Opioid Safety, Respiratory Compromise

Overdose Risk Assessment in Chronic Opioid Therapy

Before recommending opioid therapy, assess patients for risk of overdose. In this article, Peggie L. Powell, MSN, APRN, FNP-BC a family nurse practitioner, discusses using RIOSORD, the first tool intended to provide clinicians with the clinical decision support to assess the risk of OSORD and determine the possible need for naloxone. 

By Peggie L. Powell, MSN, APRN, FNP-BC

Over 100 million people suffer from chronic pain in the United States, and for some of these people, chronic opioid therapy (COT) may be appropriate. Despite the limited availability of strong scientific evidence to support long-term opioid therapy for chronic noncancer pain, COT has increased substantially over the years along with an increase in drug related deaths.

Prescription opioid related deaths have quadrupled since 1999 in the United States and approximately 80% of deaths are due to unintentional overdose. The addictive nature of opioids makes them vulnerable to misuse and abuse. Persons whom take opioids for their intended purpose can risk significant adverse events if they do not take them as prescribed (e.g., taking more than prescribed and taking them in combination with other psychotropic medications and/or alcohol). Opioids can depress the central nervous system and result in serious, life-threatening consequences such as respiratory depression, sedation, coma, and potentially death.

Considering such potentially fatal consequences, there is much concern in regards to the safety of opioid prescribing. In 2014, opioid overdose death from prescription opioids increased to approximately 19,000 deaths in the United States; this is more than three times the number reported in 2001. Such statistics are staggering and indicate a need for action to help curb this epidemic. Utilization of risk assessment tools and mitigation strategies to detect and reduce the risk of opioid overdose are needed in clinical practice.

Both the Centers for Disease Control and Prevention (CDC) and Substance Abuse and Mental Health Services Administration recommend the consideration of co-prescribing naloxone along with opioids to those at high risk of overdose as a risk mitigation strategy to prevent opioid overdose. Naloxone is an opioid antagonist that can reverse respiratory depression and save lives when administered to a person suspected of an opioid overdose whether intentional or unintentional. Laypersons such as friends and/or family members are capable of administering naloxone once properly educated and trained. Although there are no studies at this time to examine the co-prescribing of naloxone with opioids as a risk mitigation strategy, the CDC indicates that naloxone distribution programs are associated with reduced risk for overdose death at the community level.

The recommendation to prescribe naloxone to patients at increased risk of opioid overdose raises the clinical question of how the risk of overdose is measured in patients on COT. Available risk mitigation strategies include provider education, written opioid agreements, urine drug screens, and screening for risk factors associated with overdose or serious opioid-induced respiratory depression (OSORD) as well as aberrant behavior. However, the only tool that provides an actual quantitative score of opioid overdose risk is the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD).

The RIOSORD, developed by Zedler et al., is the first tool intended to provide clinicians with the clinical decision support to assess the risk of OSORD and determine the possible need for naloxone. Factors found to have the most significant positive associations of OSORD were included in the RIOSORD tool; they are MED >100mg/day, history of opioid dependence, hospitalization during the six months before the OSORD event, liver disease, and the use of ER/LA opioids. The tool is useful as a baseline risk evaluation as well as continued risk monitoring at future appointments. Use of the RIOSORD tool in clinical practice is not only feasible but provides a simple yet practical approach to screening for risk of overdose.


Peggie L. Powell, MSN, APRN, FNP-BC

Peggie L. Powell, MSN, APRN, FNP-BC

Peggie L. Powell, MSN, APRN, FNP-BC is a family nurse practitioner at VCU Community Memorial Hospital Pain Management Services in South Hill, Va, an affiliate of Virginia Commonwealth University in Richmond, Va. She obtained both her Baccalaureate and Master of Science degrees from Old Dominion University in Norfolk, Virginia. Peggie is currently pursuing her Doctorate of Nursing Practice (DNP) through Virginia Commonwealth University School of Nursing. Her project focus for the DNP program is on increasing the prescribing practices of naloxone for patients determined to be high risk for opioid overdose. Her expected graduation date is May 2018. Peggie is dedicated to providing effective pain relief to those in need while concentrating on patient safety and quality outcomes.

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