Prevent opioid overdoses in your community! We discuss opioid overdose prevention and treatment so you can counsel patients who use substances on ways to decrease their risk of overdose. We discuss optimal ways to respond to hospital overdoses, ideal doses of naloxone, and how to monitor a patient experiencing an overdose clinically. We’re joined by Dr. Alex Walley, MD MsC @AlexanderWalley (Boston University School of Medicine).
Claim free CME for this episode at curbsiders.vcuhealth.org!
By listening to this episode and completing CME this can be used to count towards the new DEA 8-hr requirement on substance use disorders education.
The Curbsiders Addiction Medicine are proud to partner with The American College of Addiction Medicine (ACAAM) to bring you this mini-series. ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website at acaam.org to learn more about their organization.
Opioid overdose is now the leading cause of death from preventable, accidental injury in the US (CDC, 2021). This is in part due to the rise of fentanyl in the unregulated US drug supply. Fentanyl and fentanyl analogs are potent opioids that may be sold alone, but are also a common contaminant of other substances such as stimulants, and counterfeit opioid and/or benzodiazepine pills. In certain parts of the country, we also see a rise in xylazine, a non-opioid veterinary anesthetic, which may contribute to the overdose crisis (Alexander, 2022).
There are four waves of the opioid overdose crisis (Ciccarone, 2021)
There are a number of populations who may be at higher risk of an overdose. Since 2019, there has been a sharp increase in overdose deaths among Non-Hispanic Black and Non-Hispanic American Indian/Alaska Native populations compared to other racial/ethnic groups overdose deaths (Karissa, 2022; Larochelle, 2021; Townsend, 2022). In 2020, mortality rates from overdose increased with increasing income inequality across most racial/ethnic groups, but Black and Hispanic persons were the most affected. This highlights the disparities and inequities in our health system.
In addition, substance use among adolescents has decreased in recent years (Monitoring the Future, 2021). Yet, there has been a dramatic increase in the number of overdose deaths in this population (Kuehn, 2023). Dr. Walley reminds us that overdose prevention is not only for individuals with a substance use disorder but also, for individuals experimenting with drugs in their younger years.
Below are common symptoms of an opioid overdose.
For individuals who overdose on substances such as oxycodone or heroin, the overdose evolves over minutes to hours. This contrasts with fentanyl, where the overdose develops over seconds to minutes. Due to this time course, Dr. Walley counsels patients to avoid using substances alone. If both individuals are using substances, he reminds them to be sure to take turns so an individual can provide naloxone if needed.
Rarely, individuals may experience wooden chest syndrome (Rosal, 2021; Pergolizzi Jr, 2021). This syndrome involves fentanyl-induced skeletal muscle rigidity and vocal cord closure, leading to challenges in providing adequate ventilation. Of note, there is a lack of clinical research on this topic, especially among people using non-prescribed fentanyl.
Opioid overdoses can be reversed if naloxone, an opioid antagonist, is given promptly.
There are many routes and delivery systems for naloxone:
Precipitated opioid withdrawal occurs when an opioid antagonist (or partial opioid agonist) is administered while a full mu-opioid receptor agonist remains in an individual’s system. This causes the full mu-receptor agonist to be abruptly kicked off the receptor and causes severe withdrawal symptoms. Providing a large dose of naloxone can cause symptoms of precipitated opioid withdrawal, which often are more intense symptoms than opioid withdrawal that is not precipitated.
Experiencing precipitated opioid withdrawal may make individuals more averse to giving naloxone. Dr. Walley feels the focus should be on increasing respiratory rate and oxygenation rather than completely waking an individual up (Suen, 2023). The goal is to titrate the dose of naloxone so people are breathing but not in severe opioid withdrawal. In cases of severe respiratory depression accompanied by complete loss of consciousness, severe hypoxia, or severe cyanosis, giving a standard dose of 0.4-2mg of naloxone IM/IV or 4mg intranasal is recommended. He also reminds us that it’s better to “get naloxone, than not get it” if an individual is experiencing an overdose, as there may be scenarios where the dose of naloxone is not titratable or scenarios where close monitoring of vitals is not possible.
In Dr. Walley’s opinion, there is not much benefit after giving more than 2 doses of 4mg dose of intranasal naloxone (8mg total dose). Instead, he recommends focusing on ventilating the individual. He recommends waiting 3 minutes to give the 2nd dose of naloxone.
