An opioid overdose is
toxicity
Toxicity is the degree to which a chemical substance or a particular mixture of substances can damage an organism. Toxicity can refer to the effect on a whole organism, such as an animal, bacterium, or plant, as well as the effect on a subs ...
due to excessive consumption of
opioids, such as
morphine
Morphine is a strong opiate that is found naturally in opium, a dark brown resin in poppies (''Papaver somniferum''). It is mainly used as a pain medication, and is also commonly used recreationally, or to make other illicit opioids. T ...
,
codeine,
heroin,
fentanyl
Fentanyl, also spelled fentanil, is a very potent synthetic opioid used as a pain medication. Together with other drugs, fentanyl is used for anesthesia. It is also used illicitly as a recreational drug, sometimes mixed with heroin, cocain ...
,
tramadol
Tramadol, sold under the brand name Ultram among others, is an opioid pain medication used to treat moderate to moderately severe pain. When taken by mouth in an immediate-release formulation, the onset of pain relief usually begins within an ...
, and
methadone
Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid agonist used for chronic pain and also for opioid dependence. It is used to treat chronic pain, and it is also used to treat addiction to heroi ...
.
This preventable pathology can be fatal if it leads to
respiratory depression, a lethal condition that can cause
hypoxia from slow and shallow breathing.
Other symptoms include
small pupils (with the exception of pethidine, where there may be dilated pupils), and
unconsciousness
Unconsciousness is a state in which a living individual exhibits a complete, or near-complete, inability to maintain an awareness of self and environment or to respond to any human or environmental stimulus. Unconsciousness may occur as the re ...
, however its onset can depend on the method of ingestion, the dosage and individual risk factors. Although there were over 110,000 deaths in 2017 due to opioids, individuals who survived also faced adverse complications, including
permanent brain damage
Neurotrauma, brain damage or brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating ...
.
Opioid overdoses are diagnosed based on symptoms and examination.
Risk factors for opioid overdose include high levels of
opioid dependence
Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Op ...
, use of opioids via injection, high dosed opioid usage, having a
mental disorder
A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitt ...
or having a predisposition for one, and use of opioids in combination with other substances, such as
alcohol,
benzodiazepines, or
cocaine
Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Ameri ...
.
[ Dependence on prescription opioids can occur from their use to treat ]chronic pain
Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between acute and chronic pain is sometimes determined by the amount of time since onset. Two commonly used markers are pain that continue ...
in individuals. Additionally, if following a period of detoxification
Detoxification or detoxication (detox for short) is the physiological or medicinal removal of toxic substances from a living organism, including the human body, which is mainly carried out by the liver. Additionally, it can refer to the period of ...
, which allows the tolerance level to fall, the risk of overdose upon return to use is high.
Initial treatment of an overdose involves supporting the person's breathing and providing oxygen
Oxygen is the chemical element with the symbol O and atomic number 8. It is a member of the chalcogen group in the periodic table, a highly reactive nonmetal, and an oxidizing agent that readily forms oxides with most elements as ...
to reduce the risk of hypoxia.[ ]Naloxone
Naloxone, sold under the brand names Narcan (4 mg) and Kloxxado (8 mg) among others, is a medication used to reverse or reduce the effects of opioids. It is commonly used to counter decreased breathing in opioid overdose. Effects begin withi ...
is then recommended to those who cannot reverse the opioid's effects through breathing.[ Giving naloxone via ]nasal administration
Nasal administration, popularly known as snorting, is a route of administration in which drugs are insufflated through the nose. It can be a form of either topical administration or systemic administration, as the drugs thus locally delivered c ...
or as an injection into a muscle
Intramuscular injection, often abbreviated IM, is the injection of a substance into a muscle. In medicine, it is one of several methods for parenteral administration of medications. Intramuscular injection may be preferred because muscles ha ...
