Perspectives of Canadian Healthcare and Harm Reduction Workers on Mobile Overdose Response Services: A Qualitative Study.

BACKGROUND: Supervised consumption sites (SCS) are an evidence-based intervention proven effective for preventing drug overdose deaths. Obstacles to accessing SCS include stigma, limited hours of operation, concerns about policing, and limited geographic availability. Mobile overdose response services (MORS) are novel technologies that provide virtual supervised consumption to help reduce the risk of fatal overdoses, especially for those who use alone. MORS can take various forms, such as phone-based hotlines and mobile apps. The aim of this article is to assess the perceptions of MORS among healthcare and harm reduction staff to determine if they would be comfortable educating clients about these services. METHODS: Twenty-two healthcare and harm reduction staff were recruited from Canada using convenience, snowball, and purposive sampling techniques to complete semistructured interviews. Inductive thematic analysis informed by grounded theory was used to identify main themes and subthemes. RESULTS: Four themes were identified: (1) increasing MORS awareness among healthcare providers was seen as useful; (2) MORS might lessen the burden of drug overdoses on the healthcare system but could also increase ambulance callouts; (3) MORS would benefit from certain improvements such as providing harm reduction resources and other supports; and (4) MORS are viewed as supplements for harm reduction, but SCS were preferred. CONCLUSIONS: This research provides valuable perspectives from healthcare and harm reduction workers to understand their perception of MORS and identifies key areas of potential improvement. Practical initiatives to improve MORS implementation outcomes exist.

Postoperative opioid-induced respiratory depression or oversedation requiring naloxone treatment in a community hospital: a case series.

Background: Postoperative opioid-induced respiratory depression and oversedation can lead to fatal events and increase perioperative mortality. In reports from major academic centers, naloxone administration has been used as a proxy for severe opioid overdose. Herein, we studied the incidence, clinical characteristics, and outcomes of postoperative naloxone use in a mid-size community hospital. Methods: This was a retrospective review of adult patients who received naloxone within 48 postoperative hours between July 9, 2017, and May 31, 2022. Results: During the study timeframe, a total of 23,362 surgical procedures were performed and a total of 19 patients received naloxone (8 in the recovery room, 11 on hospital wards), with an incidence of 8.1 [95% confidence interval 4.9-12.7] per 10,000 anesthetics. In 12 cases (63%), naloxone was indicated for oversedation, and in 7 cases (37%), for opioid-induced respiratory depression. All patients received naloxone within the first 24 postoperative hours. While all patients survived the opioid-related adverse event, 2 patients were intubated, 1 developed stress-induced cardiomyopathy, and 5 required intensive care unit admission. Conclusion: The rate of early postoperative opioid-induced respiratory depression or oversedation in our community hospital was low; however, these patients often require a substantial escalation of medical management.

Naloxone use by Aotearoa New Zealand emergency medical services, 2017-2021.

OBJECTIVE: Emergency medical services (EMS) use of naloxone in the prehospital setting is indicated in patients who have significantly impaired breathing or level of consciousness when opioid intoxication is suspected. The present study characterised naloxone use in a nationwide sample of Aotearoa New Zealand road EMS patients to establish a baseline for surveillance of any changes in the future. METHODS: A retrospective analysis of rates of patients with naloxone administrations was conducted using Hato Hone St John (2017-2021) and Wellington Free Ambulance (2018-2021) electronic patient report form datasets. Patient demographics, presenting complaints, naloxone dosing, and initial and last vital sign clinical observations were described. RESULTS: There were 2018 patients with an equal proportion of males and females, and patient median age was 47 years. There were between 8.0 (in 2018) and 9.0 (in 2020) naloxone administrations per 100 000 population-years, or approximately one administration per day for the whole country of 5 million people. Poisoning by unknown agent(s) was the most common presenting complaint (61%). The median dose of naloxone per patient was 0.4 mg; 85% was administered intravenously. The median observed change in Glasgow Coma Scale score was +1, and respiratory rate increased by +2 breaths/min. CONCLUSIONS: A national rate of EMS naloxone patients was established; measured clinical effects of naloxone were modest, suggesting many patients had reasons other than opioid toxicity contributing to their symptoms. Naloxone administration rates provide indirect surveillance information about suspected harmful opioid exposures but need to be interpreted with care.

