Opioid Overdose

In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.


One very common reason why patients seek medical care is for pain. Today, there are many ways to relieve pain, and one of them is with the use of opiates. Opiates have formally been approved for analgesia for close to 70 years, and for the most part, these drugs have been assumed to be relatively safe. However, in the last 2 decades, many reports have raised concern about the safety of these drugs. Cases of overdose and opiate toxicity are continually reported in all major cities in the United States. More notable is that the prescriptions for opiates have dramatically increased over the past 2 decades. This empirical prescription habit by healthcare workers has also led to an epidemic of an overdose outside the healthcare setting. Thus, for practicing healthcare workers, it is important to be aware of opiate toxicity in patients who are lethargic or unresponsive for no apparent reason (CDC, 2017).

Data released by the Drug Enforcement Agency (DEA) and the Centers for Disease Control and Prevention (CDC) indicate that from 2001 through 2010, the rate of opiate diversion, prescriptions for opiates, and opiate-related deaths have exponentially increased in the United States. The rates did plateau from 2011 through 2013 but again spiked from 2013 to 2014. Experts in pain management believe that the high number of opiate overdoses are not intentional but because patients may have been trying to manage unrelenting pain (CDC, 2016).

Opioid overdose occurs when a person has excessive unopposed stimulation of the opiate pathway. This can lead to decreased respiratory effort and possibly death. The frequency of opioid overdose is rapidly increasing. Drug overdose is the leading cause of accidental death in the United States, with opioids being the most common drug. The CDC currently estimates more than 1000 emergency department visits daily related to the misuse of opioids and about 91 opioid overdose deaths every day.

Prescriptions for opioid-containing medications quadrupled between 1999 and 2010. This paralleled a four-fold increase in overdose deaths due to opioids. The majority of the opioid deaths are attributable to the use of heroin and synthetic opiates other than methadone.

The issue with poorly treated pain has led medical professionals to use all types of short and long-acting opiates, and while this has made a difference in relieving pain, some patients often do not remain compliant with proper dosing. When the patient increases the dose or duration of opioids, then toxicity is a potential complication. Although annual rates of transition are low, this is commonly caused by individuals transitioning from the nonmedical use of prescription opioids to heroin.

Heroin, at about $2 a bag, is up to 10-fold cheaper and more readily available than prescription opioid medications for street purchase, which cost on average about a dollar per milligram. Additionally, there is an increasing trend of heroin mixed with fentanyl and other synthetic opioid compounds. This creates variable concentrations of opioid potency and a higher risk of overdose.

Adulterants: On the street, the majority of illicit drugs available are often contaminated with other substances. Sometimes to increase profits, sellers often add other agents to the formula without telling the end user. In many cases, these additives are pharmacologically active. Two decades ago in New York city, heroin had been adulterated with scopolamine, and this resulted in severe anticholinergic toxicity. Similarly, adulteration of cocaine is very common.

Prescription Monitoring

Most states have established prescription drug monitoring programs to counter the liberal prescription of opiates by healthcare workers (PDMP). In fact, in Kentucky, healthcare professionals must first consult with the state’s online drug database to determine which analgesic drug can be prescribed to patients. Such state enacted legislation has been developed to stop mass opiate prescription by healthcare workers. In addition, this also helps prevent diversion of legitimate opiate prescriptions (DEA, 2016).

Also, with the help of the Drug Enforcement Agency (DEA), there are now statewide registries of controlled substances that can assist healthcare providers to track usage patterns among patients in an effort to identify those individuals at high risk for opiate diversion or abuse. Even though the ready availability of opiates does play a role in opiate addiction, so far so no one has shown that there is a direct link between opiate abuse and legitimate use of these drugs for pain (DEA, 2016).

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