has shown to be equally effective. Other efforts to prevent deaths from overdose include increasing access to naloxone and treatment for opioid dependence.[
Drug use contributes to 500,000 deaths worldwide, with opioid overdose resulting in approximately 115,000 of these deaths in 2018.] This is up from 18,000 deaths in 1990. In 2018, approximately 269 million people had engaged in drug usage at least once, 58 million of which used opioids. Drug use disorders have affected around 35.6 million people worldwide in 2018. The WHO
Who or WHO may refer to:
* Who (pronoun), an interrogative or relative pronoun
* Who?, one of the Five Ws in journalism
* World Health Organization
Arts and entertainment Fictional characters
* Who, a creature in the Dr. Seuss book '' Horton He ...
estimates that 70% of deaths due to drug use are in relation to opioids, with 30% being due to overdose. It is believed that the opioid epidemic
The opioid epidemic, also referred to as the opioid crisis, is the rapid increase in the overuse, misuse/abuse, and overdose deaths attributed either in part or in whole to the class of drugs opiates/opioids since the 1990s. It includes the sign ...
has partly been caused due to assurances that prescription opioids were safe, by the pharmaceutical industry
The pharmaceutical industry discovers, develops, produces, and markets drugs or pharmaceutical drugs for use as medications to be administered to patients (or self-administered), with the aim to cure them, vaccinate them, or alleviate symptoms. ...
in the 1990s. This led to unwarranted trust and a subsequent heavy reliance on opioids. Though there are treatment interventions which can effectively reduce the risk of overdose in people with opioid dependence, less than 10% of affected individuals receive it.
Signs and symptoms
Opiate overdose symptoms and signs can be referred to as the "opioid toxidrome
A toxidrome (a portmanteau of ''toxic'' and ''syndrome'') is a syndrome caused by a dangerous level of toxins in the body. The term was coined in 1970 by Mofenson and Greensher. It is often the consequence of a drug overdose. Common symptoms incl ...
triad": decreased level of consciousness, pinpoint pupils and respiratory depression. Other symptoms include seizures and muscle spasms. Sometimes an opiate overdose can lead to such a decreased level of consciousness such that the person will not wake up.
Because of their effect on the part of the brain that regulates breathing, opioid
Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use ...
s can cause very slow or stopped breathing, during overdoses, leading to hypoxia or death if left untreated. Hypoxia is typically caused by respiratory depression. The brain uses oxygen to regulate the homeostasis
In biology, homeostasis (British also homoeostasis) (/hɒmɪə(ʊ)ˈsteɪsɪs/) is the state of steady internal, physical, and chemical conditions maintained by living systems. This is the condition of optimal functioning for the organism and ...
of the body. In animal studies, it was found that opioids act on specific regions of the central nervous system
The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain and spinal cord. The CNS is so named because the brain integrates the received information and coordinates and influences the activity of all p ...
associated with respiratory regulation, including the medulla
Medulla or Medullary may refer to:
Science
* Medulla oblongata, a part of the brain stem
* Renal medulla, a part of the kidney
* Adrenal medulla, a part of the adrenal gland
* Medulla of ovary, a stroma in the center of the ovary
* Medulla of t ...
and pons
The pons (from Latin , "bridge") is part of the brainstem that in humans and other bipeds lies inferior to the midbrain, superior to the medulla oblongata and anterior to the cerebellum.
The pons is also called the pons Varolii ("bridge of Va ...
. During cerebral hypoxia, there is a lack of sufficient oxygen supply to the brain. Prolonged lack of oxygenation from respiratory depression can lead to detrimental damage to the brain and spinal cord and can leave the person unable to walk or function normally, even if treatment with naloxone is given.
Alcohol also causes respiratory depression and therefore when taken with opioids can increase the risk of respiratory depression and death.[
In young children, opioid overdose may not be apparent right away. This is due to absorption, distribution, and metabolism differences between young children and adults, and the higher amount of opioid ingestion per kilogram of body weight.][
]
Causes
Risk factors for opioid overdose include opioid dependence
Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. Op ...
, injecting opioids, using high doses of opioids, and use together with alcohol, benzodiazepines, or cocaine
Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Ameri ...
