Risk Factors for Opioid-Induced Excessive Respiratory Depression

Cardiorespiratory failure induced by inhalation of aerosolized fentanyl in anesthetized rats

Intravenous rapid injection of fentanyl causes respiratory depression (severe apneas), leading to sudden death, which constitutes the deadliest drug reaction among overdoses of synthetic opioids. Here we asked whether acute inhalation of overdose fentanyl would also result in similar respiratory failure and death. The anesthetized and spontaneously breathing rats with tracheal cannulation were exposed to aerosolized fentanyl at 100 mg/m3 (FNTH) or 30 mg/m3 (FNTL) for 10 min. Minute ventilation (VE), electromyography (EMG) of the internal and external intercostal muscles and thyroarytenoid muscles (EMGII, EMGEI, and EMGTA), heart rate and arterial blood pressure were recorded. During the exposure, FNTH and FNTL immediately triggered bradypnea (40 % reduction, p < 0.05) with TE prolonged and then gradually decreased VE by 40 % (P < 0.05) after a brief VE recovery. The initial TE prolongation (apneas) were characterized by the cessation of EMGEI activity with enhanced tonic discharges of EMGTA and EMGII. After termination of the exposure, the cardiorespiratory responses to FNTL returned to the baseline values 30 min later, while those to FNTH were greatly exacerbated (P < 0.05), leading to ventilatory and cardiac arrest occurred 16.4 ± 4.7 min and 19.3 ± 4.5 min respectively after the onset of FNTH. The ventilatory arrest was featured by cessation of both EMGEI and EMGII and augmentation of tonic EMGTA. Our results suggest that acute exposure to an overdose of fentanyl aerosol leads to death through initially inducing a brief central and upper airway obstructive apnea as well as chest wall rigidity followed by gradual severe hypoventilation, bradycardia and hypotension, and eventual cardiorespiratory arrest in anesthetized rats.

Risk of asthma exacerbation associated with opioid and nonopioid analgesic use in children with current asthma

BACKGROUND: In the United States, asthma occurs in a vast proportion of children and adolescents. Asthma exacerbation is an acute episodic event typically characterized by difficulty in breathing, chest tightness, coughing, or wheezing. Severe asthma exacerbation can be life-threatening and lead to service utilizations such as hospitalizations and emergency department (ED) visits. Opioid analgesic use can trigger an asthma exacerbation through 2 pharmacological mechanisms. Despite the potential mechanisms, there is lack of empirical evidence to determine the risk of asthma exacerbation and its association with opioid use. OBJECTIVE: To evaluate the risk of asthma exacerbation in children with current asthma receiving an opioid vs a nonopioid analgesic. METHODS: Eligible individuals aged under 18 years with current asthma and receiving an incident analgesic prescription were identified from a large Medicaid managed care database during 2013-2018. Current asthma was defined as receipt of an asthma diagnosis and an antiasthmatic medication in the 12 months before analgesic medication initiation. Asthma exacerbation was defined as a hospitalization or ED visit with asthma as either the primary or secondary diagnosis within 3 days of receipt of an analgesic prescription. A weighted multivariable logistic regression using inverse probability treatment weighting was performed to test the association between use of analgesic medication and risk of asthma exacerbation. RESULTS: This study included 13,359 children with current asthma who filled either an incident opioid (n = 5,363, 40.1%) or nonopioid analgesic (n = 7,996, 59.9%) prescription. Asthma exacerbation was observed in 24 (0.5%) opioid analgesic recipients and 22 (0.3%) nonopioid analgesic recipients within 3 days of analgesic initiation. Weighted logistic regression results showed that children receiving opioid analgesics (adjusted odds ratio = 1.6, 95% CI = 0.9-2.9) did not have a statistically significantly higher risk of asthma exacerbation than their nonopioid analgesic recipient counterparts in the propensity score-weighted multivariable analysis. CONCLUSIONS: Asthma exacerbation associated with analgesic use in children with current asthma was an uncommon event, and the risk was comparable among children receiving opioid vs nonopioid analgesics. DISCLOSURES: This study was supported and funded by the Agency for Healthcare Research and Quality (AHRQ), Project Number: 1R03HS026790-01A1. The study content was solely the responsibility of the authors, and AHRQ had no role in the design and conduct of the study. The authors have nothing to disclose.

