any point benefits no longer outweigh the potential risks of con - tinuing therapy, other therapies should be re-evaluated, and opi- oid dosages should be tapered down or discontinued (Dowell et al., 2016). Before and periodically during opioid therapy, prescribers should reassess risk factors of opioid-induced complications. Pain man- agement plans should include strategies to mitigate risk such as offering naloxone to patients at a high risk of overdose, which in- cludes patients taking more than 50 MME per day, patients with a history of overdose or substance use disorders, and those concur- rently taking benzodiazepines. The patient’s history of controlled substance prescriptions should be evaluated periodically using prescription drug monitoring program (PDMP) data. Depending on the patient, data evaluation can range from every prescription to every three months. Urine drug testing can also be used as a Naloxone Naloxone hydrochloride (Narcan) is a competitive opioid antago- nist that reverses the effects of agonistic opioids. It can be admin- istered via intranasal spray or by intramuscular, subcutaneous, or intravenous injection, and can be safely administered to children and pregnant patients. If the patient does not respond within two to three minutes after administration, a second dose should be administered. The duration of action of naloxone depends on the dose, route of administration, and drug overdose type. Patients who have overdosed on long-acting opioids (OxyContin, MS Contin, Kadian) typically require multiple doses or a continuous infusion of naloxone, since the opioid duration of action may be longer than the naloxone duration of action. The goal of naloxone therapy should be to restore adequate spontaneous breathing, not necessarily complete arousal (Fudin, 2018; SAMHSA, 2018). Naloxone is a proven safe medication. When given to patients who are not opioid intoxicated or dependent, there are no clin- ical effects. Even though naloxone produces a rapid withdrawal in opioid-tolerant patients, it is not life threatening. These symp- toms are unpleasant, and some patients may become agitated and combative and require medication (e.g., benzodiazepine) to remain calm. Withdrawal symptoms include the following (SAM- HSA, 2018): ● Body aches. ● Diarrhea. Counseling patients on overdose risk and response Evidence has shown that laypersons can learn to recognize the signs of an opiate overdose. They also can learn how to safely administer the antidote, naloxone. Naloxone kits provided to lay- persons are safe and cost effective and reduce overdose deaths. Multiple health organizations recommend providing naloxone kits to laypersons who may witness an opioid overdose, to patients in substance abuse treatment programs, to persons leaving pris- on or jail, and as a component of responsible opioid prescribing (Dowell et al., 2016). ● Tachycardia. ● Runny nose. ● Sneezing. ● Piloerection. Signs of opioid-induced overdose ● Breathing difficulties, slow and shallow or not present at all, or the presence of the “death rattle.” ● Hard to arouse. ● Face is pale. ● Skin is clammy to the touch. ● Body is limp. ● Fingernails or lips are blue or purple. ● Person is vomiting or making gurgling noises.
tool to prevent diversion of opioids; testing before and periodi- cally during long-term opioid therapy is recommended by CDC (Dowell et al., 2016). When designing a pain management regimen for a patient, cli- nicians should avoid the combination of opioids and benzodiaz- epines. The U.S. Food and Drug Administration (FDA) added a black box warning to the labels of all opioids and benzodiazepines advising against using these medications together. Because both are CNS depressants, the combination puts patients at increased risk of slowed or difficult breathing, over sedation, respiratory depression, and death. The FDA states that these medications should be prescribed together only when alternate treatments are inadequate. When co-prescribed, the dosages and durations should be kept to the minimum possible (Dowell et al., 2016).
● Nausea. ● Vomiting. ● Restlessness. ● Agitation. ● Abdominal cramps. ● Increased blood pressure.
The FDA has approved injectable naloxone, intranasal naloxone (Narcan nasal spray and Kloxxado nasal spray)), and a naloxone autoinjector (Evzio) for the treatment of opioid overdose. Inject- able naloxone can be administered intravenously, intramuscularly, or subcutaneously in healthcare settings at doses of 0.4 mg to 2 mg every two to three minutes until respiration is restored. The Narcan nasal spray is a prefilled, needle-free device that requires no assembly. It can deliver a single 4-mg dose of naloxone into one nostril. The Kloxxado nasal spray delivers a single 8-mg dose of naloxone into one nostril. The Evzio autoinjector is injected into the anterolateral aspect of the thigh to deliver naloxone 2 mg / 0.4 mL in a prefilled autoinjector injected either intramus - cularly or subcutaneously. Once Evzio is turned on, the device provides verbal and visual guidance to the user describing how to deliver the medication, similar to automated defibrillators, in a safe, confident manner. Both Narcan nasal spray and Evzio are packaged in a carton containing two doses to allow for repeat dosing if needed. Caregivers should be advised to repeat doses in two to three minutes if no response is seen or until emergency responders arrive (Dowell et al., 2016; FDA, 2016; DiPiro et al., 2019; FDA, 2021). Healthcare Consideration: It is important to educate patients, family, and caregivers of the danger signs of respiratory depres- sion and drug overdose. Everyone in the household should be advised to obtain immediate medical attention by calling 911 while administering naloxone intranasally (a spray through the nose), intramuscularly (into the muscle), subcutaneously (under the skin), or intravenously if the person demonstrates any signs of overdose (Dowell et al., 2016; SAMHSA, 2018). ● Person is unable to speak, is confused, or has slurred speech. ● Heartbeat is very slow or stopped. Often laypersons attempt to help the overdose victim in ways that may actually harm the person more. The health care professional should educate the layperson on the appropriate way to respond to an opioid overdose (SAMHSA, 2018).
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