.[ The risk is particularly high following ]detoxification
Detoxification or detoxication (detox for short) is the physiological or medicinal removal of toxic substances from a living organism, including the human body, which is mainly carried out by the liver. Additionally, it can refer to the period of ...
.[ Dependence on prescription opioids can occur from their use to treat ]chronic pain
Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between acute and chronic pain is sometimes determined by the amount of time since onset. Two commonly used markers are pain that continue ...
.[ In young children an overdose is usually due to opioids that are intended for their parents, older siblings, or grandparents. In mothers who take codeine during breastfeeding, opioid overdoses have occurred in their baby.] Codeine is therefore not recommended in those who are breastfeeding.[
]
Co-ingestion
Opioid overdoses are often associated with benzodiazepines, tranquilisers (e.g. xylazine
Xylazine is a pharmaceutical drug used for sedation, anesthesia, muscle relaxation, and analgesia in animals such as horses, cattle, and other non-human mammals. Veterinarians also use xylazine as an emetic, especially in cats. It is an anal ...
) or alcohol use. Other CNS depressants, muscle relaxers, pain relievers, anti-convulsants, anxiolytics
An anxiolytic (; also antipanic or antianxiety agent) is a medication or other intervention that reduces anxiety. This effect is in contrast to anxiogenic agents which increase anxiety. Anxiolytic medications are used for the treatment of anxiet ...
, treatment drugs of a psychoactive or epileptic variety or any other such drug with its active function meant to calm or mitigate neuronal signaling ( barbiturates, etc.) can additionally cause a worsened condition with less likelihood of recovery cumulative to each added drug. This includes drugs less immediately classed to a slowing of the metabolism such as with GABAergic like GHB
''gamma''-Hydroxybutyric acid (or γ-hydroxybutyric acid (GHB), also known as 4-hydroxybutanoic acid) is a naturally occurring neurotransmitter and a depressant drug. It is a precursor to GABA, glutamate, and glycine in certain brain areas. ...
or glutamatergic antagonists like PCP or ketamine
Ketamine is a dissociative anesthetic used medically for induction and maintenance of anesthesia. It is also used as a recreational drug. It is one of the safest anesthetics, as, in contrast with opiates, ether, and propofol, it suppresses ...
.
Risk factors
Metabolic disorders
Opioid
Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use ...
s are primarily metabolized in the liver
The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it ...
, before being excreted through urine. Opioids are metabolized by phase 1 and/or phase 2 metabolism
Metabolism (, from el, μεταβολή ''metabolē'', "change") is the set of life-sustaining chemical reactions in organisms. The three main functions of metabolism are: the conversion of the energy in food to energy available to run c ...
, which can lead to the activation or inhibition of these drugs. Phase 1 metabolism is the CYP pathway which consists of different cytochrome P450
Cytochromes P450 (CYPs) are a superfamily of enzymes containing heme as a cofactor that functions as monooxygenases. In mammals, these proteins oxidize steroids, fatty acids, and xenobiotics, and are important for the clearance of various co ...
s – a set of enzymes that catalyze hydrolysis
Hydrolysis (; ) is any chemical reaction in which a molecule of water breaks one or more chemical bonds. The term is used broadly for substitution, elimination, and solvation reactions in which water is the nucleophile.
Biological hydrolys ...
, reduction, and oxidation
Redox (reduction–oxidation, , ) is a type of chemical reaction in which the oxidation states of substrate change. Oxidation is the loss of electrons or an increase in the oxidation state, while reduction is the gain of electrons or a ...
reactions – to create an active metabolite. In contrast, Phase 2 metabolism causes the opioids to undergo conjugation, with little to no interaction with the CYP pathway. The opioids undergo phase 1 and phase 2 metabolism until they are hydrophilic
A hydrophile is a molecule or other molecular entity that is attracted to water molecules and tends to be dissolved by water.Liddell, H.G. & Scott, R. (1940). ''A Greek-English Lexicon'' Oxford: Clarendon Press.
In contrast, hydrophobes are ...
enough to be renally
The kidneys are two reddish-brown bean-shaped organ (anatomy), organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal ...
excreted.