Utilization of opioid versus non-opioid analgesics in Medicaid and CHIP enrolled children with current asthma

PURPOSE

Opioid analgesics are frequently dispensed in children despite its known risk in children with a compromised airway function. The objectives of the study were to assess the prevalence of opioid analgesic dispensing in children with current asthma and to identify patient and prescriber factors associated with the dispensing of opioid versus non-opioid analgesics.

METHODS

Children <18 years of age, having current asthma and receiving an incident analgesic prescription were identified from a large Medicaid Managed Care Plan during years 2013 through 2018. Current asthma was defined as both receiving an asthma diagnosis and filling an anti-asthmatic medication during the 12-month period prior to the analgesic medication initiation. A scoring algorithm was applied to associate analgesic prescription with procedures and diagnoses according to perceived need for analgesia and time proximity.

RESULTS

Of the 9529 children meeting the inclusion criteria, 2681 (28.1%) received an opioid prescription. Opioid analgesic dispensing was most common among children who had an outpatient surgery/procedure (29.4%), trauma (19.4%) dental procedure (18.4%), and respiratory infection (10.6%). Multivariable analysis indicated that non-Hispanic Black (AOR: 0.39[0.3-0.5]) and Hispanic (AOR: 0.51[0.4-0.6]) children were less likely to receive an opioid analgesic compared to their non-Hispanic White counterparts. Children with prior history of asthma-related emergency department visit (AOR: 1.24[1.0-1.5]) and short acting beta agonist overuse (AOR: 1.33[1.1-1.7]) were more likely to fill an opioid analgesic prescription than those without.

CONCLUSION

Opioid analgesics are frequently dispensed to children with asthma. A higher dispensing rate was observed among non-Hispanic White children and among those with a history of uncontrolled asthma.

The impact and mechanism of ampakine CX1739 on protection against respiratory depression in rats

Background: Abuse of analgesic and sedative drugs often leads to severe respiratory depression and sometimes death. Approximately 69,000 people worldwide die annually from opioid overdoses. Purpose: This work aimed to investigate whether CX1739 can be used for emergency treatment of acute respiratory depression due to drug abuse. Results: First, the results clarify that CX1739 is a low-impact ampakine that can safely activate α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors without causing excito-neurotoxicity. Second, CX1739 rapidly crossed the blood-brain barrier (T_max = 2 min), which meets the requirement of rapid onset of action in vivo. Our work provides preliminarily confirmation that high-dose intravenous administration of CX1739 can immediately reverse respiratory depression in animal models of respiratory depression caused by opioid agonist 030418, pentobarbital sodium and ethanol.

Association between psychotropic drug use and prescription opioid use among older adults

This study investigated the association between psychotropic drug use and prescription opioid use/high dosage opioid use among older adults. A sample of 203,750 older adults enrolled in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program during 2017 was evaluated for prescription opioid and psychotropic drug usage. High dosage opioid use was defined as using >90 morphine milligram equivalents (MME)/day for ≥90 consecutive days. Overall, 20.7% of enrollees filled opioid prescriptions, of which 1.4% used them at high dosages. Multivariate logistic regression indicated that the odds of prescription opioid use increased with anxiolytic/sedative/hypnotic use and antidepressant use. Moreover, high dosage opioid use was significantly associated with anxiolytic/sedative/hypnotic use, antidepressant use and other factors including being younger, male, white, and married but living separately, and having multiple opioid prescribers. Clinicians should carefully evaluate opioid use among older patients using anxiolytics or antidepressants to minimize risks for adverse consequences of opioids.

Medication-assisted therapies for opioid use disorders in patients with chronic pain

Opioids have been used to treat pain and invoke pleasure for centuries. Modern scientific advancements have led to more potent, synthetic opioids. While certainly more effective in treating pain, they can also be much more addictive. Over the years the scientific community has developed a clearer understanding of the role opioid receptors play in causing and treating opioid use disorders (OUD) and we now know that OUD can develop in individuals taking opioids for "legitimate" pain. Current guidelines suggest that all prescribers (especially those prescribing opioids) be capable treating OUD. Pharmacological advances have led to a wide array of safe and effective treatment options to address OUDs. This paper will discuss the history of opioid development, what is known about the transition from analgesic uses to addiction and modern evidenced based treatment strategies to address OUDs.

