for Emergency Treatment of Accidental Overdose
Required Reading for All Patients Prescribed Opioids
Unintentional prescription opioid-related deaths are now considered to be of “epidemic proportions” in this country. In an effort to reduce this incidence, Opioid Overdose Rescue Kits are now available and affordable. All patients at Accurate Clinic receiving a two week or more supply of opioids are prescribed these Rescue Kits and patients are strongly advised to fill these prescriptions as household safety device.
The intent of making the Rescue Kits available in every home that houses a potentially lethal amount of opioid is to prevent the accidental opioid overdose not just of the patients for whom the opioids are prescribed, but actually for the other family members, children, house guests and even pets who may inadvertently or unexpectedly access the opioids, as unlikely as it may seem.
Buprenorphine (for pain)
Buprenorphine (for opioid SUD)
Definitions and Terms Related to Pain
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Naloxone (Evzio, Narcan®)
For the Emergency Management of Opioid Overdose
Due to the nationwide increase in accidental or unintentional overdoses from opioid pain medications, it is now recommended that anyone prescribed greater than a two week supply of opioid pain medications be provided with an emergency treatment option to prevent unnececessary death from overdose. The purpose in providing this emergency treatment option to pain management patients is not based on the likelihood of the patient overdosing since they are well-educated and informed regarding the safe dosing of opioids. Rather, it is related to the accidental, unexpected or unintended ingestion of the medications by someone else in the household such as a guest, family member or visitor to the home that somehow acquires access to the medication. Even a family dog or cat!
In the event of overdose, a lay-person can treat the victim with the naloxone which reverses the overdose effects of the opioid, including impaired breathing and low blood pressure. This action when performed in a timely manner can save someone’s life by providing the time necessary for EMTs to arrive and provide definitive management for the victim. And yes, the medicine is safe and effective for dogs and cats also.
Similar to the concept of providing patients with a history of life-threatening allergic reactions with “Epi-pen” kits for use in a life-threatening allergic reaction, patients treated with opioids can be prescribed pre-filled device containing Naloxone (Evzio®). The Evzio device is a self-contained injectable version of naloxone with a retracted needle that allows for safe injection with minimal risk to the provider for accidental needle stick. The Evzio kit comes with two single-use devices to allow for a second dose to be given when necessary. The Evzio device is covered with minimal to no co-pay (less than $10 in most cases) with most insurers including many medicaid and medicare policies.
Compounded Naloxone (Rx)
The most inexpensive version of naloxone can be purchased with a prescription from a compounding pharmacy that will provide a needle, syringe and vial of naloxone that can be drawn up and injected intramuscularly into the victim’s thigh as needed. The usual cost will be in the neighborhood of $30.
Intranasal Spray Naloxone (OTC and Rx)
Another convenient option for delivering naloxone is a nasal spray version that is available by prescription or OTC. This option can be purchased at any CVS pharmacy in LA. without a prescription for about $35. This option offers the advantage of being needle-less but may not provide as good systemic availability in the event of significant nasal o
bstruction due to excessive nasal secretions. It may be more difficult to administer to a small dog or cat.
Whichever affordable option proves best, it is strongly recommended that every patient prescribed opioids in 14-day or more quantities consider keeping one in their home. When possible, Dr. Ehlenberger advises the use of the Evzio device because of the exceptional ease of use, added convenience and safety with its use. Our staff can provide instructions for the easy administration of the medication.
How Does an Opioid Overdose Occur?
Opioids act on opioid receptors that are found throughout the nervous system, including the sections of the brainstem that control breathing. Stimulation of these receptors by opioids can cause euphoria, pain relief, nausea and other side effects including sedation. At higher doses, the sedation effects are enhanced causing loss of consciousness and at higher doses still, opioids can suppress and even stop breathing.
Who is at Risk for Opioid Overdose?
Statistics teach us the individuals at greatest risk of accidental opioid overdose are those taking other sedative drugs/medications along with their opioids, including alcohol, benzodiazepines (such as Xanax, Valium, Klonopin and Ativan among others), and Soma or other sedating medications.
Because opioids cause reduced sensitivity to oxygen and carbon dioxide levels, reducing the drive to breathe, people with COPD, emphysema and other lung diseases may be at increased risk when taking opioids. Unrecognized and/or untreated sleep apnea is another condition that places a person taking opioids at risk because of the reduced oxygen levels and elevated carbon dioxide levels associated with sleep apnea.
Obviously, the higher the doses of opioids, the greater the risk. This is especially true in patients new to opioids or patients experienced with opioids who have developed tolerance but who recently had an increase in dose, change in opioid or a recent surgical procedure that significantly reduced their chronic pain. Long-acting or extended-release opioids may also increase risk of accidental overdose in patients with sleep apnea. Studies also indicate that patient taking both short-acting and long-acting opioids have a greater statistical risk of accidental overdose.
What are the Signs of Opioid Overdose?
