SAMSHA Opioid Overdose Prevention
Opioid Overdose Prevention
TOOLKIT
Opioid Use Disorder Facts
TABLE OF CONTENTS
SAMHSA Opioid Overdose Prevention Toolkit
Opioid Use Disorder Facts…………………………………………………………………………………………………… 1
Scope of the Problem……………………………………………………………………………………………………….. 1
Strategies to Prevent Overdose Deaths ………………………………………………………………………………. 2
Resources for Communities………………………………………………………………………………………………. 4
References …………………………………………………………………………………………………………………………. 5
Acknowledgments ………………………………………………………………………………………………………………. 6
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OPIOID USE DISORDER FACTS
SCOPE OF THE PROBLEM
Opioid overdose continues to be a major public health
problem in the United States. It has contributed
significantly to overdose deaths among those who
use or misuse illicit and prescription opioids. In fact, all U.S.
overdose deaths involving opioids (i.e., unintentional,
intentional, homicide, and undetermined) increased to more
than 42,000 deaths in 2016.1
WHAT ARE OPIOIDS? Opioids include prescription
medications used to treat pain such as morphine, codeine,
methadone, oxycodone, hydrocodone, fentanyl,
hydromorphone, and buprenorphine, as well as illegal drugs
such as heroin and illicit potent opioids such as fentanyl
analogs (e.g., carfentanil).
Opioids work by binding to specific receptors in the brain,
spinal cord, and gastrointestinal tract. In doing so, they
diminish the body’s perception of pain. However, opioids can
also have an impact on other systems of the body, such as
altering mood, slowing breathing, and causing constipation.
Opioid receptor binding causes the signs and symptoms of
overdose as well as the euphoric effects or “high” with opioid
use.
HOW DOES OVERDOSE OCCUR? A variety of effects can
occur after a person takes opioids, ranging from pleasure to
nausea and vomiting, severe allergic reactions
(anaphylaxis), and overdose, in which breathing and
heartbeat slow or even stop.
Opioid overdose can be due to many factors. For
example, overdose can occur when a patient deliberately
misuses a prescription, uses an illicit opioid (such as heroin),
or uses an opioid contaminated with other even more potent
opioids (such as fentanyl). Overdose can also occur when a
patient takes an opioid as directed but the prescriber
miscalculated the opioid dose, when an error was made by
the dispensing pharmacist, or when the patient
misunderstood the directions for use. It can also occur when
opioids are taken with other medications—for example,
prescribed medications such as benzodiazepines or other
psychotropic medications that are used in the treatment of
mental disorders—or with illicit drugs or alcohol that may
have adverse interactions with opioids. At particular risk are
individuals who use opioids and combine
them with benzodiazepines, other
sedative hypnotic agents, or alcohol, all of
which cause respiratory depression.2
WHO IS AT RISK? Anyone who uses
opioids for long-term management of
chronic pain is at risk for opioid overdose,
as are individuals who use heroin or
misuse prescription pain relievers.3 Others
at risk include those who:
Are receiving rotating opioid medication
regimens (and thus are at risk for incomplete
cross-tolerance).
Have been discharged from emergency
medical care following opioid overdose.
Need opioid pain relievers, coupled with a
suspected or confirmed substance use
disorder or history of non-medical use of
prescription opioids or use of illicit opioids.
Have completed opioid detoxification or are
abstinent for a period of time (and
presumably have reduced opioid tolerance
and high risk of return to opioid use).
Have been recently released from
incarceration and have a history of opioid
use disorder or opioid misuse (and
presumably have reduced opioid tolerance
and high risk of return to opioid use).
Tolerance develops when someone
uses an opioid drug regularly so that
his or her body becomes accustomed
to the drug and needs a larger or more
frequent dose to continue to
experience the same effect.
Loss of tolerance occurs when
someone stops taking an opioid after
long term use. When someone loses
tolerance and then takes the opioid
drug again, he or she can experience
serious adverse effects, including
overdose, even if the amount taken
had not caused problems in the past.
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OPIOID USE DISORDER FACTS
STRATEGIES TO PREVENT OVERDOSE DEATHS
STRATEGY 1: Encourage providers, persons at high risk, family members,
and others to learn how to prevent and manage opioid overdose. Providers
should be encouraged to keep their knowledge current about evidence-based
practices for the use of opioid analgesics to manage pain, as well as specific steps to
prevent and manage opioid overdose.
The Substance Abuse and Mental Health Services Administration (SAMHSA)
funds continuing medical education courses that are available to providers at no
charge from the Providers Clinical Support System (PCSS) at https://pcssnow.org/.
Helpful information for laypersons on how to prevent and manage overdose is
available from Prevent & Protect at http://prevent-protect.org/.