Opioid-Induced Sedation and Respiratory Depression: Are Sedation Scales Enough to Prevent Adverse Drug Events Postoperatively?

OBJECTIVES

Nurses who care for hospitalized patients are responsible for ensuring adequate pain management is provided in a safe manner. The clinical challenge is balancing the effective control of the patient's pain with the side effects of administering opioids. The aim of this literature review is to explore the evidence on how nurses assess for opioid-induced sedation and advancing respiratory depression and how they integrate those data in their critical thinking skills when deciding to administer opioids for pain.

DESIGN

A matrix method was used to guide the review and synthesis of the evidence. Tables with column headings (citation, purpose of study, design/measurements, outcomes, and results) were constructed to record data extracted from each study.

DATA SOURCES

Primary source research articles were examined using the MESH terms sedation, sedation scale, respiratory depression, opioid, pain, pain assessment, adverse events, naloxone and postoperative.

REVIEW/ANALYSIS METHODS

Original studies such as retrospective case-control studies and descriptive studies were included. The final studies that met the inclusion criteria and were independently reviewed by the authors. The two main areas of interest were the evidence for how nurses assess for advancing sedation and excessive respiratory depression and how nurses integrate their assessment data in their critical thinking skills when deciding to administer opioids for pain.

RESULTS

Results indicated a lack of evidence examining the relationships among sedation, respiratory depression, and adverse events and the overall impact of managing these variables on patients' pain.

CONCLUSIONS

This review revealed a lack of evidence between how nurses assess for opioid induced advancing sedation and excessive respiratory depression, and the impact, including the adverse events associate with acute pain management.

The Impact and Mechanism of a Novel Allosteric AMPA Receptor Modulator LCX001 on Protection Against Respiratory Depression in Rodents

Analgesics and sedative hypnotics in clinical use often give rise to significant side effects, particularly respiratory depression. For emergency use, specific antagonists are currently administered to counteract respiratory depression. However, antagonists are often short-lasting and eliminate drug generated analgesia. To resolve this issue, novel positive AMPA modulators, LCX001, was tested to alleviate respiratory depression triggered by different drugs. The acetic acid writhing and hot-plate test were conducted to evaluate analgesic effect of LCX001. Binding assay, whole-cell recording, live cell imaging, and Ca²⁺ imaging were used to clarify mechanism and impact of LCX001 on respiratory protection. Results showed that LCX001 effectively rescued and prevented opioid (fentanyl and TH-030418), propofol, and pentobarbital-induced respiratory depression by strengthening respiratory frequency and minute ventilation. The acetic acid writhing test and hot-plate test revealed potent anti-nociceptive efficacy of LCX001, in contrast to other typical ampakines that did not affect analgesia. Furthermore, LCX001 potentiated [³H]AMPA and L-glutamate binding affinity to AMPA receptors, and facilitated glutamate-evoked inward currents in HEK293 cells stably expressing GluA2(R). LCX001 had a typical positive modulatory impact on AMPAR-mediated function. Importantly, application of LCX001 generated a significant increase in GluA2(R) surface expression, and restrained opioid-induced abnormal intracellular Ca²⁺ load, which might participate in breathing modulation. Our study improves therapeutic interventions for the treatment of drug induced respiratory depression, and increases understanding of potential mechanism of AMPA receptor modulators.

Preventing Opioid-Induced Respiratory Depression in the Hospitalized Patient With Obstructive Sleep Apnea

PURPOSE

To enhance the role of nursing interventions in the management of perioperative opioid-induced respiratory depression (OIRD) in patients with obstructive sleep apnea (OSA).

DESIGN

Narrative review of the literature.

METHODS

Literature reviewed with emphasis on recommendations by professional and accrediting organizations.

FINDINGS

Postsurgical OIRD increases hospital stay (55%), cost of care (47%), 30-day readmission (36%), and inpatient mortality (3.4 fold). OSA increases the risk of OIRD and may result in legal claims averaging $2.5 million per legal claim.

CONCLUSIONS

Nursing interventions are essential to improving outcome and reduce cost in the management of postsurgical OIRD in OSA patients.

Risk Factors for Serious Prescription Opioid-Induced Respiratory Depression or Overdose: Comparison of Commercially Insured and Veterans Health Affairs Populations

Objective

To characterize the risk factors associated with overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids in a commercially insured population (CIP) and to compare risk factor profiles between the CIP and Veterans Health Administration (VHA) population.