Initial signs of mild overdose of opioids include sedation, slurred speech, impaired thought processing and poor physical coordination. As an opioid overdose becomes more severe, the victim may be difficult to arouse with unintelligible speech and inability to sit up or stand. Signs of a potentially life-threatening overdose include decreases in respiratory rate, abnormal breathing sounds (snoring, gurgling, choking, etc.), poor responsiveness to stimulation and a blue/gray tinge of the skin, especially the lips and nail beds.
Recognizing the Life-threatening Opioid Overdose
Naloxone is indicated as an emergency intervention only in the case of severe opioid overdose. Mild symptoms of excessive opioid dosing that is associated with slurred speech, impaired coordination and mild drowsiness do not require naloxone. When signs of life-threatening opioid overdose are present, however, one should not hesitate to provide naloxone.
Signs and symptoms of life-threatening opioid overdose may include:
Cold, clammy skin
Constricted, pin-point pupils
Hypotension (low blood pressure)
Loss of consciousness/unresponsiveness
Respiratory depression – slow and/or shallow breathing
Most life-threatening overdoses involve more than one drug. If it is uncertain which drug or drugs are involved, it is still appropriate to consider using naloxone if the severity of overdose appears life-threatenng. In the case of a mixed overdose with an opioid plus an additional sedative(s) such as alcohol, Soma or a benzodiazepine like Xanax, Valium or Klonopin, while the naloxone will not reverse the additional sedatives, just reversing the contribution of the opioid component to the overdose symptoms may still provide an improved outcome and reduced risk of fatality. In the event that an overdose of unknown sedatives in the absence of opioids is treated with naloxone, there will be no benefit but also no harm. When in doubt, it is therefore best to err on the side of possible benefit rather than withold treatment.
In the absence of opioids, naloxone is safe and will have no effect when given to someone. The only exception to this is when it is given to someone physically dependent on opioids, such as the chronic pain patient who takes daily opioids for pain management or who takes Suboxone daily for opioid addiction. The use of naloxone in such an opioid-dependent individual will precipitate an immediate, severe opioid withdrawal syndrome in the individual. While not likely to result in life-threatening results, the recipient of the naloxone in this circumstance will experience severe nausea, vomiting, diarrhea and feel really bad. They will not be happy about receiving the naloxone but their symptoms will resolve within the hour.
If a person with known or suspected use of opioids exhibits signs of serious opioid overdose as listed above, proceed to inject the person with naloxone. The naloxone should reverse the overdose effects within 30 seconds to a minute. If no response is obtained, the dose can be repeated. When the person responds to the naloxone, the response may be temporary only and 911 should still be called. In some cases the opioid overdose can persist beyond the effects of the naloxone with a return to reduced consciousness and impaired breathing as the naloxone wears off, necessitating continued treatment in an emergency room setting.
See: How to Use EVZIO® (naloxone HCl injection)< /p>
Good Samaritan Law
For those who fear the possibility of being sued in the event of a naloxone intervention with an undesirable outcome, relax. Good Samaritan laws hold a person harmless and immune against lawsuit or criminal charges as long as the individual acts in good faith with reasonable cause.
Non-Emergency use of Naloxone
Naloxone in Combination with other Medications
Naloxone is also used in combination with buprenorphine in medications including Suboxone ,Zubsolv and Bunavail. These medications are used in the treatment of chronic pain and in opioid addiction. The presence of naloxone in these medications is as a deterrent against inappropriate use of these medications intranasally or intravenously as a means of abuse. When used in these ways rather than as prescribed for oral/sublingual use, the naloxone blocks the euphoria that would be experienced with these routes of use.
See: Buprenorphine for SUD and Buprenorphine for Pain
A common misconception regarding the naloxone in Suboxone and other combination products is that it makes taking these products block the activity of additional opioids ingested while taking Suboxone. But it is not the naloxone, it is the strong opioid receptor binding affinity of the buprenorphine (see above) that maintains this protective effect. The naloxone, as noted above, is not absorbed in the mouth as buprenorphine is, but is dissolved into saliva and swallowed. In fact, only 2% of naloxone is systemically available when swallowed due to extensive metabolism by the liver prior to entering systemic blood flow, so there is minimal, insignificant systemic exposure to the drug. If it were systemically available, naloxone would actually block the activity of the buprenorphine, making the entire medication useless.
Opioids Overdose: Emergency Reversal Agents
- Prescribe to Prevent – Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists
- CVS and Walgreens to sell opioid overdose antidote without individual prescription in Louisiana 5-26-16
- How to Use EVZIO® (naloxone HCl injection)
- Avoiding the Pitfalls of Opioid Reversal with Naloxone – 20102
Opioids Overdose: Mechanisms
Opioids – Safe Disposal
- Safe Disposal of Medicines > Disposal of Unused Medicines: What You Should Know
- Safe Disposal of Medicines > Medication Disposal: Questions and Answers
- Flush list Guide for Medicines
Emphasis on Education
Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.
For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.
Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.
For more information, please contact Accurate Clinic.
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