Opioid Overdose

What is Opioid Overdose?

People often go to the doctor for pain relief. One common way doctors help is by prescribing opiates, which are drugs that have been used for pain relief for nearly 70 years. Generally, these drugs have been considered safe. However, over the past 20 years, concerns have been raised about their safety. Many individuals have accidentally overdosed or experienced harmful side effects from these drugs in every major city in the U.S.

Dramatically, there’s been a significant increase in opiate prescriptions over the past two decades. This has led to a wave of overdoses outside of healthcare environments. Therefore, healthcare professionals must be aware of signs of opiate side effects in patients who appear drowsy or unresponsive for no apparent reason.

Information from the Drug Enforcement Agency (DEA) and the Centers for Disease Control and Prevention (CDC) reveals that the misuse of opiates, opiate prescriptions, and deaths caused by opiates all increased greatly from 2001 through 2010 in the U.S. Although these rates stabilized from 2011 through 2013, they began to rise again from 2013 to 2014.

Opioid overdose happens when someone takes too much of an opiate drug and it overstimulates the body’s opiate systems. This can lead to decreased breathing and even result in death. The CDC estimates that every day, there are more than 1000 visits to emergency departments due to misuse of opioids, and around 91 people die of opioid overdose.

Between 1999 and 2010, the number of prescriptions for opioid-based medications increased four times, mirroring a similar increase in opioid-related overdose deaths. Most of these deaths are linked to heroin use and other synthetic opiates.

When pain is not effectively treated, healthcare professionals often prescribe a wide array of short- and long-acting opiates. While these can help with pain relief, problems arise when patients don’t stick to the prescribed dosages. Sadly, it’s not unusual for people who misuse prescription opioids to eventually start using heroin because it’s cheaper and often easier to buy illegally.

Further complicating matters is the increasing trend of mixing heroin with fentanyl and other synthetic opioids, which can make the potency of the drug unpredictable and increases the risk of overdose. Additionally, street-bought drugs are often contaminated with other substances, which can pose further risks.

Most states now have programs that monitor opiate prescriptions to help curb the overprescription of these drugs by healthcare professionals. For example, in Kentucky, healthcare providers must first check the state’s online drug database before they can prescribe an analgesic drug to a patient. This kind of legislation is designed to prevent healthcare professionals from prescribing too many opiates and to stop legitimate prescriptions from being misused. The DEA also keeps state-by-state registries of controlled substances to help healthcare providers identify patterns of use in patients and spot those at risk of misusing opiates.

What Causes Opioid Overdose?

Opioid overdose can occur for a variety of reasons:

* Problems related to drug abuse
* Accidental overdose
* Deliberate overdose
* Mistakes in prescribed medication

The chance of experiencing an opioid overdose becomes higher for certain individuals, including:

* Those who regularly increase their doses
* Those who use again after stopping
* Those who have severe health issues like depression, HIV, or diseases of the lung or liver
* Those who mix opioids with relaxing medications
* Men more than women
* Younger people, particularly those aged between 20 to 40
* Non-Hispanic white individuals

Over 1.5 million visits to hospital emergency rooms each year are linked to opioids, which are a common cause of death resulting from an overdose.

Risk Factors and Frequency for Opioid Overdose

In the United States, doctors often prescribe opiates for moderate to severe pain. These drugs can be prescribed on their own or along with other medications like anti-inflammatory drugs or muscle relaxants. Between 2004 and 2011, the use of various opiates increased considerably:

• Buprenorphine usage increased by 2318%.
• Fentanyl usage increased by 35%.
• Hydromorphone usage increased by 140%.
• Methadone usage increased by 37%.
• Morphine usage increased by 64%.
• Oxycodone usage increased by 117%.

Meanwhile, the use of codeine, another type of opiate, decreased by 20%. Data has shown that abuse of all these opiates also increased, with hydromorphone and buprenorphine having the highest increase rates of 438% and 384% respectively. In 2013, there were roughly 420,000 emergency room visits related to opiate use. Several opiates, including hydrocodone, hydromorphone, fentanyl, morphine, oxycodone, and tramadol, have been increasingly abused or misused over the last ten years.

In 2015, poison control centers reported over 18,000 single exposures to pure opiates, resulting in 68 deaths and 764 cases of serious toxicity. There were also over 14,000 cases of combined opiate exposure with substances such as alcohol, benzodiazepines, aspirin, acetaminophen, or ibuprofen. This combination resulted in 32 deaths and 288 cases of severe toxicity.

