Chapter SC6: Prevention, Treatment, and Harm Reduction Approaches to Opioid Overdoses

INTRODUCTION

Opioid-related deaths rates in the United States continue to rise. A decades-long US prescription drug epidemic persists, driven by high rates of per capita opioid analgesic dispensing, and is now paired with a growing availability of illicit heroin, fentanyl, and fentanyl derivatives. Rates of opioid use disorders, opioid treatment admissions, opioid-related emergency department (ED) and hospital admissions, and overdose mortality have all steadily increased since 1990.⁸ In 2012, the Centers for Disease Control and Prevention (CDC) reported that for every unintentional overdose death related to an opioid analgesic, 9 people were admitted for substance abuse treatment, 35 visited EDs, 161 reported drug abuse or dependence, and 461 reported nonmedical uses of opioid analgesics.¹⁰ Recent federal and state reform efforts seek to bolster a public health response to opioid use disorders and overdose deaths.^14,50 The availability and dissemination of core evidence-based interventions that treat and prevent overdose events and fatalities, however, has not kept pace with the number of persons using, suffering harm, and dying from opioids.

Evidence for, and policies supporting core community-based overdose interventions, which are harm reduction education and counseling, and naloxone distribution and administration, are reviewed here. Overdose outcomes associated with opioid use disorder treatment, including opioid use disorder treatments with agonist (methadone, buprenorphine) and antagonist (naltrexone) pharmacotherapies and counseling-only modalities, are addressed. Larger policy efforts and national practice guidelines with important implications for overdose prevention, including state prescription monitoring requirements and recently published CDC guidelines for the use of opioid analgesia for nonmalignant chronic pain are emphasized.

EPIDEMIOLOGY

Overdose Rates

Opioid use in the US has grown steadily since the 1990s, largely because of widespread and routine opioid analgesic prescribing. As of 2014, of 47,055 total US unintentional poisoning deaths, 18,893 were attributed to opioid analgesics and 10,574 to heroin.⁹ Heroin availability and related problems appear to be accelerating, and heroin “markets” have expanded to all large US metropolitan areas as well as a substantial proportion of rural counties. More recently, novel opioids, such as U-47700 and W-18, and illicit fentanyl analogs, such as carfentanil, have entered street heroin formulations. This appears to drive local micro-epidemics and significant increases in overdose death rates.^13,35

Risk Factors

“Opioid overdose” generally refers to oversedation, hypoventilation, and anoxia stemming from an excessive dose of an opioid agonist alone or in combination with other central nervous system depressants. Established risk factors for opioid overdose include:^48,49

• Persons with opioid dependence, particularly after periods of reduced use, resulting in loss of tolerance (after detoxification, release from incarceration, cessation of recovery treatment)

• People who inject opioids

• People who use prescription opioids, particularly those taking higher doses

• People who use opioids in combination with other sedating xenobiotics

• People who use opioids and have medical conditions such as ...