STRATEGY 2: Ensure access to treatment for individuals who are misusing
opioids or who have a substance use disorder. Effective treatment of
substance use disorders can reduce the risk of overdose and help overdose survivors
attain a healthier life. Medications for opioid use disorder, as well as counseling and
other supportive services, can be obtained at SAMHSA-certified and Drug
Enforcement Administration-registered opioid treatment programs and in specialty
substance use disorder treatment programs, as well as from physicians and other
practitioners including nurse practitioners and physician assistants who are trained to
provide care in office-based settings with buprenorphine and naltrexone.
Information on treatment services available in or near your community can be
obtained from your state health department, your state alcohol and drug agency, or
the SAMHSA Behavioral Health Treatment Services Locator at
https://www.findtreatment.samhsa.gov.
STRATEGY 3: Ensure ready access to naloxone. Opioid overdose-related
deaths can be prevented when naloxone is administered in a timely manner. (For
instructions on how to use naloxone, go to http://prescribetoprevent.org). Naloxone
displaces opioids from receptor sites in the brain and reverses respiratory depression
that usually is the cause of overdose deaths. Naloxone is an appropriate response for
all opioid overdose events, including fentanyl-involved overdoses. Multiple doses of
naloxone may be required when the overdose results from ingestion of large
amounts of opioids or potent opioids such as fentanyl, carfentanil, or other opioid
analogs.4 (For more information regarding the various formulations of naloxone, see
https://www.drugabuse.gov/publications/naloxone-opioid-overdose-life-savingscience/naloxone-opioid-overdose-life-saving-science.)
On the other hand, naloxone is not effective in treating overdoses of
benzodiazepines, barbiturates, clonidine, GHB, or ketamine. It is also not effective against overdoses of
stimulants, such as cocaine and amphetamines (including methamphetamine and MDMA). However, if
opioids are taken in combination with other sedatives or stimulants, naloxone may be helpful.
Encourage
to learn
about
managing
opioid
overdose.
Ensure
access to
treatment
Expand
access to
naloxone.
Naloxone injection has been approved by the Food and Drug Administration (FDA) and used for more
than 40 years by emergency medical services personnel to reverse opioid overdose and resuscitate
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OPIOID USE DISORDER FACTS
individuals who otherwise might have died in the absence of treatment.5 Naloxone comes in several forms,
including injectable, intranasal, and auto-injector. Injectable naloxone is typically supplied as a kit with a
minimum of two doses and two syringes.6 Brief education on how to administer naloxone using a syringe
can be obtained from the provider of the naloxone kit or from http://prescribetoprevent.org/. The FDA has
also approved an intranasal naloxone product (a nasal spray) and a naloxone auto-injector that delivers a
therapeutic dose of naloxone in an overdose situation. The intranasal spray is a prefilled, needle-free device
that requires no assembly. The auto-injector can deliver a dose of naloxone through clothing, if necessary,
when placed on the outer thigh.
Prior to 2012, just six states had laws that expanded access to naloxone or
limited criminal liability.7 By mid-2017, every state and the District of Columbia had
enacted statutes that provide criminal liability protections to laypersons or first
responders who administer naloxone. Forty-six states and the District of Columbia
have statutes that provide civil liability protections to laypersons or first responders
who administer naloxone. Thirty-seven states have statutes that offer criminal
liability protections for prescribing or distributing naloxone. Forty-one states have
statutes that offer civil liability protections for prescribing or distributing naloxone,
and 46 states have statutes that allow naloxone distribution to third parties or first
responders via direct prescription or standing order. To find relevant laws for each
state, visit the Prescription Drug Abuse Policy System at http://www.pdaps.org/
STRATEGY 4: Encourage the public to call 911. An individual who is
experiencing an opioid overdose needs immediate medical attention. An essential
first step is to get help from someone with medical expertise as quickly as possible.8
Therefore, members of the public should be encouraged to call 911. All they have to
say is “Someone is unresponsive and not breathing” and give a specific address
and/or description of the location. Thirty-seven states and the District of Columbia
have “Good Samaritan” statutes that prevent prosecution for possession of a
controlled substance or paraphernalia if emergency assistance is sought for
someone who is experiencing an overdose, including an opioid-induced overdose.9
STRATEGY 5: Encourage prescribers to use state prescription drug
monitoring programs (PDMPs). State PDMPs have emerged as a key strategy
for addressing the misuse of prescription opioids and thus preventing opioid
overdoses and deaths. Specifically, prescribers can check their state’s PDMP
database to determine whether a patient is filling the prescriptions provided and/or
obtaining prescriptions for the same or a similar drug from multiple prescribers.
While nearly all states now have operational PDMPs, the programs differ from
state to state in terms of the exact information collected, how soon that information
is available to prescribers, and who may access the data. Therefore, information
about the program in a particular state is best obtained directly from the
Prescription Drug Abuse Policy System at http://www.pdaps.org/, the specific state
PDMP, or the state’s board of medicine or pharmacy.
