Based on data from the Automation of Reports and Consolidated Order Systems, from 2004 through 2011 the percentage increase of opiates was as follows:
- Buprenorphine 2318%
- Fentanyl 35%
- Hydromorphone 140%
- Methadone 37%
- Morphine 64%
- Oxycodone 117%
Use of codeine decreased by 20%.
At the same time data from the Drug Abuse Warning Network (DAWN) has revealed that abuse of all the above opiates increased, with hydromorphone and buprenorphine leading the way with a 438% and 384% increase, respectively (SAMHSA, 2014). Other data from DAWN reveal that there were nearly 420,000 visits to the emergency rooms related to opiates in 2013. Abuse and/or diversion of opiates over the past decade have included drugs like hydrocodone, hydromorphone, fentanyl, morphine, oxycodone, and tramadol.
A few years ago, in 2015, US poison control centers reported a total of 18,425 single exposures to pure opiates which resulted in 68 fatalities and 764 cases of major toxicity. In addition, there were 14,632 exposures to a combination of opiates with alcohol, benzodiazepines, aspirin, acetaminophen or ibuprofen. The combined exposures resulted in 32 fatalities and 288 cases of severe toxicity (AAPCC, 2017).
The opiate toxicity epidemic is not only an American occurrence but a global concern. The 2014 United Nations Office on Drug and Crime estimates that at least 0.4% of the population or close to 20 million people regularly use heroin or opium. The highest level of usage are in South West Asia (1.21%), followed by Southeastern and Eastern Europe (0.83%) and Transcaucasia and Central Asia (0.81%). In Europe, the major cause of opiate deaths has been associated with the illicit use of fentanyl and its analogs. In countries where there is a heroin shortage, fentanyl and related products have replaced heroin as the illicit drug of use.
An opiate is derived from the opium poppy plant, while opioids are substances that act on the opiate receptors. Opioids work via the endogenous opioid system by acting as a potent agonist to the mu receptor. This results in a complex cascade of intracellular signals resulting in dopamine release, blockade of pain signals, and a resulting sensation of euphoria. Opioid receptors are located in the brain, spinal cord, and gut. In overdose, there is an excessive effect on the portion of the brain regulating respiratory rate, resulting in respiratory depression and eventually death. The typical symptoms seen in overdose are pinpoint pupils, respiratory depression, and a decreased level of consciousness. This is known as the “opioid overdose triad.”
Opioids may be agonists, partial agonists, or agonist-antagonists of opioid receptors. The currently available opiates lower the perception of pain and in some case decrease the pain stimulus. There are several types of opiate receptors in the central and peripheral nervous system. When these receptors are stimulated, it results in the suppression of the sensation of pain. However, not all opiate receptors have the same analgesic potency when stimulated. Opioids reduce pain perception by inhibition of synaptic neurotransmission and binding of opioid receptors in the central and peripheral nervous systems.
The main opioid receptors that mediate effects of opioids are mu, kappa, and delta.
- Mu receptors mediate analgesia, euphoria, sedation, respiratory depression, gastrointestinal dysmotility, and physical dependence. Mu receptors cause a medullary diminished response to hypercarbia and also a decrease in the respiratory response to hypoxia, resulting in a decreased stimulus to breathe and development of apnea.
- Kappa receptors mediate analgesia, diuresis, miosis, and dysphoria.
- Delta receptors mediate analgesia, inhibition of dopamine release, and cough suppression.
The role of the sigma and delta opiate receptors has not been as well studied. However, when the sigma receptors are stimulated the individual will develop hallucinations, dysphoria, and psychosis, whereas the delta receptors will produce analgesia, euphoria, and seizures. Sigma receptors are no longer considered opioid because naloxone does not antagonize them.
Tolerance occurs rapidly with opioids. With overdose, patients often succumb to respiratory failure. Tolerance to loss of the hypercarbic drive takes longer to develop than other euphoric effects, but opioid-tolerant patients do not develop complete tolerance to loss of hypoxic stimulus. This leaves them susceptible to death from overdose.
Opiates can be administered intravenously (IV), topically, inhaled, intramuscularly (IM), and orally. Following intravenous administration, the peak effects of the opiate are reached within 5 to 10 minutes but may take up to 90 minutes when administered orally. Following nasal insufflation, drugs Like heroin and butorphanol can reach peak levels within 10 to 15 minutes and about 30 to 45 minutes following intramuscular injection. Fentanyl which is the only available topical analgesic agent often takes 2 to 4 hours to reach peak levels.
