Learning Objectives
By the end of this section, you will be able to:
- Define opioid use disorder
- Outline methods used to treat opioid use disorder
From 1999 to 2021, over 600,000 people died in the United States from an overdose involving prescription or illicit opioids (CDC, 2023). This rise in opioid overdose deaths happened in three distinct waves. The first wave of overdose deaths began with the increased prescription rate and misuse of opioids in the 1990s. The second wave began in 2010 with rapid increases in overdose deaths involving heroin. The third wave began in 2013 with significant increases in overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl (CDC, 2023).
Defining Opioid Use Disorder
Even though health-care providers prescribe opioids legally to address pain, the use of these medications can lead to opioid use disorder (John Hopkins Medicine, 2023b). Among the 2021 U.S. population, 8.7 million people misused prescription pain relievers, and 1.1 million people used illegal opioids such as heroin (SAMHSA, 2022c). Misuse of a prescription pain reliever is described as either using a prescription medication that is prescribed to another person or overuse (either in quantity or number of doses) of a medication prescribed to the user (SAMHSA, 2022c).
Opioids are substances that act on opioid receptors in the central nervous system. Opioid receptors in the brain are part of the body’s internal system to regulate pain. A receptor is like a lock that the opioid (similar to a key) fits into (Medline Plus, 2017). Medically, they are used for anesthesia and relief of moderate to severe pain. When misused, opioids cause a person to feel relaxed and euphoric, meaning they experience an intense feeling of happiness. Opioid prescription medications include Schedule II medications, such as morphine, oxycodone, hydrocodone, fentanyl, and hydromorphone. Heroin, an illegal street drug, is also an opioid, but it is classified as a Schedule I drug (A.D.A.M. Medical Encyclopedia, 2022). Injected opioid misuse is a risk factor for contracting HIV, hepatitis B, hepatitis C, and bacterial endocarditis. The CDC reports that people who inject drugs accounted for 9 percent of HIV diagnoses in the United States in 2016 (SAMHSA, 2022a).
Behaviors Associated with Opioid Use Disorder
People often begin using opioids legitimately for pain that is caused by surgery, traumatic injury, or disease. When taken as prescribed by the health-care provider, most people do not end up with an opioid use disorder (John Hopkins, 2023a). Some people who take opioids enjoy a sense of euphoria when taking these drugs, however. For these people there is a risk of abuse as they try to continue to replicate that euphoric feeling.
Once an opioid use disorder develops, the person may begin to have financial problems due to the expense of buying the drugs. They may start to steal other people’s opioids, belongings, or cash in order to support their habit (John Hopkins Medicine, 2023a). Along with their interpersonal relationships beginning to deteriorate as they continue to use, they may also have difficulty staying employed. According to the National Institute on Drug Abuse (2018), only a small percentage of people who have an opioid use disorder will go on to use heroin. Data collected to examine heroin use suggests that those who go on to start heroin are more often polydrug users to begin with.
Opioid Intoxication
Opioid intoxication causes problematic behavioral or psychological changes, such as initial euphoria followed by apathy, dysphoria, psychomotor retardation or agitation, and impaired judgment. Some other signs of opioid intoxication include pupillary constriction (or dilation from severe overdose), drowsiness or coma, slurred speech, and impairment in attention or memory (American Psychiatric Association, 2013). An initial assessment includes a physical examination of the skin to look for the presence of needle track marks.
The typical signs of opioid overdose are referred to as the opioid overdose triad and include pinpoint pupils, respiratory depression, and decreased level of consciousness (Jahan & Burgess, 2023). Naloxone (Narcan) reverses the effects of an opioid overdose. A single-step nasal spray delivery of naloxone is the easiest and most successful route of administration for members of the community and first responders. Also available is naloxone intramuscular injection (Eggleston et al., 2018) (Figure 19.5).
Clinical Judgment Measurement Model
Take Action: Administering Naloxone
After recognizing the signs of opioid overdose, there are five steps nurses and other health-care providers should take:
- Obtain emergency assistance—when in a facility, gather team members, and, if not in a facility, call 911.
- Provide rescue breathing, chest compressions, and oxygen as needed and if accessible. Use a barrier device when giving breaths to protect yourself from transmissible diseases.
- Administer the first dose of naloxone. This medication should be given to anyone suspected of an opioid overdose, including pregnant women.
- Administer a second dose of naloxone if the person does not respond within two to three minutes of the first dose.