Systematic Review of Naloxone Dosing and Adverse Events in the Emergency Department.

BACKGROUND: Experts recommend using the lowest effective dose of naloxone to balance the reversal of opioid-induced respiratory depression and avoid precipitated opioid withdrawal, however, there is no established dosing standards within the emergency department (ED). OBJECTIVES: The aim of this review was to determine current naloxone dosing practice in the ED and their association with adverse events. METHODS: We conducted a systematic review by searching PubMed, Cochrane, Embase, and EBSCO from 2000-2021. Articles containing patient-level data for initial ED dose and patient outcome had data abstracted by two independent reviewers. Patients were divided into subgroups depending on the initial dose of i.v. naloxone: low dose ([LD], < 0.4 mg), standard dose ([SD], 0.4-2 mg), or high dose ([HD], > 2 mg). Our outcomes were the dose range administered and adverse events per dose. We compared groups using chi-squared difference of proportions or Fisher's exact test. RESULTS: The review included 13 articles with 209 patients in the results analysis: 111 patients in LD (0.04-0.1 mg), 95 in SD (0.4-2 mg), and 3 in HD (4-12 mg). At least one adverse event was reported in 37 SD patients (38.9%), compared with 14 in LD (12.6%, p < 0.0001) and 2 in HD (100.0%, p = 0.16). At least one additional dose was administered to 53 SD patients (55.8%), compared with 55 in LD (49.5%, p < 0.0001), and 3 in HD (100.0%, p = 0.48). CONCLUSIONS: Lower doses of naloxone in the ED may help reduce related adverse events without increasing the need for additional doses. Future studies should evaluate the effectiveness of lower doses of naloxone to reverse opioid-induced respiratory depression without causing precipitated opioid withdrawal.

The onset and severity of acute opioid toxicity in heroin overdose cases: a retrospective cohort study at a supervised injecting facility in Melbourne, Australia.

AIM: To differentiate the severity of acute opioid toxicity and describe both the clinical and physiological features associated with heroin overdose in a cohort of witnessed overdose cases. METHODS: Witnessed heroin overdose cases over a 12-month period (30 June 2018 - 30 June 2019) at the Medically Supervised Injecting Room (MSIR) in Melbourne, Australia were examined. The severity of acute opioid toxicity was classified according to the level of clinical intervention required to manage the overdose cases where an escalating level of care was provided. Heroin overdose cases were classified into one of three graded severity categories and a fourth complicated heroin overdose category. RESULTS: A total of 1218 heroin overdose cases were identified from 60,693 supervised injecting visits over the study period. On the spectrum of toxicity, 78% (n = 955) of overdose cases were classified as Grade 1 severity, 7% (n = 83) as Grade 2 severity, and 13% (n = 161) as Grade 3 acute opioid toxicity severity cases, as well as 2% (n = 19) classified as complicated heroin overdose cases. The median onset time for heroin overdose cases was 17 min (IQR 11-28 min) from the time the individual was ready to prepare and inject heroin until clinical intervention was initiated. CONCLUSION: We demonstrated that heroin overdose is a dynamic illness and cases differ in the severity of acute opioid toxicity. The risk of airway occlusion including positional asphyxia was an early and consistent feature across all levels of toxicity, while exaggerated respiratory depression together with exaggerated depression of consciousness was increasingly observed with greater levels of toxicity. We also demonstrated the importance of early intervention in overdose cases, where in a large cohort of heroin overdose cases there were no fatal outcomes, a very low hospitalisation rate and most cases were able to be managed to clinical resolution on-site.

Risk factors for opioid toxicity requiring naloxone rescue in adults: a case-control study.

