People who weren’t familiar with the opioid overdose epidemic were shocked by the tragic death of Philip Seymour Hoffman. Many of my friends and co-workers (who know I work with clients suffering from opioid dependence) asked me what I thought of his death. I took this opportunity to explain to them that Mr. Hoffman’s death was in no way a solitary event. Drug poisoning (overdose) has now surpassed motor vehicle accidents as the leading cause of accidental-injury death in the United States (US); approximately 41 people die every day of a drug overdose involving prescription painkillers (CDC, 2012; Paulozzi, 2012). In the state of Ohio, approximately five people per day fall victim to fatal, opioid-related overdoses; and in my county in Ohio, we lose an average of one person every other day (Ohio Department of Health, 2013).
Opioid overdoses affect individuals, families, friends, and communities. The societal costs of opioid overdoses exceed 20 billion dollars annually; everyone is affected in some capacity (Inocencio, Carroll, Read, & Holdfored, 2013). Nurses have a social responsibility for the holistic welfare of all individuals. Given the widespread and multifaceted reach of care delivery, nurses are uniquely positioned to combat the opioid overdose epidemic on many fronts. This column will discuss how nurses are well positioned both to address the opioid epidemic and support the use of naloxone to reverse opioid-related overdoses and also to promote legislation to increase access to naloxone and decrease fatal opioid overdoses.
Nurses are encouraged to become active in the prevention of opioid-related overdoses and to incorporate overdose prevention into their daily practice. Both prescription and illicit opioids, including heroin, morphine, codeine, methadone, hydrocodone, oxycodone, hydromorphone, and fentanyl, contribute to the fatal opioid overdose epidemic. When someone is experiencing an opioid overdose, a potentially fatal cyanotic cascade of events ensues: breathing slows, oxygen levels in the blood decrease, and oxygenation to vital organs decreases. Within minutes unconsciousness, brain damage, coma, and death may follow (Harm Reduction Coalition, 2013). Respiratory depression is the hallmark symptom of an opioid overdose. Overdoses, in which a person has not ingested opioids, cause respiratory depression infrequently. Opioid overdoses are rarely immediate; and there is usually of window of time to intervene. Naloxone hydrochloride, brand name Narcan®, is a Food and Drug Administration-approved medication which, if administered in time, has the potential to effectually reverse opioid overdoses, allowing victims to receive the treatment they need (Boyer, 2012).
In 1996, community-based opioid overdose prevention programs (OOPPs) began distributing naloxone to individuals who are at high risk for witnessing an opioid overdose. Naloxone distribution has now reached over 50,000 individuals; over 10,000 overdose reversals have been reported (Wheeler, Davidson, Jones, & Irwin, 2012). Opioid overdose programs aim to teach those people who are at risk for witnessing an overdose how to prevent overdoses, recognize overdoses, respond appropriately to overdoses, and administer naloxone to reverse overdoses. Data from the 188 OOPPs in the United States indicates that people can and are willing to respond to overdoses, and that OOPP participants are saving lives by reversing overdoses (Wheeler et al., 2012).
Naloxone is safe, effective, and has no abuse potential; yet there remain barriers and opposition to preventing the widespread dissemination of naloxone to the public. First, opponents often argue that naloxone distribution provides people with a ‘license to use’ opioids. However there is no evidence to support this claim, and research indicates that participants in opioid overdose prevention programs report decreased heroin use (Seal et al., 2005). A nurse-led, opioid-overdose-prevention program in Ohio has adopted the slogan ‘Prevention not Permission.’ The program stresses the importance of preventing fatalities using naloxone as a lifeline to recovery. Winstanley’s presentation (2014) to the Ohio House of Representatives described the value of naloxone in preventing opioid-overdose fatalities. Reversing an overdose with naloxone ‘buys’ healthcare providers another opportunity to provide treatment, and we know that with adequate time, treatment works.
Secondly, opponents of naloxone often invoke the ‘choice argument,’ claiming that initial use may have been a personal choice. However, it is important to remember that many cases of opioid dependence begin with the pharmacological treatment of pain. Over time, opioid use changes the functions of the brain leading to physical dependence and tolerance. Under certain circumstances, opioid dependence will progress to opioid addiction. Addiction is a disease of the brain that is progressive, chronic, and often fatal. Naloxone is the best means of preventing opioid-related overdoses. Nurses must be at the forefront increasing the dissemination of naloxone to those who are at risk for witnessing fatal overdoses.
Nurses are encouraged to get involved in legislation to increase access to naloxone. Contact your state representatives to find out which bills expand access to naloxone. In the state of Ohio, House Bill 170 aims to increase access to naloxone to family and friends of users, law enforcement officials, and emergency medical responders. To assist with successful adoption of this bill, written testimony outlining the safety of naloxone was submitted to the Medicaid, Health & Human Services Committee. An example of Dr. Erin Winstanley’s testimony in support of HB 170 is available online.
Nurses are also encouraged to support other legislation aimed at alleviating the burden of opioid overdoses. The state of Ohio has 16 bills in the Ohio legislature that aim to decrease overdoses by targeting other areas besides naloxone. These areas include: substance abuse treatment, neonatal abstinence syndrome, chronic pain treatment, prescription drug abuse awareness education, and disclosure of drug addictiveness. Nurses providing testimony that raises awareness of the impact of the opioid epidemic and potential for this legislation to address this concern will promote a willingness to adopt these bills.
Good Samaritan laws in 17 states and the District of Columbia protect people acting in good faith during an opioid-related overdose (Davis, 2014). The Public Health Law Research (n.d.) website provides helpful information about Good Samaritan Laws related to drug overdose events. For more information on Good Samaritan laws in your state visit this website. More states are also considering medical amnesty laws that protect from liability those who seek medical attention as a result of illegal actions. Know the laws in your state. Work with officials at the state and community levels to communicate these laws to the public to decrease the fears associated with notifying emergency responders during overdose events. Research has shown that despite training, participants in OOPPs are hesitant to contact emergency responders for fear of police involvement (Sherman et al., 2008).
Incorporate overdose prevention into your everyday practice. Assess your agency’s plan for responding to on-site overdose. If your agency does not have a plan, develop a policy and a plan. Additionally, it is important to integrate overdose prevention messages into conversations with patients, teach patients the risks factors for overdose, and prepare your patients to recognize the signs and symptoms of an opioid overdose and to respond appropriately if someone is experiencing an overdose. It is also important that nursing educators include opioid-overdose-prevention-training and naloxone administration in the curriculum.
Fatal opioid overdoses have reached epidemic proportions. However, through educational efforts and naloxone distribution overdoses can be prevented. Nurses, because of our unique hold in a variety of settings, have the ability to greatly impact opioid overdoses. Naloxone is a lifeline that allows us the opportunity to save lives and provide patients with the treatment they need in order to regain their lives.
Angela Clark, MSN, RN
© 2014 OJIN: The Online Journal of Issues in Nursing
Article published August,17 2014