A NURSE IS TAKING a break from a busy shift in the ED by getting some fresh air at the hospital's front entrance when a car rapidly pulls up. The panicked driver gets out and yells for help. As the nurse approaches the vehicle, he sees a young woman in the front seat slumped to the side. He opens the door and unsuccessfully tries to arouse her. As he shouts for security to get help and bring a stretcher, he sees that the patient's respirations are slow and shallow. He assesses for a carotid pulse, which is slow and weak.
When the patient arrives at the resuscitation bay, the nurse's primary assessment findings include a patient unresponsive to pain. The patient's vital signs are heart rate, 50 beats/minute; respiratory rate, 8 breaths/minute; and BP, 84/60 mmHg. Cardiac monitoring shows sinus bradycardia and oxygen saturation is 85% on room air. Additional neurologic assessment reveals pinpoint pupils that minimally react to light. No signs of trauma, especially head trauma, are noted. When asked about the patient's pertinent health history, the boyfriend who drove her to the hospital reluctantly says that she frequently takes oxycodone extended-release tablets and has a history of heroin use.
Ventilatory support with a bag-valve-mask is begun immediately to deliver oxygen and assist the patient's respirations. The ED staff inserts a large-bore peripheral venous access device and begins an infusion of 0.9% sodium chloride solution. The ED physician orders administration of I.V. naloxone. The patient's mental status rapidly improves and her vital signs begin to normalize.
Epidemiology of a crisis
Unfortunately, the above scenario is only too common in many communities in the US. From July 2016 to September 2017, opioid overdoses increased 30% in 45 states, with the Midwest (70% increase) and urban cites (54% increase) being particularly affected.1
The National Institute on Drug Abuse reported in March 2018 that more than 115 Americans lose their lives every day due to opioid overdose with drugs such as prescription pain relievers and heroin.1 In 2016, about 66% of drug overdose deaths involved an opioid.2
Since 1999, the amount of prescription opioids in the US has quadrupled even though the amount of pain reported by patients has not changed.2 In the US, this abuse places a significant economic burden that has been estimated at $78.5 billion in direct and indirect costs as well as lost productivity.3
Three potential reasons for the prescription opioid epidemic's perpetuation have been identified.4
- The first is the strong desire by providers to alleviate their patients' pain and suffering. Because providers feel that pain management is a patient's essential right, their prescribing efforts may be interpreted as patient advocacy.
- With the advancement of patient reporting systems, patient surveys, and “at risk” compensation for low scores, providers feel compelled to treat pain more aggressively.
- Pharmaceutical companies have aggressively marketed prescription opioids to the public as pain treatment.4
Most opioids are pain relievers made from opium, which is derived naturally from the poppy plant, although some opioids, such as fentanyl, are synthetic.5 Morphine and codeine are two natural opiates that have a long history of use in healthcare. In addition, many semisynthetic opioids are similar to morphine, such as hydrocodone and oxycodone.6
The most life-threatening effect of opioids is opioid-induced respiratory depression (OIRD), which is the primary cause of injury and death from opioid abuse and misuse.6 However, even when taken at recommended doses and without any comorbidities or contributing factors, opioids can cause clinically significant respiratory depression in some patients.6,7
The effects of opioid medications can be potentiated when they are taken with other drugs and substances that produce a sedative effect, including alcohol.8 A common pattern of abuse and misuse includes concurrent use of benzodiazepines (such as alprazolam or diazepam) and skeletal muscle relaxers (such as carisoprodol or cyclobenzaprine) in combination with an opioid.8 Benzodiazepines are indicated to treat anxiety, sleep disorders, muscle spasms, alcohol withdrawal, and seizures.9 When inappropriately or unknowingly used in high doses with an opioid, this toxic combination of drugs increases the risk of OIRD and even death in certain patient populations, such as patients over age 65. Their ability to renally clear these drugs is decreased, which predisposes them to overdosing.8,10 The risk is so severe that in 2016, the FDA required manufacturers to include strong warnings in the labeling of opioid analgesics, opioid-containing cough products, and benzodiazepines to alert healthcare providers and patients to the risk of serious adverse reactions and death associated with combined use.11
As always, begin with an assessment of the patient's level of consciousness, airway, breathing, and circulation. Signs and symptoms of opioid overdose include decreased level of consciousness, bradypnea, bradycardia, and hypotension. Additionally, opioids often cause miosis, although normally reactive pupils do not rule out opioid overdose.5 Evidence at the scene may point to overdose or opioid exposure, and a history obtained from the patient, family, or bystanders may also point to a potential overdose. Nurses should inspect the skin for signs of injection drug use, including scars at injection sites (“track marks”).12 A rapid glucose assessment should be obtained in any patient with altered mental status.5
The foundation of treatment for a potential overdose is aggressive airway control. Basic airway management by maintaining a patent airway, providing supplemental oxygen, and rescue breathing when indicated are key initial steps, but expeditious endotracheal intubation may be indicated for those who cannot protect their airway.13
The next most important step is the administration of naloxone, a short-acting opioid antagonist.5 Naloxone may be administered nasally, I.V., subcutaneously, or I.M.5 After ventilation is restored with naloxone, repeat doses may be required, depending on the opioid's quantity and duration of action.5 In patients with opioid dependence, naloxone can precipitate signs and symptoms of opioid withdrawal, including nausea and vomiting, and agitation.13 Monitor patients closely and be prepared to intervene as indicated.
