The president of the United States declared the opioid crisis a nationwide public health emergency. The Centers for Disease Control and Prevention estimate that 91 Americans die from an opioid overdose each day.
The opioid epidemic began in the 1990s, when doctors became increasingly aware of the pain that their patients were in. Pharmaceutical sometimes pushed doctors, with potentially misleading marketing about the safety and efficacy of the drugs, to prescribe opioids to treat all sorts of pain. Doctors, many exhausted by dealing with difficult-to-treat pain patients, complied — in some states, writing enough prescriptions to fill a bottle of pills for each resident.
The drugs proliferated, making America the world’s leader in opioid prescriptions. As Stanford drug policy expert Keith Humphreys previously noted, “Consider the amount of standard daily doses of opioids consumed in Japan. And then double it. And then double it again. And then double it again. And then double it again. And then double it a fifth time. That would make Japan No. 2 in the world, behind the United States.”
The U.S. opioid epidemic is continuing, with drug overdose deaths nearly tripling between 1999 and 2017. These numbers show that this is a community-wide problem, and we need a community-wide response. In this course, you’ll learn what you can do to help with overdose prevention and how to respond to an opioid overdose incident.
WE WILL EXPLORE:
- What are opioids?
- What does it mean to overdose?
- What are the risk factors for opioid overdose?
- What should I do if someone overdoses?
- What is Narcan and how would I use it?
Every person who uses drugs puts themselves at risk for an overdose, regardless of the way they’re putting the drug into their body-could be smoking it, injecting it, swallowing pills.
Opioids are psychoactive chemicals that occur naturally (in the resin of the poppy plant) or can be made in a laboratory. They are sedative narcotics, used in medicine mainly for pain control. Opioids belong to a class of drugs called central nervous system (CNS) depressants. This includes the drugs Heroin, Methadone, OxyContin, Percocet, Fentanyl, Buprenorphine and others. At one time, “opioids’ referred to synthetic opiates only. Now, many use the term opioid to refer to both opiates and synthetic narcotics. All opioids affect the brain in a very similar way.
There are 3 main types of opioids:
- Natural opiates are alkaloids, nitrogen-containing base chemical compounds that occur in plants such as the opium poppy. Natural opiates include Morphine, Codeine, and Thebaine.
- Semi-synthetic/manmade opioids are created in labs from natural opiates. Semi-synthetic opioids include Hydromorphone, Hydrocodone, and Oxycodone (the prescription drug OxyContin), as well as Heroin, which is made from Morphine.
- Fully synthetic/manmade opioids are completely man-made, including Fentanyl, Pethidine, Levorphanol, Methadone, Tramadol, and Dextropropoxyphene.
These drugs are chemically related and interact with opioid receptors on nerve cells in the body and brain. They are sedative narcotics that slow down brain activity, and repress breathing.
Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use—even as prescribed by a doctor—can lead to dependence and, when misused, opioid pain relievers can lead to overdose incidents and deaths.
Extensive work has been done to reduce the availability of prescription opioid pain relievers and decrease the misuse.
50.5% get their drugs from friends or family
22.3% get their drugs from doctors
An opioid overdose can be reversed with the drug Narcan, a brand name for naloxone, when given right away. Narcan will temporarily reverse an overdose on all types of opioids and is one of the key components of overdose response. We will explore this later in the course.
Commonly used opioids:
- Tylenol #
Of all the opioids, a shocking percentage of overdose deaths in recent years have been related to Fentanyl.
This is not the Fentanyl prescribed in a medical setting, which is a fast acting, strong opioid for pain. Instead, synthetic Fentanyl is being illicitly produced in labs outside of the US and has made its way into the Heroin supply.
Fentanyl comes in pill and powder form and is extremely powerful and fast acting. The potency can vary, but Fentanyl can be up to 100 times more potent than Morphine. Other synthetic forms of Fentanyl, such as Carfentanil, can be up to 10,000 times more potent than Morphine. 20 micrograms is enough to kill a person.
Opioids vary in their duration and potency, and this plays a role in assessing risks that could lead to an accidental overdose.
For example, Heroin is a strong opioid that produces effects for 6 to 8 hours. Methadone is a strong opioid too, but acts much longer in your body – between 24 and 32 hours. Codeine is a weaker opioid whose effects last for 3 to 4 hours.
What does this mean? If a person misjudges or is unaware of how long a drug lasts or how strong it is, and takes too much of it, another dose, or another drug, this can cause an accidental overdose.
DRUG DURATION POTENCY
Heroin 6-8 Hours +++++
Methadone 24-32 Hours ++++
OxyContin 3-6 Hours +++++
Codeine 3-4 Hours +
Demerol 2-4 Hours +++
Morphine 3-6 Hours +++
Fentanyl 1-2 Hours +++++++++++
On overdose is defined as an excessive and dangerous dose of a drug. Stated simply, it is too much substance on the brain for it to handle, so the body begins to shut down. Breathing slows and eventually stops.