When administered orally, the majority of opiate absorption occurs in the small intestine. When large doses of opiates are consumed, this can lead to gastric aperistalsis and a delay in gastric emptying and absorption of the drug. Once in the body, opiates are broken down by the liver to inactive compounds that are excreted primarily by the kidneys. Opiates like buprenorphine and fentanyl are highly lipid soluble and tend to redistribute into the fatty tissues and thus, have a prolonged half-life. Since all opiates are broken down by the liver, they tend to have a long half-life when consumed in the presence of liver dysfunction (for example, cirrhosis). In these patients, opiate toxicity can occur rapidly even with small doses as the drug remains in the body for a long time.
The hepatic microsomal CYP2D6 enzyme is responsible for breaking down codeine into the active metabolite, morphine. Some individuals carry more than 2 copies of the enzyme, and these ultrarapid metabolizers breakdown codeine into morphine rapidly; thus, individuals who take even normal doses of codeine may develop morphine toxicity. The same mechanism of ultrarapid breakdown explains why tramadol can cause opiate toxicity.
Once broken down in the liver, the opiate metabolites are excreted in the urine. Individuals with renal dysfunction may develop adverse effects from the accumulated active metabolites like normeperidine.
Several other studies show that long-acting opiates used for non-cancer pain can increase the risk of adverse cardiac events compared to tricyclics or anticonvulsants.
Formulas of Opiates and Delivery
Unlike the past when opiates were only available in oral, IM, and IV formulations, today there are dermal, sublingual and inhaler formulas on the market. Butorphanol is available in an intranasal form and fentanyl is available both as a topical and as an inhaler.
The transdermal delivery of opiates like fentanyl has been widely accepted in healthcare settings for analgesic relief. This route of administration is favored because the drug levels take 4 to 6 hours to peak and there is a long elimination half-life, thus making the drug suitable for use in patients with chronic continuous pain. In addition, because of the relatively prolonged slow onset of action, this route of administration is rarely known to precipitate toxicity. However, the topical formulation of fentanyl can contribute toward the toxicity of parenteral or oral opiates.
Dextromethorphan was once widely available in many over the counter cough preparations, but because of diversion, it is no longer available in over the counter products. Dextromethorphan may have been an over the counter preparation, but at high doses, it is known to cause sedation and even respiratory depression. Further, the use of dextromethorphan by patients who have been prescribed monoamine oxidase inhibitors can lead to the life-threatening serotonin syndrome that can lead to adverse cardiac events.
Tramadol (Ultram), although classified as a non-opiate analgesic, has a dual mode of action by acting on non-opiate and opiate receptors. Tramadol has a comparatively long duration of action of 5 to 6 hours. If it is known that a patient has overdosed on tramadol, naloxone is recommended, and most people require repeated doses or a continuous intravenous infusion.
Because of the difficulty in legally obtaining prescription opiates, many clandestine laboratories have sprung up in the nation. These laboratories work under unsterile conditions and use impure substances; the eventual result is more toxic drugs that are sold on the street. The other difficult with illicit drugs made in the clandestine laboratories is that many can’t even be detected with the normal toxicological screens because the levels are so low.
There are several types of synthetic fentanyl derivatives on the street like alpha-Methylfentanyl, which are extremely potent. In fact, several deaths have been reported in drug abusers with the needle still in the arm. One other synthetic derivative, 3-Methylfentanyl, is several thousand times more potent than morphine and when people overdose on it, extremely high doses of intravenous naloxone infusions are required. Deaths from these fentanyl derivatives often occur in clusters as the sellers go from street to street, leading to multiple deaths along the way.
Pentazocine is classified as a partial agonist-antagonist and is used to treat moderate to severe pain. It acts by stimulating the K-opiate receptors (KOR) and inhibiting the Mu-opiate receptors (MOR). The drug shares many of the same features of other opiates in terms of adverse effects. The one unique feature about pentazocine is that it also is known to cause nightmares, hallucination, and delusions. The drug is also subject to a high ceiling effect, meaning once a certain dose is reached, no further pain relief can be obtained. Although the pharmacological effects of pentazocine can be reversed by naloxone, extremely high doses of naloxone (10 to 115 ng) are required.
Propoxyphene is an opiate analgesic and was once prescribed to manage mild pain and cough. Even though propoxyphene was withdrawn from the US market in 2010 because of concern for serious adverse cardiac events, sporadic cases of poisoning still continue to occur. Despite the ban, the drug still is available illegally and accounts for a fair number of poisoning each year. Naloxone can reverse the toxicity of propoxyphene but not the cardiac arrhythmias. The cardiac arrhythmias are due to the quinidine-like effects of propoxyphene and are unresponsive to naloxone. Propoxyphene is known to cause sinus bradycardia, ear block or ventricular arrhythmia. The treatment is to immediately administer sodium bicarbonate.
