#23 Opioid Overdose Treatment and Prevention with Dr. Alex Walley

September 21, 2023 | By Carolyn Chan

Audio

Video

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).

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Production Partner: ACAAM

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.

Show Segments

• Intro, disclaimer, guest bio: 00:00
• Guest one-liner: 05:10
• Case from Kashlak: 07:20
• Overview of the Overdose Crisis: 08:13
• Changes in Messaging for Fentanyl OD Prevention: 16:10
• Naloxone formulations: 22:15
• Dose and frequency of naloxone: 24:50
• Counseling a patient on overdose response/prevention: 31:25
• Good Samaritan Laws:  38:00
• Responding to hospital overdoses: 40:45
• OTC naloxone: 51:14
• Take Home Points: 55:50
• Outro: 59:19

Opioid Overdose Treatment and Prevention Pearls

1. Opioid overdose is now the leading cause of death from preventable, accidental injury. 
2. Signs and symptoms of an opioid overdose include respiratory depression, loss of consciousness, and signs of hypoxia, such as blue lips and nailbeds. 
3. Fentanyl overdoses occur over seconds to minutes: Be sure to counsel patients not to use alone, and if both individuals are using the substance, to take turns so that one individual can provide naloxone if needed.
4. Naloxone is an opioid antagonist that can reverse an opioid overdose and can be administered intranasally, intravenously, intramuscularly, subcutaneously, and through an ET tube. 
5. A large dose of naloxone can precipitate withdrawal. Dr. Walley recommends focusing on increasing the respiratory rate and improving oxygenation rather than completely waking the individual up. 
6. Counsel patients who use non-regulated substances on an overdose prevention plan. These may include not mixing substances, starting low & going slow, taking turns, never using alone, having naloxone present, having a cell phone that works, and keeping substances safe at home by locking them up. 
7. Prescribe naloxone to individuals who use non-regulated stimulants and benzodiazepines due to fentanyl contamination of the drug supply. 
8. The FDA recently approved a formulation of over-the-counter naloxone, which should be available for purchase in late summer 2023. 

Opioid Overdose Treatment and Prevention – Notes

Overview of the Overdose Crisis

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)

• First wave: Prescription opioids
• Second wave: Heroin
• Third wave: Fentanyl and fentanyl analogs
• Fourth wave: Polysubstance overdose (most commonly stimulant + fentanyl) 

At-Risk Populations

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.

Opioid Overdose Symptoms

Below are common symptoms of an opioid overdose. 

• Respiratory depression
• Loss of consciousness
• Signs of hypoxia – blue nail beds, blue lips

How fentanyl has impacted the presentation of opioid overdoses

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. 

Reversing an Opioid Overdose

Opioid overdoses can be reversed if naloxone, an opioid antagonist, is given promptly. 

There are many routes and delivery systems for naloxone:

• Intranasal Spray (fixed dose, often 4mg)
• Intravenous
• Intramuscular
• Subcutaneous
• Through an ET tube
• Autoinjector

Dose & Frequency of Naloxone Administration

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. 

Counseling a Patient

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.

Overdose Protection Plan

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:

• Use with someone else there
• Do not mix drugs
• Start low, go slow
• Take turns
• Have naloxone present
• Have a cell phone that works to call for help
• Keep substances safe at home by locking them up
• Virtual Spotting (Telephone lines like Never Use Alone, Massachusetts Overdose Prevention Helpline, or the Brave App)

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. 

Virtual Spotting

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

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/ 

Responding to Inpatient Opioid Overdoses

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. 

Clinical Tips:

• Give oxygen to maintain O2 saturation.
• If oxygenation and respiratory rate are NOT maintained, give a small dose of naloxone to improve the respiratory rate and oxygen saturation. 
• Consider giving a small dose of IV 0.04mg of naloxone or 0.08mg and see what happens.

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. 

Treating Opioid Withdrawal and Precipitated Withdrawal

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. 

Over-the-counter (OTC) Naloxone

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. 

Take Home Points

1. Talk with your patients about what they are doing to prevent overdose when they use drugs AND how they would respond to an opioid overdose. 
2. In overdose response, focus on the respiratory rate and oxygenation rather than aiming for full alertness. This is more patient-centered and will minimize severe withdrawal. 
3. The drug supply is erratic: stay current on the drug supply in your area and what substances contribute to overdose. 
4. Try to make the hospital a more welcoming place for those who use substances by adopting a patient-centered approach to treating opioid overdose. 

Links

1. The Remedy Alliance for the People
2. Good Samaritan Law/Naloxone Laws: https://pdaps.org/ 
3. Virtual Spotting (phones): Never Use Alone and the Massachusetts Overdose Prevention Helpline
4. Virtual Spotting (apps): Brave App and Canary
5. Naloxone Finder
6. Next Distro Naloxone
7. CDC Overdose Prevention Website
8. Post-Overdose Outreach: PRONTO 

Goal

Listeners will develop an approach to managing community and hospital opioid overdoses. 

Learning objectives

After listening to this episode, listeners will…  

1. Counsel patients on opioid overdose response and prevention. 
2. Describe the pharmacology of naloxone and different delivery methods (IN, IM, sc, duration of action, time to response).
3. Describe approaches to responding to an opioid overdose in the community.
4. Describe approaches to responding to an opioid overdose in the hospital. 

Disclosures

Dr. Walley reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

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.