This excess of a substance leads to CNS and respiratory depression, which can cause a person to become unresponsive and eventually to stop breathing.
Opioid overdoses are not always instantaneous because opiods can peak at different times and interact with additional risk factors. It can take between seconds to hours after using an opioid for an overdose to occur.
Typically overdoses happen over time, where breathing slows down before it stops. However, some opioids like synthetic Fentanyl hit hard and fast and can cause respiratory arrest immediately.
Symptoms of opioid intoxication include:
- small, or constricted, pupils
- slowed breathing or absent breathing
- extreme fatigue
- changes in heart rate
- loss of alertness
People are at a higher risk of overdose after a period of abstinence, or not using, even as little as two days. People who are coming out of treatment programs, such as detox, and those who are being released from jail are at a high risk for overdose if they use for this reason.
Tolerance decreases after the period of abstinence or non-use and the risk for an overdose increases. After someone has overdosed once, they are much more likely to overdose again.
Mixing drugs also puts people at higher risk. In particular, mixing opiates like heroin with other downers like benzos or alcohol.
Shifts in drug purity, or changes in the cut, from place to place or dealer to dealer, can also put people at risk.
As noted earlier, recently Fentanyl has been found in the Heroin supply. It can be indistinguishable from Heroin and with its potency and speed can put the most experienced drug users at risk of overdose.
Also, changes in the way people use drugs, like going from snorting or smoking to injecting, can also put people at higher risk of overdose.
Using alone is the biggest risk factor. This is for the obvious reason that no one is around to recognize the signs of overdose, administer Narcan or call for help.
Anyone who uses drugs can overdose. Overdose risk can increase or decrease depending on variables related to three factors:
Mixing any drugs is dangerous. Particularly, mixing CNS depressants, such as Benzos, alcohol and/or Heroin increases overdose risk. Other drugs may also play a role such as Seroquel, sleeping medications, HIV medications, or even antidepressant medications may interact with illicit street drugs in a way that increases overdose risk. Also, how much substance was used? How potent was the substance in terms of its strength, duration, and quality?
Commonly used non-opioid prescriptions with opioid use:
- Benzodiazepines: prescribed for anxiety, insomnia, nausea
- Clonidine: prescribed for blood pressure, anxiety, opioid withdrawal
- Phenergan (promethazine): prescribed for nausea
- Neurontin (gabapentin): prescribed for seizures, mood stabilization, neuropathy
Tolerance, as noted above, is a person’s diminished response to a drug, which occurs when the drug is used repeatedly and the body adapts to the continued presence of the drug. Tolerance to a substance changes rapidly within a few days of not using or reduced use. As mentioned, increased risk situations include being released from jail, discharge from a hospital or a detox program and starting or tapering methadone maintenance. Other factors that play a part in overdose situations include a person’s HIV or HCV status, prior to a non-fatal overdose and general health issues such as liver, kidney and respiratory function, a compromised immune system, high blood pressure, heart disease, dehydration, malnourishment and mental health status.
Route of Administration:
The route of administration determines how quickly the drug takes effect. Generally, the faster a drug hits the bloodstream (such as injecting it versus smoking it) the greater the risk of an overdose. Injecting poses the greatest risk of lethal overdose by enabling large amounts of a drug into the bloodstream at once.
An overdose is different than just being “high” or intoxicated. It is important for you to recognize the signs of an overdose so you can respond appropriately.
Look for blue lips and fingertips, and watch for slow or labored breathing, or if they’ve stopped breathing altogether. Try to get the individual to respond to you verbally. Gently shake the person to attempt to wake them. Rub the center of their chest (sternum). If there is no response or if you are in doubt call for help and dial or have someone dial 911. In the event you have to leave the person alone, make sure to put them in the recovery position, which means lying the person slightly on their side, their body supported by a bent knee, with their face turned to the side. This will help to keep their airway clear and prevent them from choking in the event they vomit.
Symptoms and signs of an overdose:
- Abdominal pain
- Loss of balance
- Breathing problems
- Disturbed vision
- Internal bleeding
- Blue fingertips, lips
- Changes in breathing
- Difficulty keeping consciousness
- Problems with vital signs
- Skin can be cool and sweaty or hot and dry
- Tiny pupils
- Excessive sweating
Rescue breathing is a critical component in responding to an overdose.
If there are no signs of a neck or back injury, place the individual on their back. Place your ear above the victim’s mouth and nose. Watch for signs of breathing. Gasping is not breathing. If the victim isn’t breathing, start Rescue Breathing. (Use a cardiopulmonary resuscitation (CPR) barrier mask if one is available.) If the person is not showing signs of breathing and you have reservations about giving rescue breathing perform Chest Compression-Only CPR. To perform rescue breathing:
- Pinch the victim’s nose to close nostrils, keeping the airway open by the head-tilt, chin-lift.
- Take a deep breath and seal your lips around the outside of the victim’s mouth, preferably with a CPR barrier mask, creating an airtight seal.