There are various factors that play a role in how an opioid is metabolized. In phase 1 metabolism, the CYP family has several polymorphisms, which can account for the difference in therapeutic
A therapy or medical treatment (often abbreviated tx, Tx, or Tx) is the attempted remediation of a health problem, usually following a medical diagnosis.
As a rule, each therapy has indications and contraindications. There are many different ...
responses within each individual. This diversification leads to opioids being modified at varying rates, which can cause the drug to remain in the bloodstream
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
for either a longer or shorter period of time. Therefore, these polymorphisms control opioid tolerance and facilitate overdose
A drug overdose (overdose or OD) is the ingestion or application of a drug or other substance in quantities much greater than are recommended. .
Mental health
Evidence suggests that mental health can be a significant facilitator for opioid abuse. Given that opioids are prescribed for pain management, mental health disorders, such as depression, have been shown to increase use of opioids when treating conditions associated with chronic pain
Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between acute and chronic pain is sometimes determined by the amount of time since onset. Two commonly used markers are pain that continue ...
. Evidence has shown that individuals with mood and anxiety disorders have an increased likelihood of being prescribed opioids and continuing usage for lengthy periods of time, consequently increasing likelihood for dependence. As such, affected individuals have almost double the risk of using opioids for pain relief in the long-term. Additionally, mental health challenges associated with trauma, economic depression, social environments conducive to substance abuse and risk-taking behaviours have been shown to increase opioid misuse. Furthermore, mental health challenges associated with cardiovascular disease, sleep disorder
A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Polysomnography and actigraphy are tests ...
s, and HIV
The human immunodeficiency viruses (HIV) are two species of ''Lentivirus'' (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the immune ...
can cause opioid dependence and subsequent overdose. Notably, cyclic behaviours can be observed between mental illness and opioid abuse where individuals with mental health diagnoses engage in opioid use which further perpetuates mental health challenges and increased drug usage.
Mechanism
Opioids bind with neurological opioid receptors to provoke analgesic, sedative, and euphoric
Euphoria ( ) is the experience (or affect) of pleasure or excitement and intense feelings of well-being and happiness. Certain natural rewards and social activities, such as aerobic exercise, laughter, listening to or making music and da ...
effects. Opioids function by stimulating specific G-protein coupled receptors
G protein-coupled receptors (GPCRs), also known as seven-(pass)-transmembrane domain receptors, 7TM receptors, heptahelical receptors, serpentine receptors, and G protein-linked receptors (GPLR), form a large group of protein family, evolution ...
distributed throughout the body—including the brain, skin and spinal cord. Three of the major opioid receptors include mu, kappa, delta, and nociception, each playing a role in eliciting the effects associated with opioids. An opioid overdose results from over-activation of these receptors, which can cause permanent brain damage from cerebral hypoxia or neurotoxicity.
Mu receptors have an analgesic effect on the brain, and are found in various parts of the nervous system including the cerebral cortex
The cerebral cortex, also known as the cerebral mantle, is the outer layer of neural tissue of the cerebrum of the brain in humans and other mammals. The cerebral cortex mostly consists of the six-layered neocortex, with just 10% consistin ...
and thalamus
The thalamus (from Greek θάλαμος, "chamber") is a large mass of gray matter located in the dorsal part of the diencephalon (a division of the forebrain). Nerve fibers project out of the thalamus to the cerebral cortex in all directions, ...
. They can be found in the nucleus accumbens
The nucleus accumbens (NAc or NAcc; also known as the accumbens nucleus, or formerly as the ''nucleus accumbens septi'', Latin for " nucleus adjacent to the septum") is a region in the basal forebrain rostral to the preoptic area of the hypot ...
, the pleasure centre of the brain, as well as the amygdala
The amygdala (; plural: amygdalae or amygdalas; also '; Latin from Greek, , ', 'almond', 'tonsil') is one of two almond-shaped clusters of nuclei located deep and medially within the temporal lobes of the brain's cerebrum in complex verte ...