BACKGROUND: Opioid-induced sedation and respiratory depression (OSRD) is a potentially life-threatening side effect of opioid analgesia. However, little is known about the individual and clinical-related factors associated with OSRD in the New Zealand context. AIM: To identify risk factors for OSRD in patients admitted to a large regional health board in New Zealand-Auckland District Health Board (ADHB). METHOD: A retrospective matched case-control study design was undertaken among adults who were admitted to ADHB and prescribed opioids in hospital between August 2015 and April 2020. Those who were prescribed opioids and received naloxone for OSRD were defined as cases, whereas those who received opioids but did not experience OSRD were identified as controls. Cases and controls were matched on a 1:1 basis by age (± 10 years). Data were retrieved from the electronic medical records of ADHB. A conditional logistic regression model was used to identify the risk factors for OSRD. RESULTS: We identified 51 cases, and these were matched with 51 control patients. The odds of experiencing OSRD were four times higher among opioid-naïve patients compared to those exposed to opioids prior to hospital admission (OR 4.113; 95% CI 1.14-14.89). Increased risk of OSRD was also associated with higher serum creatinine level prior to OSRD episode (OR 1.015; 95% CI 1.01-1.03) and a higher oral morphine milligram equivalent (OME) (OR 1.023; 95% CI 1.01-1.04). CONCLUSION: Increased risk of OSRD was associated with a higher OME, a higher serum creatinine level prior to OSRD episode, and opioid naivety. Our findings can inform policies that aim to prevent serious adverse effects related to opioids.

Bilateral cerebellar hemorrhagic infarcts as an early presentation following opioid-induced toxic encephalopathy in an adult patient.

In the midst of the national opioid crisis, it is necessary for emergency physicians and radiologists to be familiar with presentations of opioid-related complications. We describe a case report of a 51-year-old female who developed bilateral cerebellar hemorrhages following opioid and benzodiazepine overdose. Malignant cerebellar edema is a rare but recognized complication following opiate overdose in children or chronic heroin toxicity. However, acute cerebellar involvement is rarely reported in adults. We feel that clinicians and radiologists should keep in mind the possibility of opioid toxic encephalopathy in their differential for adults with acute bilateral cerebellar infarcts and/or hemorrhages.

Continuous wound infusion with ropivacaine alone provides adequate analgesia following laparotomy.

BACKGROUND: Although continuous wound infusion (CWI) with local anaesthetic has been used as an adjunct for pain relief following laparotomy, its use as the main modality has not been studied. This approach negates side effects related to intravenous opioid administration, therefore promoting enhanced recovery from surgery. We conducted this study to investigate the feasibility and efficacy of CWI following laparotomy. METHODS: Consecutive patients who underwent laparotomy from June 2016 to December 2019 were analysed. All patients were given CWI with only oral supplementation. Pain was assessed based on the numeric rating scale (NRS). RESULTS: One hundred and three patients were analysed. Mean age was 61.1 (standard deviation 16.7). 47.6% of patients were operated for intestinal obstruction. Large bowel resection was the most common operation performed (49.5%). 69.9% of patients underwent emergency surgery, whilst 51.5% of patients had surgery for cancer. On postoperative day 0, NRS was 3.2 (standard deviation (sd) 2.6) which decreased to 1.5 (sd 1.9) on day 3, and 1.1 (sd 1.8) on day 5. Mean time to flatus was 2.3 (sd 1.4) days, whilst mean time to first bowel movement was 3.1 (sd 1.7) days. Patients were able to commence ambulation by 2.5 (sd 1.8) days. Patients could tolerate a normal diet on day 3.9 (sd 3.3), and IV drip was removed on day 3.5 (sd 3.0). Mean length of stay was 9.1 (sd 6.9) days. Only two patients suffered from respiratory depression (1.9%) whilst five patients suffered from hypotension (4.9%). No patients had pruritus. 23.3% of patients had nausea or vomiting. Only one patient had a catheter-related complication which was easily addressed. CONCLUSION: CWI provides adequate pain relief as the principle modality of analgesia after surgery, without opioid side effects.

Pharmacists' perceived responsibility for patient care when there is a risk of misadventure: a qualitative study.