The issue of opiate abuse isn’t just happening in America; it’s a problem all around the world as well. According to estimates from the United Nations Office on Drug and Crime in 2014, around 0.4% of the global population, or close to 20 million people, regularly use heroin or opium. South West Asia has the highest usage rate. In Europe, a significant number of opiate-related deaths are linked to the illicit use of fentanyl and its derivatives. In countries where heroin is scarce, fentanyl and similar products have replaced it as the illicit drug of choice.

Signs and Symptoms of Opioid Overdose

Opiate overdose is a serious condition that often results in patients appearing very sleepy or even unconscious. Information about the overdose is typically gathered not from the patient themselves, but from those around them such as family, friends, and emergency medical responders. Items like pills, empty bottles, needles, and other drug-related items found at the scene can be helpful in identifying the cause. Other useful information includes the amount of drug taken and the time of ingestion. Naloxone, a medication used to reverse the effects of an opiate overdose, may sometimes be administered by emergency medical staff prior to hospital arrival.

People who have overdosed on opiates commonly have a decreased level of consciousness and slowed breathing due to the drugs’ effects on the central nervous system. It’s also possible to observe small, constricted pupils, though this isn’t always present. Other symptoms may include feelings of intense happiness, sleepiness, changes in mental status, new needle marks, seizures, and red eyes.

Upon examining the skin, you might find track marks from needles if the person has been injecting the drugs intravenously. Some people might also exhibit patches on their body from using fentanyl – a potent opioid. Opiates can also trigger a histamine release leading to itching, flushed skin, and hives.

In severe cases, patients may experience breathing difficulties and low oxygen levels, which can cause the pupils to dilate. Certain opiates can further impair breathing and cause symptoms such as shallow breaths, slow breathing, and even bronchoconstriction leading to shortness of breath, wheezing, and frothy sputum.

Opiates can often lead to a drop in blood pressure due to dilation of the peripheral blood vessels. However, this can usually be reversed by changing the body’s position or administering fluids. Unresponsive severe lowering of blood pressure might suggest ingestion of other substances.

Patients might also experience nausea and vomiting as opiates can slow down the movement of the stomach and intestines. Unusual psychological symptoms can also accompany opiate toxicity, these might include:

• Anxiety
• Agitation
• Depression
• Dysphoria (a state of unease or dissatisfaction)
• Hallucinations
• Nightmares
• Paranoia

Despite their general calming effects on the brain, opiates can increase the risk of seizures, especially in young kids. This is due to a paradoxical (unexpected) excitation of the brain. Adults who experience seizures after opiate use have usually taken either propoxyphene or meperidine. In rare cases, temporary hearing loss may occur, particularly in individuals who have combined alcohol with the potent opioid heroin.

Testing for Opioid Overdose

If a person appears very sleepy or lethargic and there’s no clear explanation why, doctors might suspect an overdose of substances known as opiates. This concern is especially relevant if the person is known to use illegal or prescription drugs like opiates, cocaine, antidepressants or benzodiazepines. If this person doesn’t respond to a medication called naloxone, which is used to treat opiate overdose, there’s a chance they may have also taken other substances.

To look into this further, patients suspected of drug overdose will often go through several tests. One common test, a drug screen, is usually performed on urine. This can be quite precise and can often show a positive result for opiates up to 48 hours after they were taken.

In cases of suspected opiate overdose, doctors commonly order the following blood tests:

– A complete blood cell count: A test that counts the cells in a sample of your blood.
– A comprehensive metabolic panel: A blood test that measures your sugar level, electrolyte and fluid balance, kidney function, and liver function.
– A creatine kinase test: A blood test that checks for the enzyme creatine kinase, which can indicate injuries or diseases affecting muscle tissue.
– An arterial blood gas test: A test that measures the amount of acid and oxygen in your blood.

In addition to these tests, if doctors think there may be damage to your lungs, they may order a chest X-ray. In other circumstances, such as when a person is suspected of swallowing drug packages to hide them from the police, an abdominal X-ray may be done. These swallowed packages can be very dangerous as they may leak toxic substances into the person’s intestine.

Patients who are suspected of having an opiate overdose will also typically get an electrocardiogram, more commonly known as an ECG. This test records the electrical activity of the heart. It’s particularly important for those who might have taken certain other drugs because they can cause heart rhythm problems.

Treatment Options for Opioid Overdose

At the scene of a potential drug overdose, the treatment a person receives will depend on their vital signs. If the individual is unconscious or has difficulty breathing, the first thing healthcare providers do is to stabilize their airways. Intubation, which involves inserting a tube into the person’s windpipe to ensure a clear path for airflow, is often necessary for those who are unable to maintain clear airways on their own.

