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In North America, and Canada in particular, the harms associated with the increased use of prescription and illicit opioids constitute a serious public health concern. Further to this, the recent emergence and increased availability of fentanyl in illicit drug markets has contributed substantially to an increasing number of opioid-related overdoses and deaths. Awareness of the clinical presentation, management options, and preventative measures for opioid overdose are universally important if clinicians are to help combat this growing epidemic. Here, we provide a brief review of the scope of the opioid problem and discuss how to make the diagnosis and provide evidence-based care for an individual presenting with an opioid overdose. We also review several important harm-reduction strategies that can be utilized to prevent future opioid-related harms with a focus on those utilized in Vancouver, B.C.
In recent years, fentanyl, a short- acting synthetic opioid analgesic, has increasingly contributed to premature mortality trends in Canada. Fentanyl, which is 50 to 100 times more potent than morphine, has traditionally been used for procedural sedation in the inpatient setting; it is also employed in the management of acute and chronic pain, for which its infrequent dosing and transdermal formulation carries appeal.10,11 However, its increased emergence and availability in the illicit drug market through diversion, local production, or illegal importation has resulted in a serious public health and safety concern.11-13 In British Columbia (B.C.), there has been a 7-fold increase in fentanyl-related deaths over the past four years, accounting for 25% of the province’s overall drug-related deaths.12 Given the increasing opioid epidemic, both locally and nationally, and its potentially devastating harms including overdose and mortality, we briefly review the diagnosis and treatment of an individual presenting with an opioid overdose and provide an overview of some strategies to prevent future opioid- related harms.
Opiates, which are naturally occurring and extracted from the poppy plant Papaver somniferum (e.g., morphine, codeine, thebaine), belong to a larger class of compounds called opioids. Opioids can be naturally occurring, semi-synthetic, or synthetic, and they act at the bodies of opioid receptors. Mu, kappa, and delta— the major opioid receptor subtypes— are found throughout both the central and peripheral nervous systems. When activated, these receptors contribute to a range of physiologic responses. The clinical manifestations of opioid use vary based on the dose, receptor targeted, and neurotransmitter(s) involved, but typically include analgesia, euphoria, and/ or respiratory depression.
Medical stabilization is always the priority for the management of any opioid overdose, and respiratory support, including mechanical ventilation, may be required temporarily. Routine monitoring of vitals is essential.
Figure 1:The classic signs of opioid toxicity.
in identifying other conditions requiring treatment. A decreased respiratory rate (RR) (<12 breaths per minute [bpm]), or apnea, a depressed mental status, and constricted pupils—miosis—are the classic signs of opioid toxicity, though the absence of any of these does not rule out the diagnosis (see Figure 1).14 Furthermore, it is important to exclude other potentially reversible causes for an individual’s clinical presentation (i.e., stroke, sepsis, metabolic disturbance) and consider the possibility of co-ingestions. Though not always possible, identifying the specific opioid used (i.e., a short-acting versus long-acting opioid), its formulation, and the dose taken, as well as obtaining information on the patient’s previous substance use history and intention for self-harm, can all prove useful in helping to anticipate the expected course of treatment and the need for a psychiatric evaluation.
Beyond a basic hematologic and electrolyte profile to assess for an anion gap, initial investigations should also include a serum glucose and creatinine kinase to exclude hypoglycemia and rhabdomyolysis, respectively.15,16 To investigate for co- ingestions, an acetaminophen, salicylate and alcohol level can be requested in addition to an electrocardiogram.15,16 A chest x-ray can be done to look for concurrent lung pathology and, specifically, pulmonary edema.15-17 Though a urine drug screen (UDS) can be helpful, opioid toxicity is a clinical diagnosis, and acute management should not be delayed while awaiting or interpreting the results of a UDS.18 Since both false positive and false negative results can occur, the overall clinical picture must be taken into consideration to obtain a diagnosis.
30 to 120 minutes. Therefore, repeated administrations or the initiation of a naloxone infusion may be required to overcome the toxicity associated with ingestion of a long-acting opioid or to combat the prolonged intoxication that can occur in overdose with short acting opioids due to alterations in normal pharmacokinetic properties.14,19 The variable and possibly transient response to naloxone makes close monitoring of vital signs and level of consciousness of utmost importance in the management of a suspected opioid overdose.
Needle exchange programs provide a life- saving, harm-reducing public health service.
In instances where an individual does not want to engage in treatment with pharmacotherapy, medical detoxification with subsequent referral to a community or residential treatment facility, self-help groups, a drug and alcohol counsellor, or other psychosocial interventions are potential treatment options. Unfortunately, at this time non-pharmacologic approaches are understudied and lack robust data from systematic reviews and meta-analyses. For those patients not committed to completely abstaining from opioids, continued motivational interviewing and harm reduction strategies can be maintained in the interim to improve safety and minimize risks associated with ongoing use.
In conclusion, Canada’s increasing prevalence of opioid use and disorder combined with the rapid emergence of fentanyl in the illicit drug market has resulted in a national opioid overdose crisis. Knowing the clinical findings and acute management of opioid overdose is necessary for all physicians, irrespective of one’s scope of practice. Although lives can be saved by applying the basic diagnostic and management skills reviewed in this article, the future of opioid overdose prevention lies in safe opioid prescribing, compassionate and evidence-based treatment of opioid use disorder, and the continued expansion and improved accessibility of harm reduction services.
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