Diphenoxylate/atropine: This combination product is often used to treat diarrhea. The diphenoxylate acts like an antidiarrheal agent, and the atropine is an anticholinergic that is added to deter deliberate overdose. Atropine has no antidiarrheal activity. When high doses are ingested, one may note mainly anticholinergic side effects, respiratory depression, and constipation. Because of the long half-life of diphenoxylate, the adverse effects can be worrying. The majority of cases of diphenoxylate/atropine overdose are seen in children. If the child is seen in the emergency room within a few hours after ingestion, gastric decontamination with activated charcoal may be attempted. All children need to be observed for a minimum of 6 hours to ensure that they do not develop arrhythmias.
Body packers: Over the past 2 decades, the transport of illicit drugs in the body has become very common. These individuals place drugs inside plastic bags or condoms and ingest them. Often the number of packages ingested vary from 1 to 3 dozen and even though well wrapped, sometimes the packages do break open and systemic toxicity results. Others may develop complications like bowel obstruction or intestinal perforation. In some cases, when the individual is pursued by police, he or she may stuff the drugs into the anus, vagina, or ingest them. These individuals are likely to suffer from adverse effects because the drugs are often not properly packaged. After ingestion, systemic symptoms appear rapidly, and these individuals often require aggressive medical therapy to prevent death, and in some cases, surgery is required to relieve a bowel obstruction. Even after surgery, if the drugs have been absorbed into the systemic circulation, the risk of death is often high.
History and Physical
Since the majority of patients overdosed on opiates are lethargic or comatose, the history is usually obtained from family, friends, bystanders, and emergency medical service providers. On many occasions at the scene, one may find pills, empty bottles, needles, syringes and other drug paraphernalia. Other features that one should try and obtain in the history are the amount of drug ingested, any congestion, and time of ingestion. In the prehospital setting, sometimes EMS personnel may administer naloxone, which may help make the diagnosis of opiate overdose.
Universally, patients with opiate overdose may be lethargic or have a depressed level of consciousness. Opiate overdose will also cause respiratory depression, generalized central nervous system (CNS) depression, and miosis. However, it is important for all healthcare workers to be aware that miosis is not universally present in all patients with opiate overdose and there are many other causes of respiratory depression. Other features of opiate overdose include euphoria, drowsiness, change in mental status, fresh needle marks, seizures and conjunctival injections.
Examination of the extremities may reveal needle track marks if intravenous opiates are abused. Morphine and heroin are also injected subcutaneously by many addicts. In some cases, the opium oil may be inhaled, and the individual may also have patch marks on the body from the use of fentanyl. Most opiates can cause the release of histamine which can result in itching, flushed skin, and urticaria.
In some cases of morphine toxicity, the respiratory distress and hypoxia may, in fact, present with pupillary dilatation. In addition, drugs like meperidine, morphine, propoxyphene and diphenoxylate/atropine are known to cause midpoint pupils or frank mydriasis. The breathing is usually impaired in patients with a morphine overdose. One may observe shallow breathing, hypopnea, and bradypnea. The respiration rate may be 4 to 6 breaths per minute and shallow. Since opiates can also cause bronchoconstriction, some individuals may present with dyspnea, wheezing and frothy sputum.
Most opiates are known to cause peripheral vasodilatation, which can result in moderate to severe hypotension. However, this hypotension is easily reversed with changes in body position or fluid administration. If the hypotension is severe and is unresponsive to fluids, then one must consider other coingestants.
Both nausea and vomiting are also seen in patients with opiate toxicity;. The reason is that opiates can cause gastric aperistalsis and slow down the intestine motility.
Even though opiates are generalized CNS depressants, they can cause the following neuropsychiatric symptoms:
Opiates do have the ability to lower the threshold for seizures, and generalized seizures can occur, especially in young children. This is primarily due to paradoxical excitation of the brain. In adults with seizures, the 2 opiates most likely involved are propoxyphene or meperidine. In rare cases, hearing loss may be noted especially in individuals who have consumed alcohol with heroin. However, this auditory deficit is reversible.
It is important to always consider opiate overdose or toxicity in a lethargic patient with no other identifiable cause. Many of the individuals who abuse opiates also tend to use other illicit agents like cocaine and prescription drugs like the antidepressants and benzodiazepines at the same time. Suspicion of coingestants should be raised when the usual clinical signs and symptoms of opiate toxicity differ, and the patient fails to respond to the opiate antagonist, naloxone.