OBJECTIVE: To investigate how community pharmacists view their responsibility for patient care in a scenario involving opioid use with significant risk of toxicity or misadventure. METHODS: A case scenario was developed based on an Australian coronial inquiry involving a patient suffering fatal toxicity following misuse of opioids. Community pharmacists working in Brisbane, Queensland, were invited to take part in face-to-face semi-structured interviews at their place of work. Participants were asked how they would respond to the scenario in practice and their perceived responsibilities. KEY FINDINGS: Twenty-one pharmacists were interviewed. Participants identified similar actions in response to the case, and potential barriers and enablers. Participants differed with regard to how they described their perceived scope of practice and degree of responsibility in response to the case. Most participants described their scope of practice in terms of medication management with a focus on patient outcomes. Some participants described a narrower scope of practice that focused on either medicine supply or legal aspects. Participants who described a medication management focus differed in their views regarding their responsibility for patient outcomes in the case. CONCLUSION: Pharmacists in this study varied in terms of their perceived scope of practice and responsibility to patient outcomes in response to a case involving a patient at risk of opioid-related harm. Further work on pharmacist responsibility may reduce this variability.

Prepacked naloxone administration for suspected opioid overdose in the era of illicitly manufactured fentanyl: a retrospective study of regional poison center data.

Background: Prepacked naloxone kits (PNKs) are frequently used to reverse opioid intoxication. It is unknown if the presence of illicitly manufactured fentanyl and its analogs (IMFs) in heroin supply is affecting the PNK doses given by laypersons. We investigated the trend of PNK dose administered to reverse opioid toxicity in suspected/undifferentiated opioid intoxication.Methods: We retrospectively reviewed PNK administrations reported to the Maryland Poison Center between 1 January 2015 and 15 October 2017. Primary outcome was the mean PNK dose administered to reverse opioid-induced central nervous system and ventilatory depression. Secondary outcomes included the reversal rate of opioid toxicity, patient disposition, and survival rate.Results: Our analysis involved 1139 PNK administrations. The mean age of subjects was 34.3 years; 68.8% (n = 781) were male. Ventilatory depression was present in 98.2% (n = 958) of cases, and 97% (n = 1097) were unresponsive. Law enforcement administered the majority of PNK (91.0%; n = 1035); the primary route was intranasal (97.9%; n = 1051). Toxicity was reversed in 79.2% (n = 886) of overdose victims after a mean PNK dose of 3.12 mg. EMS personnel gave 291 subjects additional naloxone (mean: 2.2 mg), reversing opioid toxicity in 94.2% (n = 254). Between 2015 and 2017, the mean PNK dose increased from 2.12 to 3.63 mg (p < .0001) while the reversal rate decreased from 82.1% to 76.4% (p = .04). One hundred and eighty-two patients (15.9%) refused transport; of those transported to a hospital, 73.4% (n = 569) were treated and released and 12.4% (n = 96) required hospitalization. Ninety-six percent (n = 1092) of the subjects survived. Forty subjects were pronounced dead at the scene. Fentanyl or its analog was detected in 36 of 55 opioid-related deaths (65.5%).Conclusions: PNK administration reversed toxicity in the majority of patients with undifferentiated opioid intoxication. Between 2015 and 2017, increasing doses of PNK were administered but the reversal rate decreased. These trends are likely multifactorial, including increasing availability of IMFs.

Comparison of lower-dose versus higher-dose intravenous naloxone on time to recurrence of opioid toxicity in the emergency department.

INTRODUCTION: The initial dose of naloxone administered to patients who present to the emergency department (ED) with opioid overdose is highly variable. The objective of this study was to determine if the initial dose of intravenous (IV) naloxone given to these patients was associated with the time to recurrence of opioid toxicity. METHODS: This was a multicenter retrospective cohort study, conducted at two academic EDs in the United States. Consecutive adults who had a positive response to naloxone for opioid overdose in the ED were included. Patients were categorized into two groups based on initial IV naloxone dose administered: 0.4 mg (lower-dose) or 1-2 mg (higher-dose). The main outcome measure was the time to recurrence of opioid toxicity requiring a second dose of naloxone. Secondary outcomes included the need for naloxone continuous infusion and adverse events. RESULTS: The study included 84 patients with 42 patients receiving lower-dose and 42 patients receiving higher-dose naloxone. Median time to re-dose of naloxone was similar between the lower-dose (72 [IQR 46-139] minutes) and higher-dose (70 [IQR 44-126] minutes) groups (p=.810). There were 12 patients (29%) in the lower-dose group and 17 patients (41%) in the higher-dose group who subsequently required continuous infusions (p=.359). The proportion of patients with adverse events was similar between lower-dose and higher-dose groups (31% versus 41%, p=.495). There was no difference in the incidence of specific withdrawal related adverse effects. CONCLUSIONS: The initial dose of naloxone given to patients in the ED does not influence the time to recurrence of opioid toxicity.

