Opioid overdose

Prevention[edit]

Opioid overdoses can often be prevented.^[35][36] Clear protocols for staff at emergency departments and urgent care centers can reduce opioid prescriptions for individuals presenting in these settings who engage in drug seeking behaviors or who have a history of substance abuse.^[37] Drug seeking behaviors include but are not limited to obsessiveness or impatience when it comes to attaining medications, seeking multiple pain adjunct medications, and inconsistent physiological presentation.^[38] A prescription monitoring program may help determine if an individual is receiving a high doses of opioids or combinations of medications such as benzodiazepines and opioids that put them at high risk.^[39] Limited amount of evidence suggests opioid therapy with extended-release or long-acting formulations may increase the risk of an unintentional overdose compared to shorter-acting agents.^[40] Routinely screening using tools such as the CAGE-AID and the Drug Abuse Screening Test (DAST-10) in adults and the CRAFFT in those aged 14–18 years is recommended.^[35] The revised risk index for overdose or severe opioid induced respiratory depression (RIOSORD) is a validated screening tool that may be used to estimate the risk of overdose in people using opioids, or the rapid opioid dependence screen may be used as a more rapid and succinct method to screen for opioid use disorder.^[24] Other "drug seeking" behaviors and physical indications of drug use should be used as clues to perform formal screenings.^[35]


There are several medication-assisted treatments available for people with opioid use disorder or opioid dependence, who are at higher risk for opioid overdose.^[1][41] The selection of treatment depends on various factors, such as a person's preference, accessibility, and history of treatment.^[41] Examples of medication-assisted treatments are buprenorphine (with or without naloxone), naltrexone, and methadone.^[42][43] Methadone and buprenorphine are associated with reduced mortality in those with opioid use disorder as well as higher drug treatment program retention, lower illicit drug use and decreased overdose deaths.^[24] The mortality benefit of long term naltrexone use in those with opioid use disorder is less well established.^[24] After a non-fatal opioid overdose, subsequent methadone or buprenorphine initiation and use reduce the risk of overdose death by 59% and 38% respectively. Initiating buprenorphine in the emergency department is associated with lower mortality and increased adherence to opioid use disorder treatment programs.^[24] Peer support groups have tentative evidence of benefit.^[44] There is also some evidence indicating benefits in community-based overdose education and naloxone distribution programs.^[45] Buprenorphine and methadone can help decrease drug cravings.^[41] Combining pharmacologic treatments with behavioral therapy, such as support or recovery groups, can increase likelihood of overcoming addiction and reduce the risk of an opioid overdose.


Individuals diagnosed with opioid dependence should be prescribed naloxone to prevent overdose and should be directed to one of treatment options available, such as needle exchange programs and treatment centers.^[35][36] A naloxone prescription is also recommended when risk factors for opioid overdose are present such as history of overdose, substance use disorder, or higher doses of opioids.^[39] With the CDC recommending naloxone be provided to all people on long term opioids who have risk factors for overdose, including a history of a substance use disorder, daily morphine equivalents greater than 50 mg or concurrent benzodiazepine use.^[24] Brief motivational interviewing can also be performed and has been shown to improve people's motivation to change their behavior.^[35][46] Despite these opportunities, the dissemination of prevention interventions in the US has been hampered by the lack of coordination and sluggish federal government response.^[36]


Unused or old opioids should not be stored in the home as there is a risk of people using the drugs for non-medical purposes. Among adolescents and young-adults, non-medical use of prescription opioids is associated with a subsequent 13-fold increased risk of heroin use later in life.^[24] Opioids that are no longer being used may be taken to drug take back programs at local pharmacies, healthcare facilities or law enforcement agencies for safe disposal. The United States Food and Drug Administration also has a "flush list"; a list of medications that may be safely disposed of by flushing down the toilet.^[47]


In the United States, 49 states and the District of Columbia have expanded naloxone access at a pharmacy level via standing order, protocol order, naloxone-specific collaborative practice agreement, or pharmacist prescriptive authority.^[48]