. Kappa receptors, in the hypothalamus
The hypothalamus () is a part of the brain that contains a number of small nuclei with a variety of functions. One of the most important functions is to link the nervous system to the endocrine system via the pituitary gland. The hypothalamu ...
, produce a similar analgesic effect. They bind with dynorphin
Dynorphins (Dyn) are a class of opioid peptides that arise from the precursor protein prodynorphin. When prodynorphin is cleaved during processing by proprotein convertase 2 (PC2), multiple active peptides are released: dynorphin A, dynorphin ...
s to stimulate anti-reward effects —dysphoria
Dysphoria (; ) is a profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation.
In psychiatry
Intense states of distress and uneas ...
— and other negative effects of withdrawal. While mu receptors are the source of addiction, kappa receptors contribute to continued abuse. They generate dysphoria
Dysphoria (; ) is a profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation.
In psychiatry
Intense states of distress and uneas ...
in response to increasing stress levels via corticotropin-releasing factor (CRF). This increases erratic shifts in mood during withdrawal period and can prompt relapse. Delta receptors, found in the basal ganglia
The basal ganglia (BG), or basal nuclei, are a group of subcortical nuclei, of varied origin, in the brains of vertebrates. In humans, and some primates, there are some differences, mainly in the division of the globus pallidus into an exter ...
of the limbic system, have been shown to reduce anxiety
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
by binding with enkephalin
An enkephalin is a pentapeptide involved in regulating nociception in the body. The enkephalins are termed endogenous ligands, as they are internally derived and bind to the body's opioid receptors. Discovered in 1975, two forms of enkephali ...
s, although this requires further research. The most recent addition to these receptors are nociception opioid receptors. Although they have been determined to be receptors to certain ligand
In coordination chemistry, a ligand is an ion or molecule ( functional group) that binds to a central metal atom to form a coordination complex. The bonding with the metal generally involves formal donation of one or more of the ligand's elec ...
s from opioids, their role has not yet fully understood.
When opioids are ingested, the ligand
In coordination chemistry, a ligand is an ion or molecule ( functional group) that binds to a central metal atom to form a coordination complex. The bonding with the metal generally involves formal donation of one or more of the ligand's elec ...
binds to these constitutively active receptors to reduce neural activity. This is accomplished by inhibiting adenylyl cyclase
Adenylate cyclase (EC 4.6.1.1, also commonly known as adenyl cyclase and adenylyl cyclase, abbreviated AC) is an enzyme with systematic name ATP diphosphate-lyase (cyclizing; 3′,5′-cyclic-AMP-forming). It catalyzes the following reaction:
:A ...
and cyclic AMP
Cyclic adenosine monophosphate (cAMP, cyclic AMP, or 3',5'-cyclic adenosine monophosphate) is a second messenger important in many biological processes. cAMP is a derivative of adenosine triphosphate (ATP) and used for intracellular signal tra ...
, which are necessary for communication within the central nervous system
The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain and spinal cord. The CNS is so named because the brain integrates the received information and coordinates and influences the activity of all p ...
. There is research indicating that opioids reduce pain by disrupting ion channels and vesicle fusion Vesicle fusion is the merging of a vesicle with other vesicles or a part of a cell membrane. In the latter case, it is the end stage of secretion from secretory vesicles, where their contents are expelled from the cell through exocytosis. Vesicles c ...
.
Prolonged exposure to opioids can cause these receptors to become internalized, leading to increased tolerance and increased opioid use.