Subjects and Methods

Analysis of data from 18,365,497 patients in the IMS PharMetrics Plus health plan claims database (CIP) who were dispensed a prescription opioid in 2009 to 2013. Baseline factors associated with an event of serious OIRD among 7,234 cases and 28,932 controls were identified using multivariable logistic regression. The CIP risk factor profile was compared with that from a corresponding logistic regression among 817 VHA cases and 8,170 controls in 2010 to 2012.

Results

The strongest associations with serious OIRD in CIP were diagnosed substance use disorder (odds ratio [OR] = 10.20, 95% confidence interval [CI] = 9.06-11.40) and depression (OR = 3.12, 95% CI = 2.84-3.42). Other strongly associated factors included other mental health disorders; impaired liver, renal, vascular, and pulmonary function; prescribed fentanyl, methadone, and morphine; higher daily opioid doses; and concurrent psychoactive medications. These risk factors, except depression, vascular disease, and specific opioids, largely aligned with VHA despite CIP being substantially younger, including more females and less chronic disease, and having greater prescribing prevalence of higher daily opioid doses, specific opioids, and most selected nonopioids.

Conclusions

Risk factor profiles for serious OIRD among US medical users of prescription opioids with private or public health insurance were largely concordant despite substantial differences between the populations in demographics, clinical conditions, health care delivery systems, and clinical practices.

Use of the Pasero Opioid-induced Sedation Scale (POSS) in Pediatric Patients

The Pasero Opioid-induced Sedation Scale (POSS) is a valid, reliable tool used to assess sedation when administering opioid medications to manage pain. The POSS is endorsed by The Joint Commission and the American Society for Pain Management Nursing to help prevent adverse opioid-related respiratory events. Although the POSS is used to assess sedation in pediatric patients at some hospitals, prior to this study, it was not formally evaluated in the pediatric population. This study used a quasi-experimental design with a convenience sample of pediatric patients admitted to a large regional medical center in southeastern North Carolina. The POSS was evaluated from three perspectives. First, the study was designed to compare the documentation of sedation when opioids were administered before (n=25) and after (n=27) implementation of the POSS to assess sedation. Second, the occurrence of respiratory adverse events before and after implementation of the POSS was compared. Third, the appropriateness of using the POSS in the pediatric population was evaluated. When the POSS was used, there was an increase in both the clarity and frequency of documentation when sedation was assessed. There was no incidence of opioid-related adverse respiratory events after implementation of the POSS. Finally, the POSS was found to be appropriate and safe to use in the pediatric population. Through a survey, the majority of registered nurses who cared for the research subjects evaluated the POSS as easy, appropriate and safe to use with pediatric patients. The nurses also noted using the POSS provided standardized communication among staff regarding patients' levels of sedation. No adverse effects, concerns, or objections were reported. Coincidentally, while it was not part of the study, frequency of documentation of assessment of pain also improved with implementation of the POSS.

Development of a Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in Veterans' Health Administration Patients

OBJECTIVE

Develop a risk index to estimate the likelihood of life-threatening respiratory depression or overdose among medical users of prescription opioids.

SUBJECTS, DESIGN, AND METHODS

A case-control analysis of administrative health care data from the Veterans' Health Administration identified 1,877,841 patients with a pharmacy record for an opioid prescription between October 1, 2010 and September 30, 2012. Overdose or serious opioid-induced respiratory depression (OSORD) occurred in 817. Ten controls were selected per case (n = 8,170). Items for an OSORD risk index (RIOSORD) were selected through logistic regression modeling, with point values assigned to each predictor. Modeling of risk index scores produced predicted probabilities of OSORD; risk classes were defined by the predicted probability distribution.

RESULTS

Fifteen variables most highly associated with OSORD were retained as items, including mental health disorders and pharmacotherapy; impaired drug metabolism or excretion; pulmonary disorders; specific opioid characteristics; and recent hospital visits. The average predicted probability of experiencing OSORD ranged from 3% in the lowest risk decile to 94% in the highest, with excellent agreement between predicted and observed incidence across risk classes. The model's C-statistic was 0.88 and Hosmer-Lemeshow goodness-of-fit statistic 10.8 (P > 0.05).

