Preventing Opioid Overdose and Harm

Due to the lethal practice of mixing highly addictive narcotics with other drugs, opioid overdoses may increase in rural and urban areas.

According to Northwestern Medicine researchers in Chicago who studied trends and used a predictive model to predict where deaths would increase, the coming wave of opioid overdoses will be more severe than ever before.

“I'm sounding the alarm because, for the first time, there is a convergence and escalation of acceleration rates for every type of rural and urban county,” said corresponding author Lori Post, director of the Buehler Center for Health Policy and Economics at Northwestern University Feinberg School of Medicine. “Not only is the death rate from an opioid at an all-time high, but the acceleration of that death rate signals explosive exponential growth that is even larger than an already historic high.”

Data from the WONDER database of the Centers for Disease Control and Prevention were used to make an analysis of geographic trends in opioid deaths between 1999 and 2020.

In order to theorize about any future waves, the team sought to determine if geography played a role in the past waves.

Researchers found that rural areas were experiencing a higher rate of opioid overdose deaths in 2020. Post said that rates of overdose deaths escalated in six types of rural and urban counties between 2019 and 2020.

“We have the highest escalation rate for the first time in America, and this fourth wave will be worse than it’s ever been before,” Post warned. “It’s going to mean mass death.”

Using toxicology reports as a basis for their study, the research team found that people are using synthetic opioids such as fentanyl (50 to 100 times more potent than morphine) and carfentanil (100 times more potent than fentanyl) along with methamphetamine and cocaine.

What’s more, Naloxone, which can reverse an overdose, is less effective with this deadly cocktail.

“The stronger the drugs, the harder it is to revive a person,” added study co-author Alexander Lundberg, assistant professor of emergency medicine at Feinberg. “The polysubstance use complicates an already dire situation.”

“It appears that those who have died from opioid overdoses had been playing pharmacist and trying to manage their own dosing,” Post said. “This is a bigger problem because you have people misusing cocaine and methamphetamines along with an opioid, so you have to treat two things at once, and the fentanyl is horribly volatile.”

The authors of the study suggested that medication-assisted treatment for addiction might be offered by methadone centers. Generally, these are found in urban areas. As Post pointed out, rural areas lack medication-assisted treatment options, and what works in large cities may not be as helpful there.

“Nobody wants to be a drug addict. It doesn’t matter if you’re taking Percocet because you broke your back while mining or if you’re a high schooler who died because they got into grandma’s medicine cabinet. We need to look at opioid addiction and overdose prevention immediately,” stated Post.

“The only path forward is to increase awareness to prevent opioid use disorders and to provide medication-assisted treatment that is culturally appropriate and non-stigmatizing in rural communities,” she added.

The study is called "Geographic Trends in Opioid Overdoses in the US from 1999 to 2020." Irene Quan and Maryann Mason are also Northwestern co-authors. A copy of the article appeared in JAMA Network Open on July 28.

In spite of the alarming situation, there are ways to prevent opioid overdoses and harm.

Talk to your doctor about your treatment options.

For the safest, most effective pain management possible, you need to assume the following responsibilities if you are prescribed opioids.

• Create a pain management plan with your doctor. You can manage your pain without opioids if you know your options.

• If you have any concerns or side effects, discuss them with your doctor.

• Talk to your doctor so you can make an informed decision.

• Keep in touch with your doctor on a regular basis.

Opioids should be taken and stored as prescribed.

Additionally, if you and your doctor agree that you should be prescribed opioids, make sure that you take to following steps to prevent misuse:

• Do not exceed the prescribed dose or frequency of taking prescription opioids.

• Alcohol and other substances or medications should not be combined with opioids. Taking opioids with other drugs, especially drowsy ones, can be very dangerous:

• Benzodiazepines (such as Xanax® and Valium®)

• Muscle relaxants (such as Soma® or Flexeril®)

• Hypnotics (such as Ambien® or Lunesta®)

• Other prescription opioids

• Prescription opioids should not be shared or sold.