Prevention
Opioid overdoses can often be prevented.[In press] Clear protocols for staff at emergency departments and urgent care centers can reduce opioid prescriptions for individuals presenting in these settings who engage in drug seeking behaviors or who have a history of substance abuse. Drug seeking behaviors include but are not limited to obsessiveness or impatience when it comes to attaining medications, seeking multiple pain adjunct medications, and inconsistent physiological presentation. A prescription monitoring program
In the United States, prescription monitoring programs (PMPs) or prescription drug monitoring programs (PDMPs) are state-run programs which collect and distribute data about the prescription and dispensation of federally controlled substances and, ...
may help determine if an individual is receiving a high doses of opioids or combinations of medications such as benzodiazepines and opioids that put them at high risk. Limited amount of evidence suggests opioid therapy with extended-release or long-acting formulations may increase the risk of an unintentional overdose compared to shorter-acting agents. Routinely screening using tools such as the CAGE-AID and the Drug Abuse Screening Test (DAST-10) in adults and the CRAFFT in those aged 14–18 years is recommended.[ Other "drug seeking" behaviors and physical indications of drug use should be used as clues to perform formal screenings.][
There are several medication-assisted treatments available for people with opioid use disorder or opioid dependence, who are at higher risk for opioid overdose.] The selection of treatment depends on various factors, such as a person's preference, accessibility, and history of treatment. Examples of medication-assisted treatments are buprenorphine
Buprenorphine is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It can be used under the tongue (sublingual), in the cheek (buccal), by injection (intravenous and subcutaneous), as a skin patch (transdermal ...
(with or without naloxone), naltrexone
Naltrexone, sold under the brand name Revia among others, is a medication primarily used to manage alcohol or opioid use disorder by reducing cravings and feelings of euphoria associated with substance use disorder. It has also been foun ...
, and methadone
Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid agonist used for chronic pain and also for opioid dependence. It is used to treat chronic pain, and it is also used to treat addiction to heroi ...
. Peer support groups have tentative evidence of benefit. There is also some evidence indicating benefits in community-based overdose education and naloxone distribution programs. Buprenorphine and methadone can help decrease drug cravings. Combining pharmacologic treatments with behavioral therapy, such as support or recovery groups, can increase likelihood of overcoming addiction and reduce the risk of an opioid overdose.
Individuals diagnosed with opioid dependence should be prescribed naloxone to prevent overdose and should be directed to one of treatment options available, such as needle exchange programs and treatment centers. A naloxone prescription is also recommended when risk factors for opioid overdose are present such as history of overdose, substance use disorder, or higher doses of opioids. Brief motivational interviewing
Motivational interviewing (MI) is a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centered counseling style for eliciting behavior change by helping clients to e ...
can also be performed and has been shown to improve people's motivation to change their behavior. Despite these opportunities, the dissemination of prevention interventions in the US has been hampered by the lack of coordination and sluggish federal government response.
In the United States, 49 states and the District of Columbia have expanded naloxone access at a pharmacy level via standing order, protocol order, naloxone-specific collaborative practice agreement, or pharmacist prescriptive authority.
Treatments
If someone is suspected to have overdosed on opioids, call for medical attention, administer naloxone
Naloxone, sold under the brand names Narcan (4 mg) and Kloxxado (8 mg) among others, is a medication used to reverse or reduce the effects of opioids. It is commonly used to counter decreased breathing in opioid overdose. Effects begin withi ...
, and provide basic life support
Basic life support (BLS) is a level of medical care which is used for patients with life-threatening illnesses or injuries until they can be given full medical care by advanced life support providers (paramedics, nurses, physicians). It can be p ...
as soon as possible.
Naloxone
Naloxone works by temporarily blocking the effects of opioids, including respiratory depression and sedation. Naloxone is safe and side effects are rare, generally limited to allergic reactions. It should be given if there is any suspicion of an opioid overdose. Naloxone is available to the public in the United States in two routes of administration: intranasal
Nasal administration, popularly known as snorting, is a route of administration in which drugs are insufflated through the nose. It can be a form of either topical administration or systemic administration, as the drugs thus locally delivere ...
and intramuscular
Intramuscular injection, often abbreviated IM, is the injection of a substance into a muscle. In medicine, it is one of several methods for parenteral administration of medications. Intramuscular injection may be preferred because muscles have ...
