UTSW Q&A: Experts talk about opioid abuse, risks, treatment

Newswise — DALLAS – Aug. 16, 2023 – Overdose deaths from opioids, including prescription painkillers and synthetics like fentanyl, continue to rise. According to the Centers for Disease Control and Prevention, an estimated 187 people in the U.S. die every day of opioid overdoses, most involving illicit and dangerous versions of fentanyl.

According to a survey conducted by health policy research group KFF in July and released in August, about 3 in 10 adults say they or a family member have been addicted to opioids.

To provide perspective on the evolving epidemic, we spoke with four experts at UT Southwestern Medical Center about the dangers of opioid addiction, how to recognize an overdose, and treatment options including Narcan, which was recently approved by the Food and Drug Administration to be sold over the counter.

Stacey Hail, M.D., FACMT, Associate Professor of Emergency Medicine in UTSW’s Division of Medical Toxicology, treats patients in the Emergency Department at Parkland Memorial Hospital and consults on toxicology patients through the North Texas Poison Center. Dr. Hail has a forensic toxicology practice and reviews opioid cases for the U.S. Department of Justice as well as for attorneys in civil matters.

Enas Kandil, M.D., Associate Professor of Anesthesiology and Pain Management, leads quality improvement projects on opioid safety initiatives at UTSW and Parkland Health, with the goal of regulating opioid-prescribing practices and ensuring hospital compliance, thus improving patient safety.

Sidarth Wakhlu, M.D., Professor of Psychiatry and a member of the Peter O’Donnell Jr. Brain Institute, specializes in the treatment of substance abuse disorders. He is Director of the Addiction Psychiatry Fellowship Program and Associate Director of the Addiction Division in Psychiatry.

Kurt Kleinschmidt, M.D., Professor of Emergency Medicine in the Division of Medical Toxicology, leads an Addiction Medicine team at UT Southwestern. He also is Medical Director of the Perinatal Intervention Program (PIP) at Parkland Health, which cares for pregnant women with substance abuse disorders, and Service Chief of the Integrated Family Planning Opioid Program at Parkland.

What are the signs of an opioid overdose?

Dr. Hail: We use a term in medical toxicology called toxidrome – “toxic” and “syndrome” mashed together. It’s defined as the constellation of signs and symptoms unique to a certain substance. In other words, overdosing on one type of drug looks different from overdosing on a drug in a different class. The opioid toxidrome consists of pinpoint pupils (very tiny pupils); central nervous system depression, which ranges from lethargy or sleepiness all the way to coma; and respiratory depression, where people breathe slower and shallower until they stop breathing and die. Respiratory depression is the most concerning aspect of opioid overdoses. Unconscious patients cannot protect their airway, and the airway tissue collapses, causing an obstructive breathing pattern. This sounds like snoring to lay people.

How do you treat a patient who has an opioid overdose?

Dr. Hail: If a person has pinpoint pupils, is unconscious, and is barely breathing and/or snoring, there is an antidote, called naloxone, that quickly reverses the opioid toxidrome. Narcan is the best-known form and is most frequently administered intravenously or through the nose. There is a substantial risk of death if Narcan is not administered expeditiously. Once a person stops breathing and no longer has a pulse, Narcan will not work. Narcan does not raise individuals from the dead. It does not reverse the effects of any other drug except opioids.

What is the significance of Narcan being available over the counter soon?

Dr. Kleinschmidt: The U.S. Food and Drug Administration approved sales of Narcan nasal spray over the counter in March 2023, but the rollout has not taken effect yet. Until they are made available over the counter, Narcan and other naloxone products can be obtained with a prescription or from the pharmacy counter by talking to a pharmacist. But patients should always check with the pharmacy on availability.

Dr. Kandil: This important move by the FDA has been supported by the American Medical Association and other societies such as the American Society of Anesthesiologists. A naloxone product is typically carried by all EMT personnel and police officers and is being made available in schools and areas of public gatherings.

Are there risks to using naloxone?

Dr. Kleinschmidt: It is a safe medication. The biggest problem is that it can put the patient into withdrawal. While withdrawal is not optimal, it is better than death. There are concerns that providing naloxone to patients who abuse opioids will encourage them to continue using drugs, as if we are giving them permission to use. This is simply not true. Patients with addiction will use opioids until they receive treatment; giving them naloxone will not change that in any way. Giving patients naloxone to take with them is harm reduction – it is given to reduce death. People who have overdosed will not be able to give naloxone to themselves; someone else must administer it.

Synthetics, including fentanyl, caused more than 82% of opioid deaths in 2020. What should people know about this deadly form of opioids?

Dr. Hail: Counterfeit pills are circulating on the streets of this country. They may be fake Percocet, Adderall, Xanax, and even aspirin. Heroin and cocaine are either tainted with fentanyl or are entirely fentanyl. Fentanyl is 100 times more potent than morphine and dangerous even to individuals who are tolerant of the effects of opioids. Because of the potency of fentanyl, most patients who overdose do not survive long enough to be transported to the emergency department. They are confirmed dead at the scene.

When do patients need opioids to manage their pain and what alternatives exist?

Dr. Kandil: Opioids are not intended as a first choice for pain control. The CDC recommends trying other non-habit-forming medications before turning to opioids. Alternatives such as NSAIDs (nonsteroidal anti-inflammatory drugs) and acetaminophen as well as topical analgesics should be considered. Massage therapy and ice therapy have been shown to be effective in reducing pain in certain conditions as well. If those fail, opioids should be considered, starting with the lowest effective dose for the shortest period possible.

