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Ma'am, ma'am, are you alright? Ma'am, ma'am, are you OK? There's no response. Go ahead and we're going to call a code or, "You in the plaid shirt, go call 9-1-1, get an AED and bring it back." I'm going to assess the pulse, I'm checking for any normal signs of breathing. Speaker 2: Yeah, I don't see any breathing. Speaker 1: She has a good pulse but she's not breathing. Speaker 2: Yeah, okay. Speaker 1: Go ahead and provide ventilations, please. Speaker 2: Okay. Speaker 1: I'm going to get the Naloxone kit prepared, because I do believe this is an opioid, or opiate overdose. Speaker 2: Okay. Speaker 1: Okay, I'm ready any time you're ready there. Speaker 2: Okay, one more breath and go ahead. Speaker 1: I'm going to go ahead and provide one milliliter, the left nostril, same for the other nostril. Go ahead and continue breathing. Speaker 2: Okay. Speaker 1: Good. Looks like she still has a pretty good pulse there. Speaker 2: Yeah. Speaker 1: Breaths are going in well. Speaker 2: It kind of looks like she's starting to take breaths on her own now. Speaker 1: Is she? Okay. Speaker 2: Yeah, it's kind of fight- oh. Speaker 1: Oh, ma'am, it's okay ma'am, ma'am, it's okay. We're here to help. It's okay. Speaker 2: We're going to take good care of you, ma'am. Just try to relax. Opiates and opioids are central nervous system or CNS depressants. The CNS controls our ability to breathe and keep our heart beating, and when depressed too far by CNS depressants, these functions can slow down and eventually stop. Most people think that only addicts and illegal drug users can overdose on opiates or opioids, and it is true that most people who are addicted suffer the most overdoses. However, anyone taking them can suffer opiate or opioid overdose, especially when they take more than was prescribed by the doctor, or they combine opiates and opioids with other CNS depressants, or they have an unknown condition that makes them more sensitive to overdose. Common opiates include heroin, morphine, and codeine. And then there are other medications like methadone and oxycodone, also commonly known as OxyContin. In recent years, we've seen the emergence of synthetic opiates, often termed 'opioids'. And while they aim to replicate the effects of natural opiates, they can be far more potent. Some notable examples include fentanyl and carfentanil. This is where the trouble begins, because there are instances where opioid drugs, especially fentanyl, are combined with other substances, including stimulants like cocaine. What's even more concerning is that some of these combinations might not show up on standard drug screens. Yet, they pose an increased risk of being deadly. Common drugs that may cause similar signs but are not opioids or opiates are cocaine, LSD, ecstasy, tranquilizers, and marijuana. Naloxone will have no real effect on non-opioid or opiate drugs. And, while you can't be certain of an opiate or opioid overdose, some signs should make you suspect that there's a problem, like bottles of drugs nearby the patient, or a very slow respiratory rate, or even pinpoint pupils. For a patient with known or suspected opioid addiction, appropriately trained rescuers or healthcare providers should administer intramuscular or intranasal Naloxone, if available, per their protocol. A Naloxone dose of two milligrams is what's recommended for rapid reversal when respiratory compromise is present. Naloxone typically takes three to five minutes for the full effect. The duration of action for Naloxone is shorter than that of most opioids, so patients must be closely monitored for recurrence of problems when the effects of the Naloxone wear off. Additional doses may be necessary to maintain reversal. It's been recommended that patients who receive Naloxone are still observed for a minimum of two hours after the last dose. And, in the case of a person who you suspect has an opiate or opioid overdose, that is not breathing normally, lay-rescuers should start CPR and a healthcare provider should check for a pulse to determine whether or not to start rescue breathing or full CPR. To administer Naloxone, assemble the nasal atomizer, tilt the head back and briskly spray half of the Naloxone up one side of the nose, that of about 1 cc, and half up the other side of the nose, which will equal 1 cc. The idea is to atomize the Naloxone into a fine mist. Rescue breathing or CPR should continue while waiting for the Naloxone to take effect. If there's no change in three to five minutes, administer another dose of Naloxone and continue CPR or rescue breathing. If the second dose of Naloxone doesn't revive them, something else is wrong. Either there are no opioids in their system, or the opioids are unusually strong and require more Naloxone.