If an opioid overdose is suspected, a drug called naloxone may be administered. Naloxone helps by reversing respiratory depression, in other words, potentially life-threatening slow or ineffective breathing. However, this drug can also make the person agitated or aggressive by reversing the opioid’s effects. For those who frequently use drugs, naloxone should be given in a low dose to start, and increased if necessary. This process can also happen in an ambulance, where restraints may be used if the individual becomes violent.

Upon arrival at the emergency department, doctors would continue the treatment protocol. If the individual is showing signs of breathing difficulties or an inability to protect their airways and hasn’t been intubated, healthcare providers wouldn’t hesitate to perform the procedure. To rule out any hidden injuries, they stabilize the neck to prevent further damage to the cervical spine, if necessary. Generally, they would also test blood glucose levels in case the person is lethargic or unconscious for an unknown reason.

Opioid overdoses are typically managed with supportive care like breathing support, cardiopulmonary resuscitation (CPR) if heartbeat or breathing has stopped, and removing the opioid source if it’s from a patch or infusion. Naloxone can also be given via multiple methods, including direct injection into a vein, muscle, or under the skin, as well as spraying into the nose. Research is ongoing to determine the effectiveness of different administration routes.

Naloxone is a medication that works against the effects of opioids, without having any opioid effects of its own. It can reverse opioid overdose effects within minutes, but it can also cause withdrawal symptoms such as pain, nausea, and agitation. So care should be taken in administering the drug especially to people who frequently use opioids.

Going forward, if the individual swallowed packets of drugs, bowel irrigation may be considered. This process involves flushing out the digestive system with fluids. However, this is not recommended if there are signs of a blocked or perforated bowel, unstable blood pressure, or unprotected airways. In rare cases where naloxone doesn’t have the desired effect, another drug called buprenorphine may help.

Doctors are beginning to allow bystanders to administrate naloxone through the nose in emergency situations outside of the hospital. This could be beneficial given the increase in opioid overdoses, and promising results have been seen in research studies. Quick administration of naloxone is crucial to give the victim their best chance of survival.

It is also noteworthy that naloxone can be given to children following a protocol related to age and weight. A recent development includes combinations of naloxone and buprenorphine, especially useful since it minimizes withdrawal symptoms. Although generally regarded as safe, naloxone can still cause unpleasant side effects such as aggressive behaviour, restlessness, and sweating. About 30% of patients may also experience nausea and vomiting.

Patients who have overdosed on opioids and have received naloxone successfully will often be kept in the hospital for monitoring for 12 to 24 hours. This is because naloxone’s effects only last about one to three hours, and some long-acting opioids might continue to cause drowsiness and breathing difficulties. To reduce the risk of overdose and bridge the gap between opioid use disorder and medical treatment, data suggest that high-risk narcotic users could benefit from home-based naloxone programs.

Finally, an amendment known as the Mainstreaming Addiction Treatment (MAT) Act enables healthcare providers holding a controlled substance license to prescribe buprenorphine, an opioid use disorder treatment drug, thereby integrating substance use disorder treatments throughout healthcare settings.

What else can Opioid Overdose be?

Several conditions can cause similar symptoms that often confuse patients and health professionals. Here are some potentially harmful health conditions that might initially appear the same, but indeed require different medical attention:

• Clonidine toxicity
• Cyanide toxicity
• Diabetic ketoacidosis
• Ethylene glycol toxicity
• Gamma-hydroxybutyrate toxicity
• Hypercalcemia
• Hypernatremia
• Hypothermia
• Meningitis
• Neuroleptic agent toxicity

It’s important to remember that a proper diagnosis can only be made by a qualified health professional based on a thorough examination and tests.

What to expect with Opioid Overdose

After an overdose of opioids (drugs like heroin or prescription pain relievers), the main threat to health and life comes from slowed or stopped breathing. In rare cases, the person might also face seizures, sudden lung damage, and harmful heart events. People who overdose on opioids and already have lung problems are at a greater risk of struggling to breathe and possibly dying, compared to the general population.

Opioid overdoses can also become more harmful if other substances are taken at the same time. For example, a study in Canada found that the risk of a fatal opioid overdose doubled when the person had also taken gabapentin, a drug that can also slow breathing. In addition, the reason behind the opioid use can affect the risks. Some people take opioids intending to harm themselves, often combining several other drugs, which greatly increases the chance of death.

If a patient experiences a serious health crisis such as a cardiac arrest due to an overdose of only opioids, it’s often because their blood pressure has dropped dangerously low, they aren’t getting enough oxygen, or their brain isn’t receiving enough blood flow. These situations are risky and recovery can be very challenging.