Encourage
the public to
call 911.
Encourage
prescribers
to use state
prescription
drug
monitoring
programs.
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OPIOID USE DISORDER FACTS
RESOURCES FOR COMMUNITIES
Resources that may be useful to local communities and organizations
include:
SAMHSA
National Helpline: 1-800-662-HELP (4357) or 1-800-487-4889 (TDD, for
hearing impaired)
Behavioral Health Treatment Services Locator (search by address,
city, or ZIP Code): https://findtreatment.samhsa.gov/
Buprenorphine Treatment Practitioner Locator (search by
address, city, or ZIP Code):
https://www.samhsa.gov/medication-assistedtreatment/physician-program-data/treatment-physician-locator
Single State Agencies for Substance Abuse Services:
https://www.samhsa.gov/sites/default/files/ssa-directory.pdf
State Opioid Treatment Authorities:
https://dpt2.samhsa.gov/regulations/smalist.aspx
SAMHSA Publications Ordering (all SAMHSA Store products
are available at no charge): https://store.samhsa.gov; 1-877-
SAMHSA-7 (1-877-726-4727)
Centers for Disease Control and Prevention
Understanding the Epidemic:
https://www.cdc.gov/drugoverdose/epidemic
Poisoning: https://www.cdc.gov/homeandrecreationalsafety/poisoning
Association of State and Territorial Health Officials
Preventing Opioid Misuse in the States and Territories:
http://my.astho.org/opioids/home
National Association of State Alcohol and Drug Abuse Directors
Opioids Fact Sheet (February 5, 2016): http://nasadad.org/2016/02/opioidsfact-sheet-2016/
Prevent & Protect
Tools for conducting overdose prevention and naloxone advocacy, outreach,
and communication campaigns: http://prevent-protect.org/communityresources-1/
Resources
that may
be useful
to local
communities
and
organizations
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REFERENCES
1 Centers for Disease Control and Prevention. Opioid overdose. https://www.cdc.gov/drugoverdose/index.html. Accessed Feb 28,
- 2 Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367(2):146-155. 3 Webster LR, Cochella S, Dasgupta N, Fakata KL, Fine PG, Fishman SM, Grey T, Johnson EM, Lee LK, Passik SD, Peppin
J. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Medicine. 2011 Jun
1;12(suppl_2):S26-35. 4 Somerville NJ, O’Donnell J, Gladden RM, Zibbell JE, Green TC, Younkin M, Ruiz S, Babakhanlou-Chase H, Chan M, Callis
BP, Kuramoto-Crawford J. Characteristics of fentanyl overdose-Massachusetts, 2014-2016. MMWR Morb Mortal Wkly
Rep. 2017 Apr;66(14):382-386. 5 Green TC, Doe-Simkins M. Opioid overdose and naloxone: the antidote to an epidemic. Drug Alcohol Depend.
2016;163:265-271. 6 Enteen L, Bauer J, McLean R, Wheeler E, Huriaux E, Kral AH, Bamberger JD. Overdose prevention and naloxone
prescription for opioid users in San Francisco. J Urban Health. 2010;87(6):931-941. 7 Davis C, Carr D. State legal innovations to encourage naloxone dispensing. Journal of the American Pharmacists
Association. 2017 Mar 1;57(2):S180-184. 8 Green TC, Heimer R, Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six
overdose training and naloxone distribution programs in the United States. Addiction. 2008;103(6):979-998 9 Legal Science. Good Samaritan prevention laws. http://www.pdaps.org/datasets/good-samaritan-overdose-laws1501695153. Accessed Feb 28, 2018.
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ACKNOWLEDGMENTS
ACKNOWLEDGMENTS
This publication was prepared for the Substance Abuse and Mental Health Services Administration
(SAMHSA) under contract number 10-233-00100 with SAMHSA, U.S. Department of Health and Human
Services (HHS). LCDR Brandon Johnson, M.B.A., served as the Government Project Officer.
Disclaimer
The views, opinions, and content expressed herein are those of the authors and do not necessarily reflect
the official position of SAMHSA or HHS. Nothing in this document constitutes an indirect or direct
endorsement by SAMHSA or HHS of any non-federal entity’s products, services, or policies, and any
reference to a non-federal entity’s products, services, or policies should not be construed as such. No official
support of or endorsement by SAMHSA or HHS for the opinions, resources, and medications described is
intended to be or should be inferred. The information presented in this document should not be considered
medical advice and is not a substitute for individualized patient or client care and treatment decisions.
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Recommended Citation
Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention
Toolkit. HHS Publication No. (SMA) 18-4742PT1. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2018.
Nondiscrimination Notice
SAMHSA complies with applicable federal civil rights laws and does not discriminate on the basis of race,
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aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.
Originating Office
Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental
Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857.
HHS Publication No. (SMA) 18-4742PT1. First printed 2013. Revised 2014, 2016, 2018.
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