CONCLUSION

RIOSORD performed well in identifying medical users of prescription opioids within the Veterans' Health Administration at elevated risk of overdose or life-threatening respiratory depression, those most likely to benefit from preventive interventions. This novel, clinically practical, risk index is intended to provide clinical decision support for safer pain management. It should be assessed, and refined as necessary, in a more generalizable population, and prospectively evaluated.

One Hospital's Initiatives to Encourage Safe Opioid Use

Pain is the leading reason people seek health care. In an effort to aggressively manage pain in the hospitalized patient, we have seen an increase in the use of opioids. Unfortunately, there has been a similar increase in the number of opioid-related adverse events. As a result, The Joint Commission issued a Sentinel Event Alert in August 2012 with suggested evidenced-based actions to help avoid these adverse events. This article describes one hospital's initiatives to provide opioids safely.

Fentanyl effects on breath generation in C57BL/6J and A/J mouse strains

We examined the effect of fentanyl on chemoresponsiveness in mouse strains divergent in the expression of spontaneous and post-hypoxic pauses. Frequency and tidal volume were recorded with plethysmography in A/J and C57BL/6J (B6) male mice. Mice selected at random received an intraperitoneal (IP) injection of either saline, low dose fentanyl (LDF = 0.04 mg/kg), or high dose fentanyl (HDF = 0.4 mg/kg) under hypoxia (8% O2) or hyperoxia (100%O2). LDF produced a decrease in frequency during hypoxia in B6, but not A/J, mice. HDF significantly decreased frequency and tidal volume in both strains under hypoxia and hyperoxia (p<0.01); naloxone, an opioid antagonist, reversed this response. The acute administration of fentanyl at any dose did not promote apneas in strains of mice exhibiting regular or irregular respiratory patterns. However, higher doses depressed respiratory frequency in both strains. The B6 mice responded with a depressive response to hypoxia that did not recover with reoxygenation, but did recover with time or naloxone.

Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients

OBJECTIVE

Prescription opioid use and deaths related to serious toxicity, including overdose, have increased dramatically in the United States since 1999. However, factors associated with serious opioid-related respiratory or central nervous system (CNS) depression or overdose in medical users are not well characterized. The objective of this study was to examine the factors associated with serious toxicity in medical users of prescription opioids.

DESIGN

Retrospective, nested, case-control analysis of Veterans Health Administration (VHA) medical, pharmacy, and health care resource utilization administrative data.

SUBJECTS

Patients dispensed an opioid by VHA between October 1, 2010 and September 30, 2012 (N=8,987).

METHODS

Cases (N=817) experienced life-threatening opioid-related respiratory/CNS depression or overdose. Ten controls were randomly assigned to each case (N=8,170). Logistic regression was used to examine associations with the outcome.

RESULTS

The strongest associations were maximum prescribed daily morphine equivalent dose (MED)≥ 100 mg (odds ratio [OR]=4.1, 95% confidence interval [CI], 2.6-6.5), history of opioid dependence (OR=3.9, 95% CI, 2.6-5.8), and hospitalization during the 6 months before the serious toxicity or overdose event (OR=2.9, 95% CI, 2.3-3.6). Liver disease, extended-release or long-acting opioids, and daily MED of 20 mg or more were also significantly associated.

CONCLUSIONS

Substantial risk for serious opioid-related toxicity and overdose exists at even relatively low maximum prescribed daily MED, especially in patients already vulnerable due to underlying demographic factors, comorbid conditions, and concomitant use of CNS depressant medications or substances. Screening patients for risk, providing education, and coprescribing naloxone for those at elevated risk may be effective at reducing serious opioid-related respiratory/CNS depression and overdose in medical users of prescription opioids.

Monitoring for opioid-induced advancing sedation and respiratory depression: ASPMN membership survey of current practice

Adverse events secondary to opioid-induced advancing sedation and respiratory depression continue to occur during hospitalizations despite efforts to increase awareness and clinical practice guidelines to address prevention strategies. In 2009, ASPMN surveyed membership on current practices surrounding this topic. ASPMN clinical practice guidelines were then published in 2011. In winter of 2013, ASPMN membership was again surveyed to assess progress in preventing adverse events. This is a report of the follow-up membership survey. In general, monitoring practices are slowly improving over time, but there are many facilities that have not instituted best practices for avoiding adverse events.