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Drug Overdose
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Overdose deaths are seemingly never-ending and have taken ahold of the United States
over the past few decades. According to Skolnick, opioid overdose is the leading cause of death
among individuals between 25 and 64 years old (2022). Over 48 million Americans have
misused illicit or prescription drugs, with an average of 115 Americans dying everyday from an
overdose (Ignatavicius et al., 2021, p. 308). Fortunately, several interventions supported by
evidence-based research are implemented in the prevention and treatment of drug overdoses.
Pathophysiology
Drug overdose, more commonly opioid overdose, has detrimental and potentially lethal
effects on the central nervous system (CNS). As the CNS drives respiration, opioid overdose
causes respiratory depression, therefore reducing the partial pressure of oxygen (PO2) within the
blood. This reduction of blood oxygen, a condition noted as hypoxemia, ultimately results in the
reduction of tissue levels of oxygen, otherwise known as hypoxia. In drug overdoses exhibiting
hypoxemic and hypercapnic respiratory failure, alveolar ventilation is insufficient in eliminating
carbon dioxide and keeping oxygen within normal range. Additionally, this retention of carbon
dioxide has important effects on arterial blood gases, resulting in respiratory acidosis (Norris,
2012). From a neurological standpoint, sustained hypoxic conditions may cause neuronal death,
leading to brain damage and ultimately, brain death. Furthermore, several pathologies following
hypoxic brain damage may lead to coma, stroke, seizures, and temporary motor paralysis
(Skolnick, 2022). If the opioid overdose is nonfatal, the following conditions may result: “mental
disorientation, an amnestic syndrome, ataxia, gait disturbances, paraplegia, catatonia, reduced
reaction time, and diminished motor skills and physical functioning” (Skolnick, 2022).
Nursing Diagnoses and Interventions
An appropriate nursing diagnosis for a patient with a drug overdose would be:
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Impaired gas exchange related to ineffective breathing secondary to drug overdose as
evidenced by hypercapnia, hypoxemia, hypoxia, arterial PO2 less than 50 mm Hg, arterial
PCO2 more than 50 mmHg, cyanosis, restlessness, confusion, delirium, respiratory rate
less than 12 per minute, cardiac arrhythmias, tachycardia, increased blood pressure, and
somnolence (Norris, 2012, p. 954; Unbound Medicine, 2023).
Pain medications act selectively at receptor sites in the CNS. Most opioids exert their effects
through mu receptors which is responsible for respiratory depression (Norris, 2012, p. 407).
Hypercapnic or hypoxemic respiratory failure occurs when the amount of oxygen traveling into
and out of the lungs is reduced; this process is also known as hypoventilation (Norris, 2012, p.
954). Additionally, misuse of synthetic medications not only induces life-threatening respiratory
depression, it may also have lethal effects on the respiratory muscles. “[P]harmacologically
relevant doses of intravenous fentanyl and its analogs can produce rigidity in the chest wall and
diaphragm as well as laryngospasm. This set of symptoms is collectively known as
Wooden Chest Syndrome (WCS)” (Skolnick, 2022). Therefore, interventions for impaired gas
exchange caused by a drug overdose would be directed towards oxygenating the patient,
administration of an opioid antagonist, and administration of a muscle relaxant.
As discussed by Skolnick, one intervention to reverse the chest and diaphragm rigidity
caused by WCS would be to administer a neuromuscular blocking agent such as succinylcholine.
The second intervention would be to administer a competitive opioid antagonist such as
naloxone to reverse the signs of overdose (2022). Naloxone, a competitive, non-selective opioid
receptor antagonist, is the gold standard medication for treating an overdose by reversing opioidinduced effects (Britch & Walsh, 2022). A randomized trial of 172 patients further supported the
efficacy of naloxone against fentanyl and fentanyl analogs. “172 patients with suspected opioid
overdose found that 72.3 and 77.5% of patients responded within 10 min of pre-hospital IN and
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IM naloxone administration” (Britch & Walsh, 2022). Furthermore, another study reported that
66% of patients who were administered naloxone had a Glasgow Coma Score greater than 14,
indicating that the patient is responsive and alert. While naloxone is generally safe and effective,
one of the primary concerns regarding the administration of naloxone is the precipitation of
abrupt onset opioid withdrawal for physically dependent users. A third intervention in the clinical
setting is directed at the preventative aspect of drug overdose. “Preventing clinically significant
opioid-induced respiratory depression begins with administering the lowest effective opioid
dose… careful titration, and closely monitoring sedation and respiratory status throughout
therapy” (Ignatavicius et al., 2021, p. 321). Excessive sedation can lead to respiratory depression,
hence a sedation scale for assessment of unwanted sedation, such as the Pasero Opioid-Induced
Sedation Scale (POSS) helps explain the appropriate action at each sedation level.