An analysis of issues in the classification and reporting of heroin-related deaths.

AIMS: To investigate the extent of variability in the reporting of heroin-related deaths in Victoria, Australia. Additionally, to identify opportunities to improve the accuracy and consistency of heroin-related death reporting by examining variability in the attribution, death certification, classification and coding of heroin-related death cases. METHODS: Heroin-related deaths in Victoria, Australia during a 2-year period (2012-13) were identified using the National Coronial Information System (NCIS) and used as the 'gold standard' measure in this study. Heroin-related death data from the Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS) were then compared. Differences in the number of deaths reported as well as the classification and coding assigned to the identified heroin-related death cases were investigated by cross-referencing these data sets and examining the assigned ICD-10 codes. RESULTS: A total of 243 heroin-related deaths were identified through the NCIS compared with 165 heroin-related deaths reported by the AIHW and assigned the heroin-specific ICD-10 code of T40.1. Forty per cent of all the missed heroin-related death cases resulted from either the attribution of the death to morphine toxicity or with non-specific drug toxicity certification; 30% occurred where the cases had been attributed to heroin but there were irregularities in death certification. Additional missed heroin-related death cases occurred as a result of late initial registration of these deaths to the Registry of Births, Deaths and Marriages, and where these cases were then not assessed by the ABS for classification and coding purposes. CONCLUSIONS: In Victoria, Australia, in 2012 and 2013, the overall number of heroin-related deaths was under-reported by 32% compared with the number of deaths currently identified by the Australian Bureau of Statistics and reported by the Australian Institute of Health and Welfare.

Implementation and evaluation of an opioid overdose education and naloxone distribution (OEND) program at a Veterans Affairs Medical Center.

BACKGROUND: In recognition of the importance of safe and effective pain management, the Department of Veterans Affairs and the Office of the Under Secretary for Health have encouraged implementation of opioid overdose education and naloxone distribution (OEND) programs at Veterans Affairs Medical Centers (VAMCs). METHODS: An OEND program was developed in August 2015 and implemented in September 2015 at a VAMC which allowed for pharmacist-lead individual and group patient education. An OEND consult service was developed to streamline referrals of patients for naloxone education and distribution. At the conclusion of the class, participants were ordered a naloxone auto-injector or nasal spray kit. To evaluate the utility of this quality-improvement initiative, data was collected from September 2015 until May 2016. Examples of data collected included participant satisfaction with education, risk for accidental overdose, and number of naloxone kits dispensed to participants. RESULTS: Of a total of 243 consults placed, 71 individuals participated in OEND education. A large quantity of consults were discontinued due to patients no-showing education. Sixty-four consult referrals were identified to have a mental health diagnosis. Most participants who received education had a risk for accidental opioid overdose of 14%. Sixty-nine education participants were provided a naloxone kit. Based on the OEND class survey, participants felt that their knowledge of accidental opioid overdose increased and were generally satisfied with the education. CONCLUSION: OEND educated 30% of the Veterans referred into the program via the consult service, the majority of whom were at a relatively low risk for opioid overdose.

Assessment of potential opioid toxicity and response to naloxone by rapid response teams at an urban Melbourne hospital.

Opioid prescriptions have significantly increased in recent years and are used for a wide variety of indications. Electronic medical records of 45 patients who received naloxone by a rapid response team over an 18-month period were retrospectively reviewed. This study found inconsistencies in the management of possible opioid toxicity with variation in the total naloxone dose and number of doses administered. This highlights the importance of a standardised protocol for recognition and management of opioid overdose.

The attribution of a death to heroin: A model to help improve the consistent and transparent classification and reporting of heroin-related deaths.