Patients with drug overdose usually undergo several investigations. Drug screens are readily available but often do not change initial management of straightforward cases. Drug screens when performed on urine and are quite sensitive. In most cases, a positive opiate result will show up even 48 hours post exposure.
In patients with opiate toxicity or overdose the following blood work is usually performed:
- Complete blood cell count
- Comprehensive metabolic panel
- Creatine kinase level
- Arterial blood gas determinations
- If any lung injury is suspected, a chest x-ray should be obtained.
- If the patient is suspected of being a body packer, then an abdominal x-ray should be obtained. In some cases, a person may swallow packages in order to hide the evidence from law enforcement. In such cases, the packages are not well prepared, and these individuals are at risk for severe toxicity if leakage inside the intestine occurs.
An ECG is recommended in all patients with suspected opioid overdose. Coingestants like the tricyclics have the potential to cause arrhythmias.
- Gamma-hydroxybutyrate toxicity
- Neuroleptic agent toxicity
Following an opiate overdose, the major cause of morbidity and mortality is due to respiratory depression. Rarely the individual may develop seizures, acute lung injury and adverse cardiac events. In individuals with prior lung pathology who overdose on opiates, the risk of respiratory distress and death is much higher than in the normal population. The other reason for the opiate toxicity may be due to coingestants, and the eventual toxicity depends on the type of co-ingestant. In one Canadian study, the risk of fatal opiate toxicity was doubled when the opiate was ingested with gabapentin; the latter is also known to depress respiration. Finally, the morbidity and mortality also depend on the reason why the opiate was ingested; some people are intent on committing suicide, and these individuals often take several other drugs at the same time, thus, greatly increasing the risk of death.
If the patient does arrest in the setting of a pure opiate overdose, the cause in most cases is severe hypotension, hypoxia and poor perfusion of the brain. The outcome for these patients is poor.
Opiates are also associated with a few other complications besides the usual respiratory and CNS adverse effects.
Acute Lung Injury
Acute lung injury is well known to occur after a heroin overdose. However, acute lung injury can also occur following methadone and propoxyphene overdose and is universally present in patients who expire from a high dose of opiate. As to how these opiates cause lung injury is not fully understood, but the eventual result is hypoventilation and hypoxia. Clinically, heroin-induced lung injury will present with sudden onset of dyspnea, frothy sputum, cyanosis, tachypnea, and rales- features consistent with pulmonary edema. Acute lung injury is also known to occur in children who have ingested high doses of opiates. Acute lung injury is very similar to ARDS in presentation, and most cases clear up with aggressive airway management and oxygen. The usual drugs used to manage pulmonary edema are not used, and in fact, the use of diuretics may exacerbate the hypotension.
In individuals who use intravenous opioids, complications include abscess, cellulitis, and endocarditis. The most common organisms involved are the gram-positive bacteria like Staphylococcus and Streptococci. If the bacteria enter the systemic circulation, the risk of epidural abscess and vertebral osteomyelitis are other potential complications. These patients may present with fever and continuous back pain. Some IV drug abusers are known to inject the opiates directly into the neck, and this can lead to jugular vein thrombophlebitis, Horner syndrome and even pseudoaneurysms of the carotid artery. Both peripheral and pulmonary emboli have been reported in IV drug users. Accidental injection into the nerves has also been reported to cause permanent neuropathy.
Endocarditis is a serious complication of intravenous drug abuse. Often these individuals use a mixture of illicit drugs and dirty needles. The diagnosis of infectious endocarditis is often difficult as the symptoms are vague initially. Although in most cases, the right-sided heart valves are affected, sometimes the left-sided valves may also be involved. The most common valves involved in intravenous drug users is the tricuspid valve. It often presents with fever, malaise and a new murmur. In some patients, recurrent septic pulmonary embolism may be the only presenting feature. The most common organism involved in right-sided endocarditis is Staphylococcus aureus, but left-sided endocarditis may be polymicrobial and include Streptococcus, E. coli, Pseudomonas or Klebsiella. In most patients, when the left-sided valves are involved, the symptoms and signs are usually more obvious compared to right-sided involvement.
Other manifestations of opioid abuse may be recurrent pneumonia, and in some cases, aspiration pneumonia may also occur with the individual is unconscious.
Rhabdomyolysis is not an uncommon complication of opiate overdose. It may occur even in the absence of a compartment syndrome.
Another life-threatening complication is necrotizing fasciitis that often presents with severe pain, fever, dark, dusky skin with crepitus. The individual will show signs of septic shock. Aggressive resuscitation and immediate surgical debridement can be life-saving.
