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Copyright (c) 2025 Kamilah Mohammad Shagiri, Fatimah Yousef Ali Qawfashi, Afnan Owaynan khalaf ALJAMEELI, Atlal Fraih Alanazi, Majed Mubarak Saeed Alshahrani, Akram Ali Ahmed Rayyani, Amal Fahad Othman Alsenani, Sabhb Abdo Mohammed Bakr, Majed ObaIdallah Matter Alharbi, HAMZAH MOHAMMED AHMED BUAYTI, ASMA MOHAMMED JABER SULAYYI, YASMEEN MUBARAK SAYED AL-DAFERI
This work is licensed under a Creative Commons Attribution 4.0 International License.
Opioid Toxicity: An Interdisciplinary Approach to Clinical Management, Nursing Care, and Health Security-An Updated Review
Corresponding Author(s) : Kamilah Mohammad Shagiri
Saudi Journal of Medicine and Public Health, Vol. 2 No. 2 (2025)
Abstract
Background: Opioid toxicity represents a major clinical and public health concern associated with respiratory depression, impaired consciousness, overdose, dependence, and death. Although opioids remain important medications for acute and chronic pain, inappropriate use, high-dose exposure, drug interactions, and substance-use disorders increase the risk of serious adverse outcomes. Nurses and health security professionals have important roles in early recognition, emergency management, monitoring, prevention, education, and coordination of care.
Aim: This review aimed to examine the causes, risk factors, clinical assessment, evaluation, medical management, nursing management, monitoring, health education, risk management, and discharge planning associated with opioid toxicity.
Methods: A narrative review approach was used to synthesize available clinical and professional literature addressing opioid pharmacology, toxicity, overdose risk, diagnostic assessment, opioid reversal, nursing interventions, medication monitoring, multidisciplinary coordination, and preventive strategies.
Results: Opioid toxicity was characterized primarily by central nervous system depression and respiratory impairment. Major risk factors included high opioid exposure, substance-use history, concurrent use of central nervous system depressants, opioid-naivety, and sleep apnea. Early recognition of hypoventilation and airway compromise was central to management. Supportive airway and ventilation measures and naloxone administration were key components of emergency care. Long-term management incorporated patient education, monitoring, pharmacotherapy for opioid use disorder, prescription surveillance, pharmacist involvement, and structured discharge planning.
Conclusion: Effective opioid toxicity management requires coordinated clinical assessment, rapid respiratory support, appropriate opioid reversal, continuous monitoring, patient education, and long-term risk reduction.
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- 1. Blondell RD, Azadfard M, Wisniewski AM. Pharmacologic therapy for acute pain. Am Fam Physician. 2013 Jun 01;87(11):766-72.
- 2. Lalic S, Jokanovic N, Ilomäki J, Gisev N, Lloyd B, Lubman DI, Bell JS. Harms associated with extramedical use of prescription opioid analgesics in Australia: A scoping review. Res Social Adm Pharm. 2019 Aug;15(8):925-935.
- 3. Rzasa Lynn R, Galinkin JL. Naloxone dosage for opioid reversal: current evidence and clinical implications. Ther Adv Drug Saf. 2018 Jan;9(1):63-88.
- 4. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010 Jan 19;152(2):85-92.
- 5. LaForge KS, Yuferov V, Kreek MJ. Opioid receptor and peptide gene polymorphisms: potential implications for addictions. Eur J Pharmacol. 2000 Dec 27;410(2-3):249-268.
- 6. Kreek MJ, Bart G, Lilly C, LaForge KS, Nielsen DA. Pharmacogenetics and human molecular genetics of opiate and cocaine addictions and their treatments. Pharmacol Rev. 2005 Mar;57(1):1-26.
- 7. Caffrey CR, Lank PM. When good times go bad: managing 'legal high' complications in the emergency department. Open Access Emerg Med. 2018;10:9-23.
- 8. Brady JE, Giglio R, Keyes KM, DiMaggio C, Li G. Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis. Inj Epidemiol. 2017 Dec;4(1):24.
- 9. Huang X, Keyes KM, Li G. Increasing Prescription Opioid and Heroin Overdose Mortality in the United States, 1999-2014: An Age-Period-Cohort Analysis. Am J Public Health. 2018 Jan;108(1):131-136.
- 10. Massey J, Kilkenny M, Batdorf S, Sanders SK, Ellison D, Halpin J, Gladden RM, Bixler D, Haddy L, Gupta R. Opioid Overdose Outbreak - West Virginia, August 2016. MMWR Morb Mortal Wkly Rep. 2017 Sep 22;66(37):975-980.