INTRODUCTION: Accurate attribution of heroin-related deaths, as well as the differentiation from other opioid analgesic-related deaths, is essential from a public health perspective. Heroin-related deaths involve a number of complexities where heroin-specific or non-specific metabolites and indicators (6-acetylmorphine [6-AM], morphine, and codeine) may or may not be detected. The aims of this study were therefore to develop a model for improved consistency in the attribution of heroin-related deaths and to determine areas of variation in the current decision-making processes. METHODS: A model was developed using different toxicological indicators of heroin use (6-AM, morphine to codeine ratio (M:C) or morphine alone) along with investigative evidence of heroin use (circumstances, scene and clinical findings) which were used to assign a weighted score. The combined scores for the toxicological and investigative evidence were used to determine the relative strength of association for the death being attributable to heroin according to three categories: suspected; likely; or strong. An expert panel was convened to validate the model and a series of test cases were provided to a cohort of forensic toxicologists and pathologists in order to identify sources of variation in decision-making within this group. The model was also evaluated for sensitivity and specificity by reviewing potential heroin-related cases and examining the evidence associated with the attribution of these cases to heroin or not. RESULTS AND DISCUSSION: Across all potential heroin-related death cases, the use of this model enabled a greater level of consistency in the attribution of death to heroin, especially in cases where 6-AM was not detected. The largest amount of variation in the attribution of a death to heroin was observed with potential intoxication-related deaths and in toxicity cases where a M:C ratio only was reported, even more than when no toxicological evidence was available. The reviewed cases highlighted the same variation in the attribution of a death to heroin, including a large number of cases that were attributed to morphine where 6-AM was not detected. CONCLUSION: This model provides a useful tool for improved accuracy and consistency in the differentiation, attribution and reporting of heroin-related deaths. Previously challenging cases where death occurred after a significant period of time and either no 6-AM was detected or no samples were taken, are able to be captured using this model.

Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis.

BACKGROUND: Drug overdose is a public health crisis in the United States, due in part to the unintended consequences of increases in prescribing of opioid analgesics. Many clinicians evaluate risk markers for opioid-related harms when prescribing opioids for chronic pain; however, more data on predictive risk markers are needed. Risk markers are attributes (modifiable and non-modifiable) that are associated with increased probability of an outcome. This review aims to identify risk markers associated with fatal and non-fatal prescription drug overdose by synthesizing findings in the existing peer-reviewed and grey literature. Eligible cohort, case-control, cross-sectional, and case-cohort studies were reviewed and data were extracted for qualitative and quantitative synthesis. FINDINGS: Summary odds ratios (SOR) were estimated from 29 studies for six risk markers: sex, age, race, psychiatric disorders, substance use disorder (SUD), and urban/rural residence. Heterogeneity was assessed and effect estimates were stratified by study characteristics. Of the six risk markers identified, SUD had the strongest association with drug overdose death (SOR = 5.24, 95% confidence interval (CI) = 3.53 - 7.76), followed by psychiatric disorders (SOR = 3.94, 95% CI = 3.09 - 5.01), white race (SOR = 2.28, 95% CI = 1.93 - 2.70), the 35-44 year age group relative to the 25-34 year reference group (SOR = 1.52, 95% CI = 1.31 - 1.76), and male sex (SOR = 1.33, 95% CI = 1.17 - 1.51). CONCLUSIONS: This review highlights fatal and non-fatal prescription drug risk markers most frequently assessed in peer-reviewed and grey literature. There is a need to better understand modifiable risk markers and underlying reasons for drug misuse in order to inform interventions that may prevent future drug overdoses.

Intranasal Fentanyl Intoxication Leading to Diffuse Alveolar Hemorrhage.

CONTEXT: Increasing rates of opioid abuse, particularly fentanyl, may lead to more presentations of unusual effects of opioid toxicity. Diffuse alveolar hemorrhage is a rare complication of fentanyl overdose. CASE DETAILS: A 45-year-old male presented in hypoxic respiratory failure secondary to diffuse alveolar hemorrhage requiring intubation. Comprehensive drug screening detected fentanyl without exposure to cocaine. Further history upon the patient's recovery revealed exposure to snorted fentanyl powder immediately prior to presentation. DISCUSSION: Diffuse alveolar hemorrhage is a potential, though rare, presentation of opioid intoxication. CONCLUSIONS: Recognition of less common complications of opioid abuse such as diffuse alveolar hemorrhage is important in proper management of overdoses.

