The goal of the administration of naloxone is to restore adequate ventilation, rather than to reverse all the effects of the opioid and potentially precipitate withdrawal. Naloxone can be administered intravenously, intramuscularly, and subcutaneously, but in patients who are in respiratory arrest, naloxone is often administered nasally (perhaps by a trained bystander) at a dose of 2 mg or 4 mg, which can be repeated, if needed. Read the Case Records of the Massachusetts General Hospital.
Q: What are some of the features of opioid-induced noncardiogenic pulmonary edema?
A: Noncardiogenic pulmonary edema occurs as a complication of opioid overdose in approximately 0.8 to 2.4% of cases. The majority of patients who have noncardiogenic pulmonary edema related to opioid overdose have respiratory symptoms immediately after overdose, but the symptoms may be delayed up to 4 hours. Treatment consists of supportive therapy with supplemental oxygen; mechanical ventilation is required in approximately one third of patients. Symptoms resolve within 24 to 48 hours in the majority of patients.
Q: What physician practices may help in preventing opioid overdose?
A: The prevention of opioid overdoses requires a multifaceted approach. Primary prevention of opioid-use disorder involves limiting a patient’s exposure to prescription opioids, starting with the first encounter. Patients for whom opioid prescriptions are considered should be assessed with the use of a prescription-monitoring program. If opioids are prescribed, a defined treatment plan should be discussed with the patient. Both the dose and the duration of the first opioid prescription should be limited, since the probability of prolonged opioid use increases linearly with the number of days for which the drug is initially supplied. Patients who already use opioids should be considered to be at risk for possible overdose, and secondary prevention efforts could be initiated. When patients receive opioids in the emergency department, they could be offered kits that contain naloxone, an opioid antagonist. Patients’ friends and family could also be offered kits and training in overdose recognition, so that they can administer naloxone if needed.
Q: What are some of the recommended emergency department measures for the management of opioid overdose?
A: Reversal is only the first step in the management of opioid overdose in the emergency department. In Massachusetts, patients who are resuscitated after an opioid overdose are offered an evaluation for substance-use disorder before discharge, with the goal of helping them to connect with inpatient and outpatient resources for long-term treatment of addiction. Evidence shows that inpatient detoxification programs are of limited value and the most effective approach is long-term opioid-agonist therapy with methadone or buprenorphine, which increases treatment retention and reduces ongoing opioid use, health care costs, and mortality. Initiation of addiction treatment with buprenorphine or methadone in the general hospital or emergency department is a strategy that results in higher rates of treatment retention than do detoxification programs or referrals to community treatment. Although psychosocial services should be made available to all patients, medication alone effectively reduces ongoing opioid use.
Q: What factors contribute to limited access to or use of opioid-agonist therapy for opioid addiction?
A: Access to opioid-agonist therapy remains limited. Only 1% of specialists in emergency medicine have waivers that allow them to prescribe buprenorphine, and half the counties in the United States do not have a single specialist who can prescribe buprenorphine. Qualitative studies that included people who had been incarcerated showed that fear of forced withdrawal led them to opt against opioid-agonist therapy. In addition, the standard practice of forced withdrawal of opioid-agonist therapy at the time of incarceration results in lower treatment retention in the community after release. A major barrier to expanding the use of opioid-agonist therapy is stigma perpetuated by the widely held misperception that these medications “replace one addiction with another.” Despite the vast amount of data supporting the use of opioid-agonist therapy, physicians are not immune to this stigma. The prevailing societal view that people with addiction have “brought upon themselves the suffering they deserve” may also affect physicians and contribute to the low frequency of offering buprenorphine treatment.
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