In overdose situations where the patient has combined opioid medications with alcohol or sedative medications, keep in mind that naloxone will reverse the effects of the opioid medication only. The patient may need additional measures to manage the effects of concomitant drugs.14 Nurses also need to anticipate combative behavior from patients who have received naloxone. Nurses should call for adequate help, including security personnel, and be prepared to use patient restraints as needed.
The ultimate goal is to decrease the supply of opioids in our homes and communities and to ensure that those who have access to these medications are educated on their proper use, storage, and disposal. Tackling issues at both the healthcare level (prescribers, nurses, and other healthcare professionals, such as pharmacists) and the community level (patients and families) helps to guarantee appropriate measures are in place to safely prescribe, dispense, and use opioid medications when necessary.
Many public health initiatives have been launched to address the current crisis. To learn about needle exchange programs and safe injection sites, see “Making the Case for Harm Reduction Programs for Injection Drug Users” in the June issue of Nursing2018.
Many states are enacting legislation to reflect recent updates to the Federal Controlled Substance Act such as the North Carolina Strengthen Opioid Misuse Prevention (STOP) Act of 2017. This legislation details requirements for prescribers and dispensers of opioid medications, and provides greater funding for community-based and recovery services.15 An important component of the STOP Act is the use of a Controlled Substances Reporting System (CSRS), an electronic database on the prescribing and dispensing of controlled substances. Studies have shown a 30% reduction in the prescribing of schedule II opioid medications with implementation of CSRS.16 While awareness of opioid registries is high among attending and resident physicians, their utilization has been reported significantly low.17
Secure take-back programs make medication drop boxes available to the public. Such boxes provide a venue for users to properly dispose of expired or unused medications, which lessens the risk of medication abuse or theft. Generally, these boxes are supervised by a registered pharmacy, which assures contents are packaged and shipped to appropriate vendors for destruction. A similar system provides users with a medication disposal pouch that includes components that chemically deactivate hazardous medications. This system can be used anywhere including patients' homes, although the amount of medication that can be deactivated per bag is limited. In addition, this system tends to be expensive for routine public use. Similarly, many communities now sponsor Medication Take-Back events, which are often done through a partnership with local law enforcement.
Another important approach relates to emergency treatment of potential overdoses, which lessens the likelihood of a fatal outcome. Most states and the District of Columbia now have legislation allowing the layperson to access naloxone, generally in intranasal form.18 Naloxone overdose prevention laws vary from state to state, but generally protect professional and lay responders from civil or criminal liability related to opioid antagonist administration. This legislation may also cover participating pharmacies that agree to stock and dispense naloxone without a prescription if certain criteria are met.19
However, the greatest impact may be made by actively educating ourselves, our patients, and our communities to the dangers of opioid abuse; proper administration, storage, and disposal of opioids; availability of treatment programs; and emergency treatments for overdose. It is imperative that healthcare providers at all levels, healthcare organizations, and other community organizations partner to address this ongoing public health challenge.
4. Weiner SG, Malek SK, Price CN. The opioid crisis and its consequences. Transplantation
6. Yaksh TL, Wallace MS. Opioids, analgesia, and pain management. In: Brunton LL, Chabner BA, Knollmann BC, eds. Goodman & Gilman's Pharmacological Basis of Therapeutics
. 12th ed. New York, NY: McGraw-Hill Education; 2011.
8. Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis. BMJ
9. Valium [package insert]. Nutley, NJ: Roche Pharmaceuticals; 2008.
10. van der Schier R, Roozekrans M, van Velzen M, Dahan A, Niesters M. Opioid-induced respiratory depression: reversal by non-opioid drugs. F1000Prime Rep
12. Dugosh KL, Cacciola JS. Clinical assessment of substance use disorders. UpToDate. 2018. http://www.uptodate.com
16. Bao Y, Pan Y, Taylor A, et al Prescription drug monitoring programs are associated with sustained reductions in opioid prescribing by physicians. Health Aff (Millwood)
17. Feldman L, Skeel Williams K, Knox M, Coates J. Influencing controlled substance prescribing: attending and resident physician use of a state prescription monitoring program. Pain Med