Opioid Overdose: Keep Your Patient Alive, But Protect Yourself

Exposure to even a small amount of fentanyl can be fatal

A picture of a woman on the ground after overdosing and her ghost looking down at her

Imagine that you’re home in bed late one night when there’s a frantic knock at your door. It’s your next-door neighbor, who says her daughter may have overdosed on opioid medication. She remembered that you were a nurse and hoped that you might be able to help.

Would you know what to do in this situation? If not, now would be a good to learn. In 2016, almost 2,000 Californians died of opioid overdose. Most could have been saved with prompt intervention. Knowing how to respond to a suspected overdose could save a life — and safeguard your health.

The Opioid Overdose Triad

Olivia Olmos, RN, MSN, ENPC, works in the ED of White Memorial, a busy hospital in the Boyle Heights area of downtown Los Angeles. Her unit sees a lot of overdose cases.

One of the first challenges of responding to an overdose is recognizing what you’re dealing with. When responding to a potential overdose case, Olmos explains, “We quickly go into detective mode in order to understand and pinpoint which medication is the root cause. As with any situation, there can be patients who do not respond to any tactile or verbal stimuli, which will require emergent intervention to maintain their airway and provide safe care.”

According to the World Health Organization (WHO), the “opioid overdose triad” includes unconsciousness, pinpoint pupils and respiratory depression. The latter is the principal cause of overdose fatalities and may manifest as slow or irregular breathing or respiratory arrest. This may be accompanied by cyanosis of the lips and nails.

Overdose patients may be delirious and extremely drowsy or completely unconscious. If the patient loses consciousness, it may be impossible to awaken them even with sternal rub. An overdose victim may also exhibit low blood pressure and reduced heart rate.

Common risk factors for opioid overdose include a history of substance abuse; depression; lung or liver disease; and taking opioid medication in combination with other sedatives such as benzodiazepine or alcohol. Although these factors seem straightforward, prescribers may not always check for them and patients are not always informed.

The higher the individual’s daily dose, the greater the overdose risk. Sadly, patients who have previously detoxified may be at elevated risk of overdose because their tolerance for the drug has decreased.

Overdose Treatment: Naloxone

Olmos recalls one overdose patient who was found lying in front of a liquor store. “The patient was unresponsive to any painful, verbal and motor stimuli and also presented with pinpoint pupils,” she says.

“At that moment, I was already thinking endotracheal intubation and Narcan because my thought and every nurse’s thought should always be airway. Because if you don’t have an airway, you don’t have a patient.”

Narcan is Adapt Pharma’s trade name for naloxone hydrochloride, an FDA-approved drug that can actually reverse opioid overdose. (Kaléo Pharma also manufactures naloxone under the trade name Evzio.) Naloxone is an opioid antagonist, binding to the body’s opioid receptors to block and undo the effects of opioid use. This reverses life-threatening symptoms like respiratory depression and bradycardia.

Between 1996 and 2014, naloxone saved more than 26,000 lives. Many were through administration by laypeople rather than healthcare providers or first responders. With increased public attention on the opioid epidemic, naloxone is now available without a prescription in California and many other states, making the drug much more accessible to the people who need it.

Call 911

Naloxone usually works very quickly, but it may not be effective for all types of opioid overdoses, including those involving buprenorphine. Some patients may need multiple doses of naloxone and might require subsequent doses over a period of up to 24 hours. Also, a patient with severely depressed respiratory function may still require CPR until their breathing returns to normal.

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If you find yourself administering naloxone outside a healthcare setting, the drug’s manufacturers stress that you should still call 911. The goal is not to replace medical help, but to keep the patient alive long enough to receive it.

Fentanyl Is a Danger to the Medical Team

If you’re not careful, dealing with opioid overdose patients might leave you needing a dose of naloxone yourself. Contact with the patient during assessment and treatment can expose you to the same drug the patient was exposed to, which could be extremely dangerous.

Last August, three nurses at a hospital in Massillon, Ohio, had to be treated with naloxone after cleaning a room where an overdose patient had recently been treated. All three had become sick and passed out after coming into contact with a substance believed to be fentanyl.

Fentanyl is the generic name for an extremely potent synthetic opioid at least 50 times stronger than morphine. Some chemically similar drugs are even more powerful; carfentanil, which is used to tranquilize elephants, is 10,000 times more potent than morphine!

Illicit drug traffickers sometimes mix or replace narcotics like heroin with these powerful synthetic versions, greatly increasing the risk of accidental overdose. According to the CDC, 29 percent of all U.S. opioid deaths in 2015 were caused by fentanyl and its chemical cousins. Not only can synthetic opioids like fentanyl easily kill an unwary user, they also pose a major hazard to first responders and healthcare workers. Some forms of these drugs can be absorbed through the skin and they’re so powerful that contact with even a tiny amount can produce overdose symptoms within minutes.

Protect Against Unknown Substances

Carrie Kappel, RN, B.S., is a licensed drug and alcohol counselor for the Hazeldon Betty Ford Foundation, a treatment and recovery provider. She says that when it comes to working with patients under the influence of opioids or in opioid withdrawal, she and her fellow nurses “take basic universal precautions, like using barrier methods to avoid any direct contact with unknown substances, particularly powdered substances.”

In California, Cal/OSHA’s Injury and Illness Prevention Program requires employers to identify and evaluate workplace hazards. “This includes occupational exposure to synthetic opioids, such as through the skin, via inhalation and via ingestion,” notes Cal/OSHA Senior Safety Engineer Grace Delizo. Employers are then responsible for providing appropriate personal protective equipment and emergency procedures.