Seizures: Opiates are known to increase the risk of seizures, especially drugs like propoxyphene, meperidine, pentazocine, intravenous fentanyl, and heroin. The individual may present with a prolonged seizure which may result as a result of CNS hypoperfusion and hypoxia or a result intracranial injury due to a fall.
Narcotic Bowel Syndrome
Narcotic bowel syndrome is a type of opiate bowel pathology that is characterized by frequent episodes of moderate to the severe abdominal pain that worsens with escalating or continued doses of opiates. Narcotic bowel syndrome appears to occur in people with no prior bowel pathology and is a maladaptive response. The syndrome can also be associated with intermittent vomiting, abdominal distension, and constipation. Eating always aggravates the symptoms, and the condition can last for days or weeks. Anorexia can lead to body weight loss. There is delayed gastric emptying and intestinal transit. The syndrome is often confused with bowel obstruction. The key to the diagnosis is the recognition of continued and escalating doses of opiates that worsen the abdominal pain, instead of providing relief. The treatment of narcotic bowel syndrome is some psychotherapy combined with tapering or discontinuing the opioid. The key to successful treatment is to develop a strong patient-physician relationship and trust with the patient; the narcotic should be gradually withdrawn, and other non-pharmacological treatments used to manage pain.
Withdrawal symptoms following cessation of opiates are common, but the symptoms are often vague and not as severe as those observed with alcohol or benzodiazepines discontinuation. The onset of symptoms depends on the drug ingested and usually occur within 2 to 4 days with methadone and 8 to 10 hours after meperidine. The autonomic symptoms may include excessive lacrimation, sweating, piloerection, rhinorrhea, repeated yawning, myalgia, nasal congestion, diarrhea and abdominal cramps. The symptoms usually peak between 36 to 48 hours and gradually subside in 72 hours. In chronic drug addicts, the symptoms may last for 7 to 14 days. The treatment of withdrawal symptoms is supportive. The use of additional opiates to counter the symptoms of withdrawal is not recommended. For severe withdrawal cases, one may use clonidine, especially when methadone may be inappropriate or unavailable. After the acute treatment, the patient should be recommended to join a long-term drug rehabilitation program to prevent relapse.
Deterrence and Patient Education
In early 2015, the US Dept of Health and Human Services acknowledged the expanded use of naloxone among healthcare professionals to counter the opiate overdoses in the nation. Now, pharmacists, emergency medical personnel, and physicians can all play an active role in the prevention of opiate overdose. In addition, the current recommendations also suggest co-prescription of naloxone to the patients who are prescribed opiates. Several studies are showing that patients who had been prescribed naloxone at the same time as an opiate, have fewer opiate-related emergency room visits than those who did not receive naloxone. Today, some healthcare workers have started to prescribe naloxone to patients who are prescribed high doses of opiates.
Recently, the US Food and Drug Administration also approved the use of a hand-held auto-injector that can be prescribed to caregivers or family members for managing a person who is suspected of having an opiate overdose. In addition, all over the country, numerous naloxone organizations have cropped up to fight the opiate overdose epidemic.
In some states, there are now programs that permit pharmacists to prescribe naloxone to prevent the epidemic of opiate overdose. Recent data indicate that patients have started to acquire naloxone rescue kits, but there are no long-term data to determine their role in preventing opiate toxicity.
Enhancing Healthcare Team Outcomes
With the drastic increase in opioid abuse and overdose-related death, there has been a lot of focus on the “opioid epidemic.” All healthcare workers (including nurse practitioners) who prescribe controlled substances have a role to play in decreasing the opioid epidemic.
New research is focusing on finding effective interventions and identifying risk factors for overdose. Examples of some of these efforts include treatment programs, take home intranasal naloxone, and monitored injection facilities. A review article of research exploring overdose education and naloxone distribution suggests a reduced fatality for patients who receive counseling and prescription of home naloxone.
Naloxone has been shown to have a very safe side effect profile. There have been several studies on opiate-naive patients who were given large doses of the drug without significant effects, but when given to patients who are opioid-tolerant, acute, opioid withdrawal symptoms can develop. Individuals administered naloxone in the setting of opioid overdose can experience a sudden withdrawal syndrome, which includes sudden aggression, agitation, restlessness, diaphoresis, and tachycardia. GI symptoms such as nausea and vomiting also occur in about 30% of patients. Most symptoms are not very severe or sustained, and less than 1% of patients require admission. Acute withdrawal symptoms are more likely when larger doses of naloxone are used.