• You should keep prescription opioids in a secure location that cannot be reached by others, such as children, family, friends, and visitors.

• Following instructions from the Food and Drug Administration, you can dispose of unused prescription opioids through a community drug take-back program.

Encourage safer user, guide to recovery.

Chin Hwa (Gina) Dahlem, Ph.D., FNP-C, FAANP, a nurse practitioner and overdose prevention expert at the University of Michigan Health notes that meeting people where they are and facilitating positive change is key to harm reduction.

“The fact that the person who is actively using drugs then comes to our clinic is a positive change,” she said. “The person who decides to reduce their drug use, seek sterile syringes and needles, or access social services are other examples of positive change.”

Every person's recovery process is different, and there are many paths to recovery.

“When you talk with people who use drugs, they will say they are in recovery even if they have not used for over 20 years because they realize addiction is a chronic disease,” she said. “The whole philosophy of care is to treat patients with compassion and dignity and not mistreat or judge them for using substances.”

Recovery is a process that involves several steps. Providers can help patients manage discomfort and work towards recovery by offering buprenorphine, a drug designed to reduce dependence on opioids without causing a high.

Recognize the signs of opioid overdose.

An opioid overdose is a life-threatening emergency that must be treated immediately. In order to save lives, it is essential to recognize the signs of opioid overdose.

Immediately call 911 if you observe any of these symptoms:

• Paleness and/or clammyness are present on their faces

• Their bodies become limp

• There is a purple or blue color on their nails or lips

• Their stomachs begin to gurgle or they start vomiting

• It is impossible to awaken them or get them to speak

• There is a slowing or stopping of their breathing or heartbeat

Naloxone: increase distribution, access, and training.

Naloxone is the primary tool for reducing overdose deaths. In case of an opioid overdose, naloxone, also known as Narcan, can restore normal breathing and save a person's life.

The availability of naloxone for individuals, health care providers, and first responders has increased over the last decade. Studies have found that states that enacted laws to increase access to naloxone saw overdose deaths drop by 14%.

“The gold-standard model of overdose death prevention is direct distribution of naloxone at the point of care,” said Keith Kocher, M.D., M.P.H., an emergency physician at U-M and the program director of the Michigan Emergency Department Improvement Collaborative.

“Rather than relying on a prescription or hope that a patient can get naloxone at a standing order pharmacy, we should try to achieve a standard in which providers and other outlets can give it seamlessly at the point of care.”

According to Kocher's study, less than 10% of patients in the emergency department for opioid overdoses are prescribed naloxone. In the second study, only 54% of Michigan pharmacies participated in the standing order for naloxone, which allows naloxone to be dispensed without a prescription.

“Those just represent additional barriers; they may work at times, but they’re still barriers,” Kocher said. “The emergency department should be a key access point for naloxone for those at risk of future overdose. However, similar efforts are happening elsewhere, including at a local library where anyone can get naloxone for free from specially designed kiosks.”

Increasing the availability and accessibility of naloxone is important not only for addicts but also for the general public. As a medication, Naloxone is unlikely to be administered by the patient themselves, unless they are in a condition where they are doing so.

A person can overdose in a public place, in a parking lot, in a library, in a bathroom, at a gas station, or at home. In addition, one in three overdoses occur in the presence of a bystander, when family members, friends, or individuals in the community can prevent death.

In Delaware, you can buy Narcan without a prescription at participating pharmacies. A statewide distribution and training program is available as well. After all, in Delaware, “An individual who is public safety personnel is authorized to receive, carry, and administer the drug naloxone if the individual has completed a Department-approved training course.”

Additionally, a nonprofit organization, NEXT Distro, is partnering with Delaware's Division of Public Health (DPH) to provide Narcan to uninsured Delaware residents at no cost via mail.

For more information on where to get Narcan in Deleware, please visit Help is Here Delaware.