Opioid Toxicity and Antidote Training

Palm Desert Resuscitation Education LLC (PDRE) had the pleasure of welcoming a semi-retired family practice physician, Dr. Janet Roberts MD, who attended our American Heart Association (AHA) Basic Life Support (BLS) for Healthcare Providers (Online Part 1) and Skills Evaluation Testing in the afternoon of March 15, 2017. Dr. Roberts is the previous Medical Director for the Live Well Health Centers in Pittsburgh, Pennsylvania.

During her scheduled skills evaluation testing, Dr. Roberts mentioned an interesting and important topic in her online part 1 portion of her BLS course that mentioned some education on opiate toxicity and its antidote Naloxone, an opioid antagonist medication that reveres and decreases the risk of opioid-related intoxication and death from respiratory depression and other related complications.

We actually delved into this national opioid addiction and overdose epidemic that have affected many people in the United States in recent years from all aspects of life, especially the high-profile celebrities that have lost their lives with this significant widespread maladaptive dependence and craving.

According to the 2016 Facts and Figures of Opioid Addiction from the American Society of Addiction Medicine (ASAM), the Schedule II/IIN Controlled Narcotic Substances (2/2N) – such as oxycodone, hydrocodone, codeine, morphine, fentanyl and others – chemically interact with opioid receptors on nerve cells in the central nervous system (CNS) and peripheral nervous system (PNS) to produce the pleasurable effects and pain relief that a normal over-the-counter analgesic (i.e., acetaminophen and ibuprofen/NSAID) may not alleviate.

These strong opioid analgesics or “pain killers” when combined dangerously with benzodiazepines (e.g., alprazolam/Xanax and lorazepam/Ativan, and diazepam/Valium), alcohol, and other sedating agents may cause not only constipation (paralytic ileus), dependence and withdrawal symptoms but also life-threatening respiratory depression (apnea), arrest, and failure in addition to circulatory depression, hypotensive shock and subsequent cardiac arrest. Yes, they are a necessity when one has had major surgery and/or severe trauma for a certain limited time only, as in a few days or even a couple of weeks, or as much as it is allowed to contain one’s severe subjective pain, which may be difficult for a clinician to objectively determine.

Because of the potential for addiction and dependence to opioids, there has to be more education for not only healthcare providers such as Dr. Roberts, who took a blended BLS online and classroom-based course, but also for the surrounding communities especially where there is apparent legal and illegal use and abuse of opioids and other illicit drugs. If need be, PDRE is cognizant of promoting education on this important national opioid epidemic by educating the interested healthcare providers, non-healthcare providers, and lay persons on the symptoms and signs of opioid toxicity, overdose, and treatment in combination with resources around your community to aid in the prevention, treatment, and relapse of opioid abuse, addiction and dependence.

Another primary care physician, Dr. Reham Attia MD, who completed an Addiction Medicine Fellowship and is currently practicing medicine and a Family Medicine Attending at Eisenhower Medical Center (EMC) in Rancho Mirage, California, had recently completed the skills evaluation portion of both her AHA HeartCode Basic Life Support (BLS) and HeartCode Advance Cardiac Life Support (ACLS) on May 16, 2017 and had referenced the need for more accessibility of the antidote for opioids, Naloxone. She had explained that Narcan (Nalaxone HCL) Nasal Spray 4 mg/actuation can be readily available for purchase (about $60 per Dr. Attia) without a doctor’s prescription at some local pharmacies in cases of emergency treatment of known or suspected opioid overdose, as displayed by respiratory and/or CNS depression. Education should be increased in all of the departments of the hospital and outpatient healthcare settings as the treatment for opioid overdose is easily administered and understood in the directions (i.e., initial dosing of 1 spray delivered intranasal administration). It should not delay seeking emergency medical assistance as soon as possible before and especially after the administration of the first dose of Narcan.

Narcan Nasal Spray

Once in the hospital emergency room, the healthcare providers should obviously treat with Nalaxone the often-reversible symptoms and signs of opioid overdose before life threatening neurological, respiratory, and cardiovascular compromise becomes apparent. The requirement for repeat doses will depend on the amount, type, and route of administration of the opioid ingested and being antagonized. This brings us also to Mr. Richard Howell Pharm.D, an in-house staff pharmacist of EMC and a part-time pharmacist of Temecula Valley Hospital in Temecula, California, who had mentioned in his classroom-based ACLS course on May 27, 2017 there can be high false negatives on the urine toxicology screening for certain opioid derivatives that might have been modified illegally in the streets. Actually, Dr. Attia and Mr. Howell cited the drug carfentanyl or carefentanil that is another analog of the synthetic opioid analgesic fentanyl is 10,000 times more potent than morphine, making it the most powerful commercially used opioids. Per Dr. Attia and the 2016 article on Time.com, “Heroin is Being Laced with a Terrifying New Substance,” in recent years carfentanil overdose (over 300 cases since August to November 2016) has been spreading in the United States and moving from the states of Florida, Kentucky, Indiana, West Virginia, and Ohio. This new opioid drug epidemic is moving to the western United States because it is less expensive than heroin and easier to get apparently in the streets or online. What is more complicating is what Mr. Howell stated above that carfentanil may not be interpreted effectively on Opiate Urine Drug Screens simply because it is a newer form of opioid analog, which is scary to think because there are probably more chemically manipulated drugs that are sold out there that may not also show up in drug tests. It made our ACLS course that day with Mr. Howell and another emergency department nurse thought-provoking to think about the cardiac arrest algorithm with the “Hs” and “Ts” and not finding the reversible causes due to the intricacy of this toxin and other opioid analog’s chemical make-up and the poor accuracy, validity, reliability and precision of the urine and serum toxicology screening and diagnostic tests.

The following are some more attention-grabbing facts related to this opioid epidemic from the American Society of Addiction Medicine (ASAM).

Opioid Addiction:

Addiction is a primary, chronic and relapsing brain disease characterized by an individual pathologically pursuing reward and/or relief by substance use and other behaviors
Of the 20.5 million Americans 12 or older that had a substance use disorder in 2015, 2 million had a substance use disorder involving prescription pain relievers and 591,000 had a substance use disorder involving heroin.
It is estimated that 23% of individuals who use heroin develop opioid addiction.

National Opioid Overdose Epidemic:

Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.
From 1999 to 2008, overdose death rates, sales and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999; and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate.
In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.
Four in five new heroin users started out misusing prescription painkillers.
94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.”

Below is a short list of countless of famous celebrities and iconic figures who have died of opioid overdose or combined drug intoxication (CDI).

Prince (fentanyl)
Heath Ledger (CDI)
Philip Seymour Hoffman (CDI)
Chris Farley (morphine and cocaine)
Kurt Cobain (heroin and diazepam)
John Belushi (“Speedball” – heroine and cocaine)
Jim Morrison (heroin)
Elvis Presley (CDI)
Sigmund Freud (morphine)

If you are interested in learning more about opioid related topics and other CPR and ECC courses by PDRE, please don’t hesitate to contact us and call us for more information!