- Monitor the person’s response. Naloxone should work within two to three minutes of being administered, but it is short-acting and the person’s overdose symptoms can return; thus, the person should be taken to the ED if they are not already in a facility with medical care available.
Health Risks Associated with Illegal Use of Opioids
According to Jahan and Burgess (2023), opioid use can affect many body systems and cause the following side effects:
- stroke, seizures
- cardiac failure with chronic use
- memory loss and overall cognitive deficits
- psychosis
- nasal septal perforation
- respiratory depression
- muscle breakdown from overuse, leading to rhabdomyolysis
- hepatitis B and C infections, HIV, sepsis, and gangrene
- coma and death
Some of the side effects are associated with the form in which a person uses the substance. For instance, snorting can cause nasal septal perforation. Use of IV forms of the substance can lead to blood-borne infections—Hep B and C and HIV—if people are sharing needles (Cleveland Clinic, 2022b). The more that a person uses a substance, the higher their risk for overdose, suicide, or death.
Link to Learning
This article debates a needle exchange program in rural Kentucky. As you read this article, weigh the pros and cons presented and think about how such programs might work in your own community.
Approaches to Treating Opioid Use Disorder
There are several approaches to treating opioid use disorder. These methods include outpatient counseling, intensive outpatient treatment, short-term residential treatment, long-term therapeutic communities (sober living), and medication-assisted treatment (MAT) (Cleveland Clinic, 2022b). The most effective treatment combines the use of medication with counseling and behavioral therapy.
Three FDA-approved medications for the treatment of opioid use disorder exist: buprenorphine, methadone, and naltrexone (Cleveland Clinic, 2022b). Buprenorphine is a medication that blocks the euphoria produced by opioids and reduces withdrawal symptoms and cravings. This medication must be given in the provider’s setting in either oral form or by monthly injection. Methadone is available in specific clinics designated to administer this medication. It prevents the symptoms of withdrawal and reduces cravings. Naltrexone blocks the euphoria of opioids. It is only available in provider settings in oral form or monthly injections.
CBT helps clients adjust their thinking and behavior in relation to using opioids. This therapy helps the client to act in a healthier manner by examining their thoughts and reactions when they were using. Self-help programs, such as Narcotics Anonymous, also provide behavior modification using the support and guidance of others with lived experience.
Planning Nursing Care for a Client in Opioid Withdrawal/Detoxification
When caring for a client enduring opioid withdrawal/detoxification, the nurse’s initial concerns revolve around symptom management. Part of the assessment process involves the use of the CINA or COWS to determine the level of withdrawal symptoms the client is having at set intervals throughout the day. The scoring on this scale assists the nurse with determining medication administration to help manage symptoms. Withdrawal/detoxification length and severity depend upon the opioid that the client has been taking and when their last use was prior to coming in for treatment. The goal is to minimize withdrawal symptoms to the point that the client can begin working on discharge planning.
Planning Nursing Care for a Client with Opioid Use Disorder
Once detox is complete, the nurse and other health-care professionals will begin to talk to the client about their expectations for further treatment, motivation to change, and desire to stay sober. These important conversations help to pave the way for continuing treatment as the client begins to feel better. Nurses spend this time educating their clients on the seriousness of OUD, the negative effects it has on physical and emotional health, and on available resources to support them once they leave inpatient treatment.
Collaborative Care for Clients in Opioid Use Recovery
In both the inpatient and community health settings, collaborative care provides the highest efficacy for clients with OUD. Clinicians work together to plan individualized interventions, treatment plans, and outcomes. For instance, the physician or psychiatrist may suggest the use of medications to assist with sobriety. The social worker will provide a list of resources (outpatient services, short-term recovery services, sober living houses) that the client can review. The nurse provides support and additional education to assist the client in determining the best course of action for their life circumstances. Together, the team takes a harm reduction approach, which focuses on meeting the client where they are and helping to prevent overdose, reducing transmission of infectious diseases (such as HIV), and improving the overall health of the client (SAMHSA, 2022b). Harm reduction supplies and services can be funded by grants and can offer naloxone kits, health-care supplies, vitamin supplements, snacks, educational materials, and public health referrals and services. Using this approach, the team works with the client to set their own goals (SAMHSA, 2022b). The CDC partners with SAMHSA to provide more intensive harm reduction services, such as needle exchange programs and care to vulnerable populations through the National Harm Reduction Technical Assistance Center (NHRTAC).