- Give the victim 2 full breaths (1 second each), taking your lips off the victim’s mouth to inhale between each breath.
- Check for chest rising and falling with each breath you give. The rising of the chest during your exhalations indicates the effectiveness of your breaths.
If there are no signs of coughing, gasping or movement you will need to begin CPR as quickly as possible. Perform 5 sets of the 30-to-2 cycle within 2 minutes. Continue cardiopulmonary resuscitation (CPR) until an automated external defibrillator (AED) is applied, the person starts to move, help arrives, or until you can no longer continue.
Rescue breathing is essential when responding to an opioid overdose. CPR in an unresponsive person who is not coughing, gasping or moving is even more important than rescue breathing.
- Assess the person
- Rub firmly on the middle of the chest )sternum) to attempt to elicit a response
- If no response call 911
- Perform rescue breathing if the person is not visibly breathing/Perform CPR if the individual is not coughing, moving or gasping
- Administer Narcan (naloxone). If there is not response after 3-5 minutes or the symptoms of the overdose return a second dose of Narcan can be administered in the alternate nostril.
- Monitor and support
- Place the person in the rescue position if you have to leave them or they become responsive
Narcan blocks opioid receptors in the brain. Narcan Nasal Spray, the most frequently used method, is administered in the nostril and does not require evidence of breathing through the nose during administration.
When someone takes an overdose of opioids, the opiates overwhelm certain areas in the brain and interrupt a key part of the body’s impulse to breathe. Breathing slows dangerously or stops. Quickly rescuing this person is crucial because prolonged, severe breathing problems can lead to brain injury or death.
Other forms of Narcan include the multi-step nasal spray, the auto injector that comes with visual and voice instructions and an injectable form of Narcan that needs to be delivered directly into the muscle.
- Narcan acts within 2 to 8 minutes
- Narcan lasts 30 to 90 minutes, overdose may return
- Narcan is not addictive, cannot be abused and does not cause overdose.
- Administering Narcan will not cause harm
- You cannot give too much Narcan
- Narcan has no effect in people who are not taking opioids
Some states require its police officers to carry naloxone to revive people who have overdosed. Many firefighters, emergency medical personnel and other first responders also carry Narcan. It’s good to be prepared with Narcan if you serve individuals dealing with substance use disorders, or if you’re an employer who wants to be prepared to respond to an overdose in the workplace.
Narcan is available through a standing order at pharmacies without a prescription in some states. Most insurances cover Narcan. Many pharmacists have Narcan Rescue Kits for purchase. The cost is approximately $130 to $140 for a kit that includes two doses. Some community-based organizations focused on treating drug addiction may provider Narcan for free.
If you keep Narcan available remember:
- Narcan should be easily accessible.
- Check expiration dates
- Do not split Narcan kits. Each kit has two doses for a reason
- There should be a kit on a visible, accessible location on each floor of the organization
- Create an Overdose Response Protocol that all staff are trained on in case of emergency
Be aware that bathrooms are a frequent location for overdoses. Make bathrooms safer with good lighting, doors that open out, call buttons, intercom systems, rescue kits and gloves.
Narcan does not make people violent, but they will likely be disoriented, and may feel like they are sick or in withdrawal. Explain to them that they overdosed, and that you gave them Narcan. Keep the person calm, be compassionate, and talk to them until medical help arrives.
Even if you can reverse an overdose using Narcan, this only works on opioids, not other drugs that may have been taken or were in the “cut”.
The person may also have other medical issues that require professional treatment in addition to the overdose itself.
Do no use Narcan if the individual is allergic to naloxone hydrochloride (HCl) or any of the ingredients Narcan, which include:
- Benzalkonium chloride (preservative)
- Disodium ethylenediaminetetraacetate (stabilizer)
- Sodium chloride
- Hydrochloric acid (to adjust pH)
- Purified water
*Use in infants with extreme caution. Please visit www.narcan,com for important safety and full prescribing information.
Narcan may cause serious side effects, including sudden opioid withdrawal symptoms. In someone who has been using opioids regularly, opioid withdrawal symptoms can happen suddenly after receiving Narcan and may include:
- Body aches
- Increased heart rate
- Runny nose
- Nausea or vomiting
- Restlessness or irritability, shivering or trembling
- Stomach cramping
- Increased blood pressure
- Nasal dryness, edema, congestion and inflammation
In infants less than 4 weeks old who have been receiving opioids regularly, sudden opioid withdrawal may be life threatening if not treated the right way. Signs and symptoms include: seizures, crying more than usual and increased reflexes.
Abrupt reversal of opioid effects in persons who were physically dependent on opioids has precipitated signs and symptoms of opioid withdrawal including:
- Body aches
- Runny nose
- Shivering or trembling
- Restlessness or irritability
- Diarrhea, nausea or vomiting
- Abdominal cramps
- Increased blood pressure
If you are concerned that someone has overdosed call 911