Possible Complications When Diagnosed with Opioid Overdose

Opiates, or drugs derived from opium, can cause various complications aside from their typical impact on the respiratory and central nervous systems.

One such problem is Acute Lung Injury. This can happen following an overdose of opiates such as heroin, methadone or propoxyphene. In all severe opiate overdose cases, acute lung injury is universally present, leading to hypoventilation (slow or shallow breathing) and hypoxia (lack of oxygen in the body). It causes symptoms such as rapid onset of breathing difficulties, frothing at the mouth, turning blue due to lack of oxygen (cyanosis), rapid breathing (tachypnea), and rales which indicate fluid in the lungs. This condition is like ARDS (acute respiratory distress syndrome) and typically gets better with aggressive management of the airway and oxygen supply.

Infections are another complication for those who inject opiates into their bodies. This can lead to abscesses, skin inflammation (cellulitis), and inflammation of the heart’s inner lining (endocarditis). Such infections are often caused by a variety of gram-positive bacteria including Staphylococcus and Streptococci. When bacteria reach the bloodstream, there’s a risk of epidural abscesses and vertebral osteomyelitis. Symptoms include a persistent fever and backache. Injecting opiates directly into the neck can lead to complications such as inflammation of the jugular vein, Horner syndrome, and pseudoaneurysms of the carotid artery. Injecting into nerves can cause permanent nerve damage.

Endocarditis is a serious issue linked to intravenous drug misuse, often in individuals who use a mix of illegal substances and unclean needles. This complication presents with vague initial symptoms, making diagnosis difficult. Though it frequently affects right-sided heart valves, sometimes it might affect the left side. The tricuspid valve, typically affected in intravenous drug users, often shows symptoms such as fever, fatigue and a new heart murmur. Septic pulmonary embolism (blockage in one of the pulmonary arteries) can sometimes be the only symptom. Different bacteria are involved depending on which side of the heart is affected, with Staph aureus mostly seen in right-sided endocarditis while polyspecies of microbes are involved on the left side.

Using opioids can also lead to recurrent pneumonia. Rhabdomyolysis, a condition causing severe muscle damage, can occur even without acute compartment syndrome (increased pressure within a muscle compartment). Another severe complication is necrotizing fasciitis, a flesh-eating disease presenting with severe pain, fever, and dark skin. It can progress to septic shock, requiring immediate aggressive treatment and surgical intervention.

Several opioids can increase seizure risk. Seizures could be due to low CNS oxygen levels or injuries due to falls.

Narcotic Bowel Syndrome, another problem, results from increasing or steady opioid doses which worsen abdominal pain instead of relieving it. Symptoms worsen with eating and can last for days or weeks. It can also cause vomiting, bloating, and constipation. The condition is often mistaken for bowel obstruction. The main treatment involves psychotherapy and lowering or discontinuing the opioid with a strong patient-doctor trust relationship being key to success.

Finally, withdrawing from opiates can produce symptoms such as excessive tears, sweating, goosebumps, running nose, frequent yawning, muscle pain, nasal congestion, diarrhea, and abdominal cramps. Symptoms are usually at their worst about 36 to 48 hours after cessation, gradually fade after 72 hours, and can last for a week or two in chronic drug users. Treatment includes support and, in severe cases, clonidine (a blood pressure medication). After immediate treatment, patients should enter a long-term drug rehabilitation program to avoid a relapse.

Preventing Opioid Overdose

In 2015, the US Department of Health and Human Services recognized the need for wider use of a drug called naloxone. Naloxone is commonly used by healthcare professionals to quickly reverse the effects of an overdose from opioids, a group of drugs that includes painkillers and illegal drugs like heroin. This means that not just doctors, but also pharmacists and emergency medical staff, can help prevent opioid overdoses by using naloxone.

Current suggestions also include giving out naloxone alongside opioid prescriptions. Research has shown that patients who get naloxone at the same time as their opioid prescription tend to have fewer emergency room visits due to opioid-related issues versus those who don’t receive naloxone. Some healthcare providers are now prescribing naloxone to patients who are prescribed high doses of opioids.

The US Food and Drug Administration has approved a hand-held device that automatically injects naloxone. This device can be given to caregivers or family members to help someone they believe is experiencing an opioid overdose. Also, several organizations across the country are popping up to combat the opioid overdose problem, primarily by spreading the use of naloxone.

In some parts of the country, there are now programs that allow pharmacists to directly give out naloxone to further prevent opioid overdoses. Recent information points out that more and more patients have started to get naloxone rescue kits. However, long-term data is not yet available to determine the role of these kits in preventing harm from opioid misuse.