What’s critical to know about the health risks from opioids?

Dr. Kandil: Opioids are beneficial in controlling pain when other modalities have failed. However, they should be used under direct supervision of a licensed health care provider as they are not without risks. Known short-term risks include respiratory depression, sedation, constipation, and tolerance, which may lead to dependence. Opioids also carry long-term health risks, including decreased immunity, weight gain, and decreased sex drive.

How can patients who are prescribed opioid medications avoid becoming addicted?

Dr. Kandil: Patients who use the medications as prescribed should not be concerned about addiction. They should regularly follow up with their provider and discuss any concerns. Patients should be careful about combining opioids with other respiratory depressant medications such as benzodiazepines and sedatives. Alcohol should also be avoided while taking an opioid.

Dr. Wakhlu: Men and women who have suffered preadolescent sexual/physical trauma or have a history of substance abuse disorder have a greater likelihood of developing an addiction to opioids. Childhood sexual trauma gives rise to post-traumatic stress disorder (PTSD), which is associated with substance use disorders and is two to three times more common in women than men. Any patient with a history of substance abuse disorder should share those details with their physician, who should have a discussion with the patient and their significant other about the addictive potential of opioid pain medications. This communication is critical to prevent misuse and abuse.

Why are opioids so addictive?

Dr. Wakhlu: Opioids can cause euphoria and a rush of energy for some people. Gradually people start using more and more opioids as they develop tolerance. When they stop using opioids cold turkey, they develop withdrawal symptoms characterized by anxiety, agitation, insomnia, irritability, runny nose, nausea, vomiting, diarrhea, and chills. Withdrawal from opioids is like a severe case of the flu.

How is opioid withdrawal most effectively treated?

Dr. Hail: Unlike alcohol withdrawal, which is life-threatening, opioid withdrawal is not life-threatening – but it is very uncomfortable. Opioid-dependent patients call this “dope sick.” In the ER, we treat the symptoms with anti-nausea, anti-diarrhea, and anti-anxiety medications, a drug called clonidine for drug craving, and IV fluids.

What makes a treatment program for opioid addiction effective?

Dr. Wakhlu: The best evidence for the management of opioid addiction is the combination of medication plus therapy, such as individual therapy and support groups like 12-step recovery meetings and SMART (Self-Management and Recovery Training). Medications like buprenorphine and methadone are beneficial for eliminating opioid withdrawal symptoms and cravings. Both are safe, effective medications that significantly decrease the risk of relapse and opioid overdose. The World Health Organization has placed them on its “Model List of Essential Medicines.” They should be taken long term. I like to use the analogy that a patient with diabetes needs insulin for day-to-day functioning. In the same vein, a patient with opioid addiction needs buprenorphine or methadone for stability and to significantly decrease the risk of relapse.

Opioids overdose data

• Between 1999 and 2022, U.S. overdose deaths from prescription opioids, heroin, and synthetic opioids such as fentanyl saw an eightfold increase.
• Opioids caused nearly 69,000 deaths in 2020 – almost 75% of drug overdose deaths that year.
• The deadliest synthetic opioid authorities have found, carfentanil, is estimated to be 10,000 times more potent than morphine – which is also an opioid.
• CDC data showed total drug overdose deaths in 2022 increased at least 9% in eight states compared with 2021 – including Texas at 11.1%. Opioid deaths decreased in two states severely affected by the crisis, West Virginia and Maryland.

Source: Centers for Disease Control and Prevention

Signs of an opioid overdose

• Constricted, pinpoint pupils
• Falling asleep or loss of consciousness
• Slow, shallow breathing
• Choking or gurgling sounds
• Limp body
• Pale, blue, or cold skin

Source: Centers for Disease Control and Prevention

Resources

• Centers for Disease Control and Prevention (CDC)
• Substance Abuse and Mental Health Services Administration (SAMHSA)
• National Institute on Drug Abuse (NIDA)

About UT Southwestern Medical Center
UT Southwestern, one of the nation’s premier academic medical centers, integrates pioneering biomedical research with exceptional clinical care and education. The institution’s faculty has received six Nobel Prizes, and includes 26 members of the National Academy of Sciences, 19 members of the National Academy of Medicine, and 14 Howard Hughes Medical Institute Investigators. The full-time faculty of more than 2,900 is responsible for groundbreaking medical advances and is committed to translating science-driven research quickly to new clinical treatments. UT Southwestern physicians provide care in more than 80 specialties to more than 100,000 hospitalized patients, more than 360,000 emergency room cases, and oversee nearly 4 million outpatient visits a year.

About Parkland Health
Parkland Health is one of the largest public hospital systems in the country. Premier services at the state-of-the-art Parkland Memorial Hospital include the Level I Rees-Jones Trauma Center, the only burn center in North Texas verified by the American Burn Association for adult and pediatric patients, and a Level III Neonatal Intensive Care Unit. The system also includes two on-campus outpatient clinics – the Ron J. Anderson, MD Clinic and the Moody Outpatient Center, as well as more than 30 community-based clinics and numerous outreach and education programs. By cultivating its diversity, inclusion, and health equity efforts, Parkland enriches the health and wellness of the communities it serves. For more information, visit parklandhealth.org.