Treatment for opioid abuse generally starts with treatment of withdrawal in the acute phase. Managing symptoms of overdose and preventing death are the first objectives. Securing an airway and supporting the patient during the tremors, seizures, hypertension, nausea, vomiting, and pain are often handled in an ED or medical/surgical setting.
Naloxone (Narcan) can be used for reversal of opioid overdose and is available in IV, SQ, IM, and nasal routes. If a patient is unconscious, follow the ABCs of emergency response such as calling 911, checking for a pulse, securing an open airway, and providing rescue breaths. Give the first full dose of naloxone and continue rescue breaths. If the patient doesn’t respond, give the second full dose of naloxone. Patients will often respond quickly and be confused and possibly combative. Monitor the patient after recovery with naloxone to prevent another dose of an opioid and follow up with further medical attention.
Most states have passed laws to widen the availability to naloxone for family, friends, and other potential bystanders of overdose. In April 2019 the FDA approved the first generic naloxone hydrochloride nasal spray that can stop or reverse the effects of an opioid overdose. Naloxone nasal spray delivers a measured dose when used as directed. This product can be used for adults or children and is easily administered by anyone, even those without medical training. The drug is sprayed into one nostril while the patient is lying on his or her back and can be repeated if necessary (FDA, 2019).
As the FDA stated in 2019:
The use of naloxone nasal spray in patients who are opioid-dependent may result in severe opioid withdrawal characterized by body aches, diarrhea, increased heart rate (tachycardia), fever, runny nose, sneezing, goose bumps (piloerection), sweating, yawning, nausea or vomiting, nervousness, restlessness or irritability, shivering or trembling, abdominal cramps, weakness, and increased blood pressure.
Using pharmacologic blocking agents is helpful in stopping the opioid overdose. Antagonist medications block opioid receptors so that the desired effect is no longer active. Three opiate substitution medications are currently available in the United States—methadone, levomethadyl acetate, and naltrexone—but are only available in strictly regulated environments where medication is received under clinical observation and limited outpatient use (Dowell et al., 2016).
Methadone and buprenorphine are synthetic opioid agonists and act on the same mu receptors that opioids activate; therefore, they have been a popular treatment for addiction that is known as opioid substitution therapy (OST). Methadone has a slow onset of action and long elimination half-life of about 24 hours. A longer-acting opioid receptor agonist is buprenorphine, a partial opioid agonist that can reduce cravings and symptoms of withdrawals.
Naltrexone works differently than methadone and buprenorphine in the treatment of opioid dependency. While methadone and buprenorphine reduce cravings, Naltrexon eliminates the desire to take opioids. If a person using naltrexone relapses and uses the abused drug, naltrexone blocks the euphoric and sedative effects of the abused drug and prevents feelings of euphoria.
These drugs can be taken less frequently and can help wean a patient from likely fatal opioids. Control trials show that they are more effective than a placebo and can help decrease fatalities from opioids.
In 2018 the FDA approved the first non-opioid medication, lofexidine (Lucemyratm), for use in reducing symptoms associated with opioid withdrawal in adults, whether they have been using opioids appropriately or experience OUD. “The fear of experiencing withdrawal symptoms often prevents those suffering from opioid addiction from seeking help. And those who seek assistance may relapse due to continued withdrawal symptoms,” says FDA Commissioner Scott Gottlieb. “The FDA will continue to encourage the innovation and development of therapies to help those suffering from opioid addiction transition to lives of sobriety” (FDA, 2018).
People with OUD can benefit from taking medication-assisted treatment (MAT) for varying lengths of time, including lifetime treatment. Treatment with OUD medication is linked to better outcomes and retention than treatment without medications. Further, studies show that medication as part of treatment of OUD is cost-effective.
Access to these drugs is still dependent upon physician-controlled prescribing or treatment programs (Schuckit, 2016). Research shows that many people in need of treatment for substance use disorder do not receive treatment.
- NSDUH data indicate that in 2018, an estimated 21.2 million people aged 12 or older needed substance use treatment in the past year. Stated another way, about 1 in 13 people aged 12 or older (7.8%) needed substance use treatment.
- In 2018 approximately 3.7 million people aged 12 or older received substance use treatment in the past year, or 1.4% of the population. (SAMSHA, 2019)
Getting into approved treatment programs, where these drugs can be given and monitored closely, in combination with behavioral therapy, is often difficult, expensive, and not approved by insurance companies. Strict control of opiate-substitution drugs is necessary because they do produce a euphoric sensation like the opiates and there is a concern for creating a new market of illicit use. These medications can be given in sublingual, oral, and even intranasal forms. These opioid antagonist drugs act as competition for the mu receptors and, ideally, block the effectiveness of other opiates.
What is your facility’s process for treatment of an opioid overdose? Do you know how to use Narcan?