As the opioid epidemic rages on and grows, learning how to treat for opioid overdose becomes even more important. And that's the focus of this lesson – learning how to assess for, and provide treatment for, opioid/opiate overdose.
Opioids are central nervous system depressants. The central nervous system is responsible for controlling every organ, system, and function in the human body, including both the respiratory system and the cardiovascular system.
When the central nervous system becomes depressed too much, these organs, systems, and functions will begin to slow down and eventually cease to operate.
Who is at Risk of an Opioid Overdose?
While you're right to think that addicts and illegal drug users are most at risk, the truth is that anyone who takes an opiate or opioid is at risk of overdosing, particularly when:
- An amount is taken beyond the prescribed dose
- It's taken in combination with other central nervous system depressants, like alcohol
- The patient has an unknown medical condition that creates a hypersensitivity to opioids
Common opiates/opioids include:
- Heroin
- Morphine
- Codeine
- Methadone
- Hydrocodone (brand names: Vicodin, Lortab)
- Oxycodone (brand name: Percocet)
There are some commonly used drugs that can cause signs and symptoms similar to an opioid overdose, including:
- Cocaine
- LSD
- Ecstasy
- Tranquilizers
- Marijuana
Pro Tip #1: While the standard and immediate treatment for opioid overdose (spoiler alert: Naloxone) works well to reverse the condition and revive the patient, if their problem is one related to another substance, like those in the list above, naloxone will have zero effect.
How to Provide Care
As always, the first thing you want to do is make sure the scene is safe and that your gloves are on. Make sure you have your rescue mask with a one-way valve handy and begin calling out to the victim to assess whether or not he or she is responsive.
Are you OK? Can you hear me?
If the patient is unconscious, you'll want to assess for normal breathing and determine if the patient has a pulse. As you know by now, the presence of a pulse but not normal breathing means you'll go right into rescue breathing. While the absence of both means you'll perform full CPR.
While it may not always be possible to be certain of an opiate/opioid overdose, there are some signs to point in that direction, including:
- Drugs or empty drug packages near the victim
- Very slow respiration
- Pinpoint pupils
Treatment for Opioid Overdose
For patients with known or suspected opiate/opioid addiction issues, the immediate course of treatment is administering naloxone, either by intramuscular injection or intranasal mist. Of course, make sure administering naloxone is allowed per your organization's regulations and protocols.
Pro Tip #2: The recommended dose of naloxone is 2mg for the rapid reversal of overdose symptoms when respiratory distress is present.
The benefit of using a nasal atomizer is that it will administer the naloxone in a readily available form, like a fine mist which the patient can quickly absorb. To administer naloxone via the nasal atomizer, proceed with the following steps:
- Assemble the nasal atomizer per the instructions.
- Tilt the patient's head back slightly.
- Position the nasal atomizer into one nostril and briskly spray half of the amount (approximately 1cc).
- Position the nasal atomizer into the other nostril and spray the remaining naloxone.
- Wait 3-5 minutes.
Continue to perform rescue breathing or CPR while waiting for the naloxone to take effect. If there isn't any change in the patient after 3-5 minutes, administer a second dose of naloxone.
If a second dose doesn't revive the patient, something else is likely wrong. Either there aren't any opiates in the patient's system. Or they're unusually strong or plentiful and will require more naloxone.
A Word About the Signs and Symptoms of Substance Abuse and Misuse
Many of the signs and symptoms of substance abuse and misuse are similar to those of other medical emergencies. Which means you cannot necessarily assume that individuals who are stumbling, disoriented, or have a fruity, alcohol-like odor on the breath are intoxicated by alcohol or other drugs, as this may also be a sign of a diabetic emergency.
As in other medical emergencies, you don't have to be certain of your diagnosis for substance abuse or misuse to provide care. It can be helpful, however, if you notice certain clues that suggest what the problem really is. Such clues will also help you provide as much complete information to advanced medical personnel so that they can continue providing prompt and appropriate care.
Often these clues will come from the patient, bystanders, or the scene itself. As mentioned earlier, look for containers, pill bottles, drug paraphernalia, and signs of other medical problems. If the patient is incoherent or unconscious, try to get information from any bystanders or family members.
Since many of the physical signs of substance abuse mimic other conditions, you may not be able to determine that a patient has overdosed. To provide care, you only need to recognize abnormalities in breathing, skin color and moisture, body temperature, and behavior, any of which may indicate a condition requiring professional help.