/ subcutaneous. Intranasal forms include Narcan, approved in 2015, and Kloxxado, approved in 2021. Formulations that are injectable into the intramuscular or subcutaneous spaces include Evzio, approved in 2014, and Zimhi, approved in 2021. The doses are approved for both children and adults and may be repeated every 2-3 minutes. Synthetic opioids like fentanyl
Fentanyl, also spelled fentanil, is a very potent synthetic opioid used as a pain medication. Together with other drugs, fentanyl is used for anesthesia. It is also used illicitly as a recreational drug, sometimes mixed with heroin, cocain ...
and carfentanil
Carfentanil or carfentanyl, sold under the brand name Wildnil, is a very potent opioid analgesic which is used in veterinary medicine to anesthetize large animals such as elephants and rhinoceroses. It is typically administered in this context ...
are much more potent than prescription opioids and heroin. There is some debate about whether increased doses of naloxone are required to reverse overdose from synthetic opioids, however this concern has prompted FDA approval of higher dose naloxone formulations such as Kloxxado and Zimhi. If a person suspected of overdose regains consciousness, medical attention is still necessary. Naloxone is temporary and people revived with the medication can stop breathing again.
Access to Naloxone
Opioid overdose should be reversed as soon as possible. To shorten the time between overdose and naloxone administration, multiple programs have been enacted to improve naloxone access for drug users, caregivers, and first responders. These efforts include FDA approval of intranasal and injectable naloxone over the counter, professional organizations recommending physicians to co-prescribe naloxone when opioids are used for pain management, free community overdose education and naloxone distribution (OEND) programs, and efforts to train non-medical first responders such as firefighters and police to use naloxone. These actions have reduced opioid-related deaths at the state and national levels and are cost-effective.
Basic Life Support
Opioid overdose leads to death when people stop breathing. Bystanders trained in first aid can evaluate people who have overdosed and provide basic life support including rescue breathing via bag valve mask
A bag valve mask (BVM), sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or "self-inflating bag", is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathi ...
or mouth to mouth. If the person who has overdosed does not have a pulse, rescuers should begin CPR
Cardiopulmonary resuscitation (CPR) is an emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore sponta ...
.
Other Treatments
Another medication that can be used to treat opioid overdoses is Nalmefene
Nalmefene is an opioid antagonist medication used in the management of opioid overdose and alcohol dependence. It is taken by mouth.
Nalmefene is an opiate derivative similar in both structure and activity to the opioid antagonist naltrexone. ...
, Which is an opioid derivative structurally similar to Naltrexone
Naltrexone, sold under the brand name Revia among others, is a medication primarily used to manage alcohol or opioid use disorder by reducing cravings and feelings of euphoria associated with substance use disorder. It has also been foun ...
. It works similarly to Naloxone but has a longer half life. It is approved for intravenous, intramuscular, and subcutaneous administration by prescription only, unlike the over the counter formulations of naloxone.
Epidemiology
In 2016, the World Health Organization estimates 34 million people used opioids and 19 million used opiates. Of these, about 27 million people had opioid dependence, with the majority—but a decreasing number—using illicit heroin. In 2015, 118,000 people died from opioid use disorders, causing almost one third of all drug related deaths.
United States
Of the 70,200 overdose deaths in the US in 2017, opioids were involved in 47,600 with three male deaths for each female death. This is an increase from 2016 where over 64,000 died from drug overdose, and opioids were involved in over 42,000.[ Source lists US totals for 2015 and 2016 and statistics by state.] In 2017, the five states with the highest rates of death due to drug overdose were West Virginia
West Virginia is a state in the Appalachian, Mid-Atlantic and Southeastern regions of the United States.The Census Bureau and the Association of American Geographers classify West Virginia as part of the Southern United States while the B ...
(57.8 per 100,000), Ohio
Ohio () is a state in the Midwestern region of the United States. Of the fifty U.S. states, it is the 34th-largest by area, and with a population of nearly 11.8 million, is the seventh-most populous and tenth-most densely populated. The sta ...
(46.3 per 100,000), Pennsylvania
Pennsylvania (; ( Pennsylvania Dutch: )), officially the Commonwealth of Pennsylvania, is a state spanning the Mid-Atlantic, Northeastern, Appalachian, and Great Lakes regions of the United States. It borders Delaware to its southeast, ...