A second appropriate nursing diagnosis for a patient with a drug overdose would be:
Decreased cardiac output related to ineffective myocardial contractility secondary to drug
overdose as evidenced by cardiac arrhythmias, altered blood pressure, vasoplegia,
abnormal skin color, clammy skin, and decreased peripheral pulses (Unbound Medicine,
2023).
In addition to the raging opioid epidemic, cardiovascular medication overdose accounts for 3.5%
of drug overdoses and exhibits a mortality rate of 16%. “The cardiovascular collapse associated
with these drugs is due to impaired cardiac contractility, profound vasodilation, and/or rhythm
disturbances” (Vignesh et al., 2018). One intervention to minimize the effects of overdose would
be the administration of activated charcoal and gastric lavage, limiting the absorption of the drug.
A second intervention would be to fix the hypovolemic condition through the resuscitation of
fluids and the administration of inotropic or vasopressor support. Lastly, a third extreme
intervention to restore hemodynamic stability, when all other interventions have failed, would be
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the utilization of venoarterial extracorporeal membrane oxygenation support (VA ECMO).
ECMO may be considered in patients who are experiencing severe refractory shock because of
cardiovascular medication toxicity. However, this intervention warrants several device-related
complications such as limb ischemia and bleeding. Despite its complications, it was concluded
that all three patients from the case reports survived the refractory shock and were successfully
discharged (Vignesh et al., 2018).
Watson’s Caritas Process
The findings and interventions from the articles are a reflection of Caritas process eight:
creating a healing environment at all levels. As Watson stated, “[s]afety concerns affect all of the
nurse’s activities related to supporting, protecting, and correcting the environment for healing at
all levels” (2008, p. 131). The nurse can utilize various interventions to control pain and human
suffering, and ultimately ensure the patient’s safety. These interventions are directed towards
healing the individual at all levels of the human body system. In correcting drug-induced
respiratory depression, the respiratory system is healed. In correcting drug-induced
cardiovascular collapse, the cardiovascular system is healed. However, it is vital to note that
these systems are all interconnected and require healing the patient as a whole and at all levels.
Therefore, incorporating Caritas process eight in one’s care means continually assessing and
monitoring the patient for symptoms associated with drug overdoses, as well as reassessing the
patient’s symptoms following an intervention to promote patient safety.
Conclusion
Drug overdoses are preventable and with timely interventions may drastically increase
the individual’s chances of survival. If left untreated, complications such as respiratory
depression and cardiovascular collapse may occur, all of which may be fatal. Fortunately, several
interventions supported by research have improved the likelihood of survival following a drug
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overdose. For drug-induced respiratory complications, interventions include the administration
of succinylcholine, the administration of naloxone, and close monitoring of sedation and
respiratory status. For cardiovascular complications, a few interventions include the
administration of activated charcoal, inotropic drugs, and vasopressors; gastric lavage; fluid
resuscitation; and hemodynamic support. In conclusion, the development of more effective
overdose interventions and continued research is necessary to reduce the impact of drug misuse.
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References
Britch, S. C., & Walsh, S. L. (2022). Treatment of opioid overdose: current approaches and
recent advances. Psychopharmacology, 239(7), 2063-2081.
Ignatavicius, D.D., Workman, M.L., Rebar, C.R., & Heimgartner, N.M. (2021). Medical-surgical
nursing: Concepts for interprofessional collaborative care, (10th ed.) [electronic book].
Elsevier
Norris, T. L. (2012). Lippincott CoursePoint for Norris: Porth's Pathophysiology (10th ed.).
Wolters Kluwer Health. https://coursepoint.vitalsource.com/books/9781975101145
Skolnick, P. (2022). Treatment of overdose in the synthetic opioid era. Pharmacology &
therapeutics, 233, 108019.
Vignesh, C., Kumar, M., Venkataraman, R., Rajagopal, S., Ramakrishnan, N., & Abraham,
B. (2018). Extracorporeal membrane oxygenation in drug overdose: a clinical case series.
Indian Journal of Critical Care Medicine, 22(2), 111–115.
https://doi.org/10.4103/ijccm.IJCCM_417_17
Watson, J. (2008). Nursing: The philosophy and science of caring. University Press of Colorado.