Remember that naloxone will not reverse overdoses from other sedatives such as benzos, gabapentin, xylazine, and clonidine.
Many individuals have lived experience of reversing an overdose. Ask your patient how they felt about that experience. For some individuals, it can be a traumatic experience, and others may feel pride in saving a life.
Next, ask your patient, “How do you protect yourself against overdoses?” In Dr. Walley’s experience, patients commonly respond by saying, “I am not planning on using it again.” In response, he praises people for having abstinence as a plan A, but then asks them about their plan B to keep themselves safe if they use again.
Some tips for patients to consider for preventing an overdose are listed below:
Ask, “What is your plan if you witness an overdose in the future?”. Ask about comfort in administering naloxone, rescue breathing, and calling for medical help. Consider encouraging patients to obtain CPR training if they are at risk of witnessing overdoses because if individuals are found without a pulse, they would need support beyond just naloxone.
Most overdoses occur at home alone, without a bystander (O’Donnell, 2021). If someone is going to use substances alone, encourage an individual to call someone on the phone who knows where they are to make sure they are safe. If they become unresponsive, that person calls for help and sends someone to respond at the correct location. Using digital technology to provide support, such as overdose monitoring, is called “virtual spotting” (Matskiv, 2022). Never use alone, is one example of virtual spotting, which is a national overdose prevention line in the US. Massachusetts Overdose Prevention Helpline is an example of a state-based helpline. Another example is the Brave App phone application.
Good Samaritan laws provide some protection and instruction not to arrest or prosecute individuals who respond to an overdose. None of these laws protect individuals from parole, probation, or warrant checking, and law enforcement often applies these protections at their discretion. Dr. Walley believes the relationship between local law enforcement and people who use substances in a community is important. Some local law enforcement may take more of a community health approach when responding to an overdose. Learn more about your local Good Samaritan laws at this link:https://pdaps.org/
If an individual experiences an overdose in the hospital, you can monitor vital signs closely. Remember that overdose response is not JUST about giving naloxone. If an individual is oversedated but saturating well, step up nursing care, and monitor their pulse ox until they wake up. Some individuals may have taken more than one substance, such as an opioid and a benzodiazepine. While naloxone will assist with reversing an opioid overdose, it will not reverse overdoses from other substances.
If you give an opioid-dependent individual a large dose of naloxone (e.g. 4mg), they will go into precipitated opioid withdrawal and may be more likely to just leave the hospital leading to a premature discharge without completing treatment.
If someone has been given a lot of naloxone in the field and is sick from precipitated withdrawal, consider offering and providing either a full opioid agonist, buprenorphine, or methadone. Help manage their withdrawal symptoms quickly. Once their withdrawal symptoms are managed, one can talk with the patient regarding their medical care and treatment options for opioid use disorder.
The FDA has approved an OTC version of naloxone currently on store shelves as of September 2023. Dr. Walley thinks this space will continue to evolve, and it’s unclear whether it will impact the equity of access to naloxone. In many states, naloxone is available without a prescription at the pharmacy behind the counter. Many insurance companies will cover the cost of the medication, though copays may be expensive depending on an individual’s insurance plan.
Listeners will develop an approach to managing community and hospital opioid overdoses.
After listening to this episode, listeners will…
Dr. Walley reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Chan CA, Walley A, Stahl N., Leyde S. “#23 Opioid Overdose Treatment and Prevention with Dr. Alex Walley”. The Curbsiders Addiction Medicine Podcast. https://thecurbsiders.com/episode-list September 21st, 2023.
Producer: Natalie Stahl, MD, MPH
Show Notes, Infographic, Cover Art: Carolyn Chan, MD, MHS
Hosts: Carolyn Chan, MD, MHS and Natalie Stahl, MD, MPH
Reviewer: Sarah Leyde, MD
Showrunner: Carolyn Chan, MD, MHS
Technical Production: Podpaste
Guest: Dr. Alex Walley
Got feedback? Suggest an Addiction Medicine topic. Recommend a guest. Tell us what you think.
We love hearing from you.
Yes, you can now join our exclusive community of core faculty at Kashlak Memorial Hospital along with all the perks:
Close this notice to consent.