(Part 1) Introduction and Accidental OverdoseJolomi Ikomi, MD, Chris J. Tuell, EdD, LPCC-S, LICDC, Lindner Center of HOPE, Staff Psychiatrist; University of Cincinnati College of Medicine, Adjunct Assistant Clinical Professor of Psychiatry
Opioids are indicated in treatment of acute and chronic non-cancer pain. Opioids are psychoactive substances and can cause an increased sense of euphoria via their action on the brain opiate receptors. This effect, which is beneficial for altered pain perception, is also the main reason for their misuse potential.
Opioids can be highly addictive. When used for recreational purposes, or when prescribed by treatment providers and not adequately monitored, can progress rapidly to an opioid related disorder. Opioid related disorders include opioid use disorder, opioid withdrawal, opioid intoxication, opioid induced mood disorder, opioid induced anxiety disorder and opioid induced psychotic disorder. There is an increased prevalence of mental illness in individuals with opioid related disorders than within the general population. About 90% of patients with opioid dependence will also have an additional psychiatric disorder, most commonly major depressive disorder, alcohol use disorders, anxiety disorders and personality disorders.
Since the 1990s, there has been greater awareness about adequate pain control for patients experiencing not just acute pain, but also chronic non-cancerous pain. This has led to an increase in the rise of prescription opioids, which in turn has led to a steady rise in opioid prescription addiction. The United States and Canada have significantly higher rates of prescribed opiates than any other developed country in the world. Prescription opioids are costly and the high cost of obtaining them has led individuals to seek cheaper alternatives. Heroin resurgence has occurred in the last decade. Patients addicted to prescription opiates are seduced by its cheap price and more rapid onset of action. Increased prevalence of heroin use has led to a rise in drug related felonies (larceny, prostitution) and medical complications such as HIV and Hepatitis C seroconversion and accidental overdose.
Opioid overdose is a global health concern accounting for considerable mortality among patients with opioid use disorders. About 50% of all deaths of heroin users in the United States are as a result of opioid overdose. 73% of all prescription overdose related deaths are due to prescription opioid medications.
To understand overdose, we first need to define the term “Tolerance”. This refers to an individual requiring more of a psychoactive substance to achieve a desired effect or when the same dose of a previously used substance does not give the desired effect. Individuals with opioid use disorders develop tolerance to the drug over a prolonged period of time. Opioids have respiratory depressant as well as euphoric effects. Tolerance to respiratory depressant effects occurs much slower than to the euphoric effects. This means whenever an individual rapidly increases the amount of the drug used in order to achieve a euphoric effect, they are at significant risk of respiratory compromise and death. Tolerance also rapidly decreases during periods of abstinence, such as following an opioid detoxification. Risk of overdose is greatly increased during the immediate opioid detoxification period. This is as a result of intense craving for the drug, as well as loss of tolerance to the drug.
Treatment of Overdose
Naloxone (Narcan) is a short acting opioid receptor blocker that is a life saving measure and should be immediately administered in suspected overdose. Signs to look for in an individual with suspected overdose include diminished level of consciousness or coma, pinpoint pupils and respiratory depression with rate less than 12 per minute (normal is 12-20). Administration of intravenous Narcan works within 2 minutes and slightly longer if given intramuscularly. This medication is safe and has no significant side effects. The main draw back with Narcan is the short half-life so its effects last much shorter than the effects of most opioids. Thus, once the medication has been administered, emergency medical services must be called immediately. Failure to do so will lead to immediate return of overdose symptoms within minutes, after effects of Narcan have worn off.
Administration of Narcan is easy and everyone, not just trained professionals can administer it. It can be administered in the community by trained lay persons. Family members and friends usually witness early symptoms of overdose. Training the support network as well as the individual with a history of opioid use disorder is imperative for the risk reduction of overdose deaths. Prescription of a Narcan kit to all individuals with a history of opioid use disorder has been shown to significantly reduce overdose deaths in the community. This is being practiced in some European countries and in several states across the U.S.
Narcan is not treatment, it is only an emergency life saving measure to prevent death and buy time before the arrival of emergency services and referral to treatment centers for long term treatment. Long-term treatment of opioid use disorders will be discussed in the subsequent series.