What Is Opioid Overdose?
An opioid overdose occurs when an individual ingests an excessive amount of opioid drugs, leading to potentially life-threatening symptoms such as respiratory depression, extreme sedation, and coma. Opioid overdose is a rising public health issue that has recently been connected to higher mortality rates.
The identification and treatment of opioid overdose cases, which can present with various symptoms and necessitate quick action to avert complications or death, fall under the emergency department's (ED) purview. Prescription opioids and illegal narcotics like Heroin and Fentanyl are the most prevalent opioids in the United States for drug overdose deaths.
Who Is at Risk for Opioid Overdose?
The risk of opioid overdose is increased by several factors, including.
-
Having an opioid use disorder, injecting opioids, resuming opioid use after a period of abstinence, using prescription opioids without medical supervision, taking high doses of opioids, and using opioids in combination with other substances that suppress respiratory function. Individuals with certain medical conditions, such as HIV (human immunodeficiency virus), liver or lung disease, or mental health conditions, are also at increased risk of overdose.
-
Men and those with lower socioeconomic status are at higher risk of overdose than women and those with higher socioeconomic status, while older individuals are also at increased risk compared to younger age groups.
How Is Opioid Overdose Recognized in the Emergency Department?
When diagnosing opiate overdose, the majority of patients are found to be lethargic or comatose. It is a common practice to obtain a history from family, friends, witnesses, and emergency medical service providers, which may include details on the quantity of substance used, whether any congestion occurred, and the timing of ingestion. Naloxone may be administered in the prehospital setting, which can aid in the diagnosis. The diagnostic methods involve the following:
-
Skin Analysis: If intravenous opiates are abused, examination of the extremities may reveal needle track traces. The use of opioids can also result in the release of histamine, which can induce urticaria (hives), skin flushing, and itching.
-
Pulmonary Effects: Opioids like Morphine can lead to hypoxia and respiratory distress, both of which can result in pupillary dilation. Opioids have a history of producing midway pupils or outright mydriasis. Patients who have overdosed on Morphine typically have shallow breathing, hypopnea (decreased ventilation), and bradypnea (slow breathing rate). Due to the constriction of the airways, some people may exhibit dyspnea (shortness of breath), wheezing, and foamy sputum.
-
Cardiovascular Effects: A common side effect of most opiates is peripheral vasodilatation, leading to mild to severe hypotension (fall in blood pressure). Fluid administration or adjustments to body posture can quickly cure hypotension.
-
Gastric Effects: Due to slow intestinal motility, nausea, and vomiting are frequent in patients with opiate poisoning.
-
Mental Health Effects: Opiates are CNS (central nervous system) depressants, but they can also produce neuropsychiatric symptoms such as agitation, anxiety, despair, nightmares, and paranoia.
-
Others: The threshold for seizures can be lowered by opiates, and generalized seizures can happen, especially in young children.
How Is Opioid Overdose Diagnosed?
The diagnostic parameters of opioid overdose include the following
Laboratory Investigations:
Complete blood cell count, comprehensive metabolic panel, creatine kinase level, and arterial blood gas determinations. In most cases, a positive opiate result will appear even 48 hours post-exposure. Drug screens are also readily available.
Imaging Studies:
A chest X-ray should be obtained if any lung injury is suspected. Then an abdominal X-ray is recommended if the patient is suspected of being a body packer. An electrocardiogram (ECG) is recommended in all patients with suspected opioid overdose.
How Is Opioid Overdose Managed?
The management of opioid overdose involves several steps, including recognizing the signs and symptoms of overdose, calling for emergency medical services, providing supportive care, and administering opioid antagonists.
Initial Management:
Recognizing the early symptoms and indicators is the first step in managing an opioid overdose. These include unresponsiveness, loss of consciousness, slow or shallow breathing, bluish lips or nails, and pinpoint pupils. Emergency medical attention is required in these cases. Supportive care may be given at first. This may include placing them in the recovery position, providing oxygen if available, and monitoring their breathing and vital signs. It is important to avoid giving the person any additional opioids or sedatives, as this can worsen the overdose.
Naloxone:
The primary treatment for opioid overdose is the administration of opioid antagonists, such as Naloxone. Naloxone works by binding to the same receptors in the brain as opioids, thereby reversing their effects and restoring normal breathing. Naloxone is available in several different formulations, including intranasal, injectable, and auto-injector devices. In some jurisdictions, Naloxone can be obtained without a prescription and is often carried by first responders, healthcare providers, and family members of individuals at risk of opioid overdose.
If the person does not respond to the initial dose of Naloxone, additional doses may be administered every two to three minutes until they respond or until emergency medical services arrive. Naloxone can rapidly reverse the effects of opioids, it is not a substitute for medical care, and the person should still be transported to a hospital for further evaluation and management.
Dosing of Naloxone:
-
Naloxone is available in different formulations, including injectable, intranasal, and auto-injector devices. The recommended starting dose of Naloxone for opioid overdose is typically 400 micrograms to 0.00007 ounces given intravenously, intramuscularly, or subcutaneously.
-
The intranasal formulation of Naloxone is typically administered in doses of 0.00007 ounces to 0.0001 ounces in each nostril.
Conclusion:
The recognition and management of opioid overdoses are essential aspects of emergency medicine. Given the increasing prevalence of opioid use and its associated risks, healthcare providers in the emergency department must be knowledgeable about the signs and symptoms of an overdose and equipped with the appropriate tools and interventions to manage this medical emergency. Early recognition and prompt administration of opioid antagonists, such as Naloxone, can be life-saving and improve outcomes for those affected by overdose. Furthermore, a multifaceted approach, including prevention, education, and treatment, is needed to address the opioid epidemic and reduce the burden of opioid-related morbidity and mortality. By working together, healthcare providers, policymakers, and community members can make a significant impact in addressing this critical public health issue.
