It is important to educate patients, family, and caregivers of the danger signs of respiratory depression and drug overdose. Everyone in the household should be advised to obtain immediate medical attention by calling 911 while administering naloxone intranasally, intramuscularly, subcutaneously, or intravenously if the person demonstrates any signs of overdose. Signs of opioid-induced overdose include: 182,197 • Breathing difficulties, breathing that is slow, 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 • 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. Things that patients should be counseled to do or avoid when responding to an opioid overdose include: 197 •
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DON’T put the person into a cold bath or shower. This increases the risk of falling, drowning, or going into shock. DON’T inject the person with any substance (speed, saltwater, milk, heroin). The only safe treatment for opioid overdose is naloxone. DON’T try to induce vomiting to remove drugs that they swallowed. Choking or inhaling vomit into the lungs can cause a fatal injury.
Risk factors for developing benzodiazepine use disorder include: 200 • Non-Hispanic white race • Ages 18-35 • Comorbid psychiatric disorders • Personal or family history of substance use disorder Assessment When evaluating patients for benzodiazepine use disorder, a complete history of benzodiazepine use, treatment, and other substance use is critical to ensuring proper treatment. Since patients can obtain benzodiazepines by prescription or illicit methods, it is important to explore both avenues. Prescription use should be reviewed to determine if the patient is adherent to their prescribed directions; evaluation of the state’s Prescription Drug Monitoring Program (PDMP) can help providers identify all controlled substance prescriptions that a patient is legally prescribed in their state. Patients should specifically be asked about the type of benzodiazepines they use, the dose, the average number of tablets they consume each day, when they were last used, and the duration of use. This information can help providers evaluate the potential severity of withdrawal symptoms and the proper course of treatment. 191 Patients should also be asked about non- prescribed and illicit substance use; if necessary, urine drug screens can be used to evaluate current drug use. The use of benzodiazepines with other sedating agents such as opioids or alcohol can increase the risk of overdose and death. 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, and dosages and durations should be kept to the minimum possible. 182
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BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 6. Benzodiazepine Use Disorder Benzodiazepines are Schedule IV controlled substances commonly used to treat anxiety and insomnia. They work by increasing the binding of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) to the GABA A receptor, increasing its ability to exert calming effects. This effect can be helpful in the treatment of anxiety and insomnia, but has also been associated with physical dependence and addiction. In addition, when benzodiazepines are used chronically, tolerance can develop, creating a need for higher doses to achieve the same effect. Dependence can also develop with chronic use; approximately 50% of patients who use benzodiazepines for longer than one month develop dependence. Withdrawal symptoms are seen when benzodiazepines are discontinued abruptly after long term use. 199,200 Benzodiazepine use disorder can be a chronic, relapsing condition and is associated with increased morbidity and mortality. It can involve misusing benzodiazepines that have been prescribed, as well as diversion of unprescribed benzodiazepines. 200 According to the Substance Abuse and Mental Health Administration’s 2020 National Survey on Drug Use and Health, approximately 4.8 million people misused benzodiazepines in 2020, and approximately 1.2 million people were diagnosed with a sedative or tranquilizer use disorder 8 .
DO call 911 for emergency medical attention upon finding a person who has overdosed. DO support the person’s breathing by performing rescue breathing. DO administer naloxone as prescribed in the kit. DO turn the patient onto their side so they are in the recovery position if he is breathing independently. DO keep the person warm and don’t leave them alone. DON’T try to forcefully stimulate the person, such as by slapping them, as this can cause further injury. They may be unconscious if you are unable to wake the person by shouting, rubbing your knuckles on the sternum, or lightly pinching them.
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Instructions: Spend 5 minutes reviewing the case below and considering the questions that follow. Case Study 6
John is a 28-year-old patient with opioid use disorder who is starting medically supervised withdrawal. He had been using oxycodone for several years, and he recently was found unconscious after taking alprazolam and hydromorphone that he obtained illicitly in addition to his usual extended- release oxycodone dose. He is now motivated to “get his life back on track” and wants to start medication therapy. His last doses of oxycodone and hydromorphone were 72 hours ago, and he wants to begin treatment today. 1. Which of the following treatments is strongly recommended as a first line treatment in patients with moderate to severe opioid use disorder? A. Buprenorphine
B. Naloxone C. Clonidine D. Naltrexone
Answer: A. Buprenorphine is strongly recommended as the first line treatment MAT in patients with moderate to severe opioid use disorder. Its partial action at the opioid receptor allows for easier stabilization at the beginning of therapy while minimizing the risk of overdose.
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