What are the risks and knowledge deficits for prescribing and administering opioids in the ward environment? A quality project on assessing and improving knowledge.

Investigations into Medical Emergency Team (MET) calls and related clinical incident reviews at a large district teaching hospital provided evidence that over sedation can be a significant issue post opioid administration and that safe and effective pain management requires accurate opioid knowledge and patient assessment skills. The aim of the study was to develop education that was directed at identified knowledge deficits, and to evaluate the impact of this tailored education program on knowledge of safe prescribing and administration of opioids. Knowledge levels were explored using a structured questionnaire in a pre and post-test design. A convenience sample of 34 nurses and 5 junior medical officers across three surgical wards in a tertiary referral hospital had their knowledge assessed. Results showed significant improvement when repeat questionnaires were given two weeks post-delivery of education. Mean scores were 68% at baseline and 89% two weeks post completion of the education program. The greatest improvement in scores was recorded for drug knowledge including dose, half-life and administration. The findings from this study suggest that the opioid education program is effective in improving the knowledge of safe prescribing and administration of opioids, however further studies are required.

Reversal of Opioid-Induced Ventilatory Depression Using Low-Dose Naloxone (0.04 mg): a Case Series.

INTRODUCTION: Naloxone is commonly administered in emergency department (ED) to reverse opioid intoxication. Several naloxone dose recommendations exist for acute management of opioid intoxication based on limited published clinical data. A case series of ED patients with opioid-induced ventilatory depression that was reversed using a low-dose naloxone (0.04 mg with titration) is presented. METHODS: ED patients with opioid-induced ventilatory depression requiring naloxone administration were identified through medical toxicology consultation. Retrospective review of medical records was performed. Collected data included history, and pre- and post-naloxone data, including respiratory rate (RR), pulse oximetry (pulse ox), end-tidal CO2 level (ET-CO2), and Richmond Agitation Sedation Scale (RASS). RESULTS: Fifteen ED patients with moderate to severe opioid-induced ventilatory depression (median RR, 6 breaths/min) who were managed using low-dose naloxone strategy were identified. Twelve of 15 patients reported ingestion of methadone (range, 30 to 180 mg). The median naloxone dose of 0.08 mg (range, 0.04 to 0.12 mg) reversed opioid-induced ventilatory and CNS depression. Two patients experienced acute opioid withdrawal after receiving 0.08 mg. CONCLUSION: ED patients with moderate to severe opioid-induced ventilatory depression can be reversed using 0.04 mg IV naloxone with appropriate dose titration.

Use of naloxone for reversal of life-threatening opioid toxicity in cancer-related pain.

OBJECTIVE: To review the emergency-based approach to opioid toxicity reversal in cancer-related pain patients. DATA SOURCE: A MEDLINE and PubMed search was conducted (1966 to May 2014) using the terms opioids, cancer, naloxone, respiratory depression, morphine, morphine derivatives, emergency, and anaphylaxis. METHODS OF STUDY SELECTION: English articles in human subjects identified from the MEDLINE and PubMed search were evaluated. Citations were excluded if they addressed acute overdoses, non-cancer pain, and/or acute, non-chronic pain. DATA EXTRACTION AND SYNTHESIS: Pain is a common occurrence in the oncology population. Although toxicity from opioids is common, life-threatening toxicities are not. The use of naloxone in this particular patient population occurs frequently for any perceived opioid-related effect and can be detrimental to the oncology patient's care and quality of life. Difficulties exist when attempting to separate opioid toxicity from disease progression or metastases and, therefore, a thorough history is needed prior to complete opioid reversal in this population. Severity of the opioid intoxication should dictate reversal strategy. Dosing strategies that take into account both the treatment of the opioid-related effects as well as the negative effects reversal will have on the patient are offered. We also review the pre-hospital setting and identified the need for protocols that not only take the patient's symptoms into account, but also the patient's cancer history. CONCLUSION: Opioid reversal protocols should be developed by a multi-disciplinary team. Each protocol should differentiate those toxicities which are life-threatening and require complete opioid reversal with toxicities that require small aliquots of naloxone to mitigate the presenting symptoms.