If you missed out on the custom Around the Practice video program on naloxone, we've got you covered. Read a recap here.
What is the current state of the opioid epidemic, and what role does naloxone play in the emergency treatment of patients with known or suspected opioid overdose?
These questions and more were addressed in this installment of the custom Around the Practice video program. Panelists for this important discussion included Matthew A. Torrington, MD; Daniel E. Buffington, PharmD, MBA; Thomas R. Kosten, MD; and Bill H. McCarberg, MD.
“This is not a new epidemic,” said Kosten, adding the opioid crisis started as early as 2015. “One can say it was led by the overprescribing of opiates, but what has taken over [the expanding crisis] is fentanyl.”
The panel agreed it has spread across age groups, making it everyone’s problem.
Naloxone may be a solution, Buffington explained, but it may need to be administered several times to counter opioid overdose in emergency situations due to the “increased prevalence of higher-potency fentanyl products” in recent years.
Case Vignette 1
A 27-year-old man presents for evaluation in extreme pain from a car accident. He has a past history significant for substance use disorder, high blood pressure, and diabetes. He takes buprenorphine 2 mg, lisinopril 20 mg, and metformin 500 mg per day. During the next 4 hours, his pain levels vary. Imaging shows a broken ankle, a broken rib, and a small hairline fracture on his clavicle; a CT and MRI show no tissue or brain damage. He gets a cast for his ankle and is started on low-dose opioid therapy—1 oxycodone acetaminophen every 4 to 6 hours as needed for pain for 5 days, until he can see his primary care provider.
This is where the real problems begin, the panel agreed, as the patient is discharged without appropriate pain management. “If you don’t do enough to treat this guy’s pain, you can drive him to the illicit market, and that’s when he becomes the real victim of overdose,” explained Torrington. “I see as a lot of this substandard pain treatment, which makes people—even reasonable people—go to the illicit market to get something else to help them with their discomfort... If we don’t do an adequate job, they’ll take matters into their own hands.”
Acknowledging that this patient is at risk for overdose, the panel discussed the potential use of naloxone.
Kosten recommended 8 mg of naloxone, stating, “If he did go to the illicit market, unfortunately, fentanyl might be in that and you’re going to need a big dose of naloxone to do something.”
McCarberg agreed that this patient is a good candidate for naloxone. “This person has an opioid use disorder—I assume he was given the buprenorphine because of treatment for the opioid use disorder, even though it was a subtherapeutic dose,” he explained. “He’s still drinking, he’s smoking cigarettes, all of which put him at high risk for going outside of the standard prescribing realm to get medication...So he really is high risk given all of these factors together. This is the guy that needs the naloxone and a discussion with the wife or whoever’s the other members of the family about what to look out for if he overdoses.”
Case Vignette 2
A 49-year-old unemployed male truck driver is found semiresponsive, and an opioid overdose is suspected. He has a past medical history of high blood pressure, diabetes, obesity, and chronic pain, as well as opioid use following a previous motor vehicle accident. He smokes 1 pack of cigarettes a day, is recently divorced, and lost his job during the pandemic. During the physical exam, he is hypertensive and unresponsive to sternal rub. During the clinical work-up, he has pinpoint pupils, has gone pale, and has clammy skin. His blood pressure is 60/40 mm Hg. His heart rate is 28 beats per minute.
After confirming his airway is clear, he is given supportive breathing and then 8 mg of naloxone intranasally. He is monitored for opioid withdrawal and/or non–naloxone resistance.
“I think you have to think about longer-term treatment,” Kosten said. “Based on the 8 mg of naloxone that it took to reverse him and what is on the street, he probably did get fentanyl in his system. Then the question is: What do you want to treat him with? Could you treat him with naltrexone?” Kosten posed. “An injectable naltrexone lasts a month, so you do not have compliance problems. If he is not opiate dependent, that’s a real possibility.”
“This person absolutely needs comprehensive individualized multimodal treatment over time that’s biologic, psychologic, social, spiritual, and nutritional to have the best possible chance of overcoming his challenges,” Torrington added. “There are so many things that you could do with this teachable moment, but I’m afraid that in real life, many times this guy wakes up and goes home, and not that much else happens.”
The panel noted it was important to involve the family to prevent negative outcomes.
“I had a recent overdose rescue in my practice, and what struck me was that the wife said, ‘I didn’t know if I should give it or not. I couldn’t tell.’ The question comes up: Should she use it when she’s not sure? Should we be advising family members to use the drug if they’re not absolutely certain that it’s an overdose? The side effects, the risk-benefit profile for using the drug is so much in favor of using the drug if you’re not sure because of the fact that there hardly are any side effects from the drug. There are withdrawal side effects, but if you don’t know, it’s better to use it than to not use it because a side effect or a withdrawal is much better than a death. If you don’t know for sure, error on the side of something that is less harmful to the patient.”
The panel further agreed that to keep patients off the streets looking for medications, care needs to go beyond undertreating pain.
Kosten concluded: “[Providers] have to have an open mind that substance abuse and major psychiatric disorders are not totally divergent—that they, unfortunately, are totally convergent and come together. You can die of suicide. You can also die of an overdose just as easily and a whole lot more quickly.”
Dr Torrington is a board-certified family medicine and addiction medicine physician practicing in Culver City, CA. Mr Buffington is president and CEO at Clinical Pharmacology Services in Tampa, FL. Dr Kosten is the Jay H. Waggoner Endowed Chair and professor of psychiatry, pharmacology, immunology, and neuroscience, as well as vice-chair for psychiatry, and codirector of the Dan L. Duncan Institute for Clinical and Translational Research, and a professor of at the Baylor College of Medicine in Houston, TX. He is also on the editorial board for Psychiatric TimesTM. Dr McCarberg is founder of the Chronic Pain Management Program for Kaiser Permanente and adjunct assistant clinical professor at the University of California San Diego School of Medicine. ❒