When it comes to possible fentanyl exposure, Delizo says, the National Institute of Occupational Safety and Health (NIOSH) recommends “use of a P100 (or higher) half-mask filtering face-piece respirator, gloves, eye protection and protective clothing. NIOSH also recommends not to eat, drink or smoke in the area of suspected fentanyl, and that employees wash their hands and inspect their clothing for contamination after performing any activity potentially involving fentanyl.”

The DEA’s briefing booklet for first responders recommends that individuals who may come into contact with fentanyl or similar synthetic opioids use eye protection, paper coveralls (including shoe covers), nitrile gloves and N95 particulate filter masks. Gross contamination may require even greater protection and self-contained breathing apparatus.

Of course, you can’t always open your door wearing protective gear, but if you are uncertain what an overdose patient may have been exposed to, uninformed, unprotected contact with that patient is like a game of Russian roulette.

If you encounter an unknown powder or other substance while responding to an overdose situation, the substance should not be disturbed. Instead, contact the DEA.

Brutal Opioid Withdrawal

Naloxone can save an overdose patient’s life, but that may be only the beginning of their ordeal. For a patient who does not routinely use opioids (like the nurses who were accidentally exposed to fentanyl), WHO says the aftereffects of naloxone are usually “minimal.” However, for a habitual user, overdose reversal is quickly followed by withdrawal.

Hiring Now

“The patient will wake up screaming and in pain,” says Olivia Olmos. “So, please be prepared to handle a very upset patient and have enough support to assist you. It is so important to understand how to care for patients that have overdosed on opioids or any other medications.”

Opioid withdrawal can be even more brutal than withdrawal from other drugs. Symptoms can include pain, muscle cramps, tremors, nausea, intense anxiety, insomnia, tachycardia and even convulsions. This may tempt the patient to make it all go away with another dose of opioids.

“Withdrawal is one of the more powerful factors driving dependence and addictive behaviors,” explains Carrie Kappel, who in addition to her work at Betty Ford serves as associate director of the Health Care Professionals Program, which helps healthcare providers overcome substance use disorders. “So, our biggest challenge is to help patients manage their withdrawal symptoms and see the light at the end of the tunnel, so that they don’t leave treatment early and/or return to using.”

Staying away from opioids over the long term can be a daunting challenge for patients. “A desire to feel ‘normal’ again, to escape this seemingly permanent state of dysphoria, puts them at a high risk of relapse and, even more tragically, at a high risk of accidental overdose and death during relapse,” Kappel says. “An opioid user who returns to the same dosage after losing his or her tolerance to that drug risks respiratory suppression and death.”

Treatment Options

There are a number of treatment options for opioid dependency, including counseling and medication-assisted treatment with drugs such as buprenorphine, naltrexone or methadone. Kappel provides support, comfort and medication while connecting patients to others who have faced similar issues and can help them out of the vicious cycle of opioid use disorder.

If you have not been trained in models like SBIRT (screening, brief intervention and referral to treatment), you may want to talk to your colleagues or other professionals like social workers to learn what resources are available in your community for treating opioid use disorder. That way, you can advise patients appropriately should the need arise.

You can also refer patients to the federal Substance Abuse and Mental Health Administration (SAMHSA), which offers a free confidential hotline to help people find substance abuse treatment resources. The hotline, 1-800-662-4357, is available 24 hours a day and has operators who speak Spanish as well as English.

Treating overdoses won’t end the opioid crisis, but nurses can play an important part in mitigating the epidemic by staying informed, helping to save people who have overdosed and advocating new ways to improve opioid treatment and overdose response.


Opioid Education Resources

Here are some online resources offering free or low-cost information on opioid safety and treatment for nurses and other healthcare professionals:

• U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, Pathways to Safer Opioid Use – health.gov/hcq/training-pathways.asp

• National Institute on Drug Abuse and Medscape Education, Opioid and Pain Management – www.drugabuse.gov

• Institute for Healthcare Improvement, Advancing Pain Management and Opioid Safety – www.ihi.org

• Boston University, SCOPE of Pain: Safe and Competent Opioid Prescribing Education – www.scopeofpain.com

• CDC, Guidelines for Prescribing Opioids – https://www.cdc.gov/opioids/providers/prescribing/guideline.html

• Institute for Research, Education & Training in Addictions (IRETA), SBIRT Toolkit (Screening, Brief Intervention, Referral to Treatment) – ireta.org/improve-practice/toolkitforsbirt

• Substance Abuse and Mental Health Services Administration (SAMHSA) offers a variety of resources, including a free opioid overdose prevention toolkit and information on SBIRT – www.samhsa.gov


Naloxone Nasal Spray

Naloxone is normally injected intramuscularly, but the FDA has now approved Narcan nasal spray in 2 mg and 4 mg doses. CVS, Walgreens and several other pharmacies now sell over-the-counter two-packs of these prepackaged, single-use sprayers, which are administered by spraying the complete dose into the patient’s nostril.

Narcan nasal spray is more expensive than the injectable form, but is much easier for laypeople to use, presents no risk of needle stick and is just as effective as injection. Adapt Pharma’s official product website, www.narcan.com, has a section for healthcare professionals that provides an instructional video and other clinical resources on the nasal spray.

DARIA WASZAK, RN, DNP, CEN, COHN-S, is a Long Beach native and SDSU and UCLA alumna. She has over 20 years of clinical and leadership experience and is currently a RN/BSN faculty member.

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