(44.3 per 100,000), Kentucky
Kentucky ( , ), officially the Commonwealth of Kentucky, is a state in the Southeastern region of the United States and one of the states of the Upper South. It borders Illinois, Indiana, and Ohio to the north; West Virginia and Virginia ...
(37.2 per 100,000), and New Hampshire
New Hampshire is a state in the New England region of the northeastern United States. It is bordered by Massachusetts to the south, Vermont to the west, Maine and the Gulf of Maine to the east, and the Canadian province of Quebec to the nor ...
(37.0 per 100,000).[Drug Overdose Deaths]
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...
, National Center for Injury Prevention and Control The U.S. Centers for Disease Control and Prevention's National Center for Injury Prevention and Control's mission is to provide leadership in preventing and controlling injuries, i.e., reducing the incidence, severity, and adverse outcomes of injur ...
. Click on a map year. The data table is below the map. Number of deaths for each state, and the age-adjusted rates of death for each state. Also, place cursor on map states to get data.
Concerning the 2017 data in the charts below, deaths from the various drugs add up to more than 70,200 because multiple drugs are involved in many of the deaths.[ According to the National Safety Council, the lifetime odds of dying from an overdose in the United States is 1 in 96.
File:US timeline. Opioid deaths.jpg, US yearly deaths from all opioid drugs. Included in this number are opioid analgesics, along with heroin and illicit synthetic opioids.][
File:US timeline. Deaths involving other synthetic opioids, predominately Fentanyl.jpg, US yearly deaths involving other synthetic opioids, predominately ]Fentanyl
Fentanyl, also spelled fentanil, is a very potent synthetic opioid used as a pain medication. Together with other drugs, fentanyl is used for anesthesia. It is also used illicitly as a recreational drug, sometimes mixed with heroin, cocain ...
.[
File:US timeline. Prescription opioid pain reliever deaths.jpg, US yearly deaths involving prescription opioids. Non-methadone synthetics is a category dominated by illegally acquired ]fentanyl
Fentanyl, also spelled fentanil, is a very potent synthetic opioid used as a pain medication. Together with other drugs, fentanyl is used for anesthesia. It is also used illicitly as a recreational drug, sometimes mixed with heroin, cocain ...
, and has been excluded.[
File:US timeline. Heroin deaths.jpg, US yearly overdose deaths involving heroin.][
]
Awareness
The Substance Abuse and Mental Health Services Administration
The Substance Abuse and Mental Health Services Administration (SAMHSA; pronounced ) is a branch of the U.S. Department of Health and Human Services. It is charged with improving the quality and availability of treatment and rehabilitative services ...
hosts an annual health observance known as National Prevention Week. Every third week of May, they encourage communities across the country to unite to share stories about positive mental and behavioral health and the importance of implementing prevention methods. They also sponsor recovery Month every September. Recovery Month aims to raise awareness about mental and substance use disorders and to honor individuals who recover, promoting the positive message that prevention works and that treatment is effective.
International Overdose Awareness Day is on 31 August to remember those who have died from an overdose, to decrease stigma of drug-related deaths, and to promote prevention of overdose.
See also
*Harm reduction
Harm reduction, or harm minimization, refers to a range of public health policies designed to lessen the negative social and/or physical consequences associated with various human behaviors, both legal and illegal. Harm reduction is used to d ...
*List of deaths from drug overdose and intoxication
Drug overdose and intoxication are significant causes of accidental death and can also be used as a form of suicide. Death can occur from overdosing on a single or multiple drugs, or from combined drug intoxication (CDI) due to poly drug use. ...
*Responsible drug use
Responsible drug use maximizes the benefits and reduces the risk of negative impact psychoactive drugs cause on the lives of the user. For illegal psychoactive drugs that are not diverted prescription controlled substances, some critics believe tha ...
References
External links
*
{{Opioidergics
Poisoning by drugs, medicaments and biological substances
Drug overdose
Opioids
Medical emergencies
Wikipedia medicine articles ready to translate
Causes of death