- 11. Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician. 2012 Jul;15(3 Suppl):ES67-92.
- 12. Borgundvaag B, McLeod S, Khuu W, Varner C, Tadrous M, Gomes T. Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. CMAJ Open. 2018 Mar 01;6(1):E110-E117.
- 13. Gnanadesigan N, Espinoza RT, Smith R, Israel M, Reuben DB. Interaction of serotonergic antidepressants and opioid analgesics: Is serotonin syndrome going undetected? J Am Med Dir Assoc. 2005 Jul-Aug;6(4):265-9.
- 14. Sporer KA. Acute heroin overdose. Ann Intern Med. 1999 Apr 06;130(7):584-90.
- 15. Panchal SJ, Müller-Schwefe P, Wurzelmann JI. Opioid-induced bowel dysfunction: prevalence, pathophysiology and burden. Int J Clin Pract. 2007 Jul;61(7):1181-7.
- 16. Wanger K, Brough L, Macmillan I, Goulding J, MacPhail I, Christenson JM. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med. 1998 Apr;5(4):293-9.
- 17. LoVecchio F, Pizon A, Riley B, Sami A, D'Incognito C. Onset of symptoms after methadone overdose. Am J Emerg Med. 2007 Jan;25(1):57-9.
- 18. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med. 1996 Jul;3(7):660-7.
- 19. Owusu Obeng A, Hamadeh I, Smith M. Review of Opioid Pharmacogenetics and Considerations for Pain Management. Pharmacotherapy. 2017 Sep;37(9):1105-1121.
- 20. Ciejka M, Nguyen K, Bluth MH, Dubey E. Drug Toxicities of Common Analgesic Medications in the Emergency Department. Clin Lab Med. 2016 Dec;36(4):761-776.
- 21. Melanson SE, Baskin L, Magnani B, Kwong TC, Dizon A, Wu AH. Interpretation and utility of drug of abuse immunoassays: lessons from laboratory drug testing surveys. Arch Pathol Lab Med. 2010 May;134(5):735-9.
- 22. Stotts AL, Dodrill CL, Kosten TR. Opioid dependence treatment: options in pharmacotherapy. Expert Opin Pharmacother. 2009 Aug;10(11):1727-40.
- 23. Kosten TR, Kleber HD. Strategies to improve compliance with narcotic antagonists. Am J Drug Alcohol Abuse. 1984;10(2):249-66.
- 24. Wong F, Edwards CJ, Jarrell DH, Patanwala AE. Comparison of lower-dose versus higher-dose intravenous naloxone on time to recurrence of opioid toxicity in the emergency department. Clin Toxicol (Phila). 2019 Jan;57(1):19-24.
- 25. Pauly JB, Vartan CM, Brooks AT. Implementation and evaluation of an opioid overdose education and naloxone distribution (OEND) program at a Veterans Affairs Medical Center. Subst Abus. 2018;39(2):206-210.
- 26. Sivilotti ML. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol. 2016 Mar;81(3):428-36.
- 27. Saloner B, McGinty EE, Beletsky L, Bluthenthal R, Beyrer C, Botticelli M, Sherman SG. A Public Health Strategy for the Opioid Crisis. Public Health Rep. 2018 Nov/Dec;133(1_suppl):24S-34S.
- 28. Wiese B, Wilson-Poe AR. Emerging Evidence for Cannabis' Role in Opioid Use Disorder. Cannabis Cannabinoid Res. 2018;3(1):179-189.
- 29. Metfessel BA, Mentel MD, Phanel A, Dimartino MA, Allen M, Ho S. Opioid Use is Associated with Higher Severity-Adjusted Episode Costs in Patients with Conservatively Managed Degenerative Joint Disease of the Back and Neck. Pharmacoeconomics. 2019 Mar;37(3):419-433.
- 30. Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med. 2013 Jul;125(4):115-30.
- 31. Langham S, Wright A, Kenworthy J, Grieve R, Dunlop WCN. Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among Heroin Users in the United Kingdom. Value Health. 2018 Apr;21(4):407-415.
References
1. Blondell RD, Azadfard M, Wisniewski AM. Pharmacologic therapy for acute pain. Am Fam Physician. 2013 Jun 01;87(11):766-72.
2. Lalic S, Jokanovic N, Ilomäki J, Gisev N, Lloyd B, Lubman DI, Bell JS. Harms associated with extramedical use of prescription opioid analgesics in Australia: A scoping review. Res Social Adm Pharm. 2019 Aug;15(8):925-935.
3. Rzasa Lynn R, Galinkin JL. Naloxone dosage for opioid reversal: current evidence and clinical implications. Ther Adv Drug Saf. 2018 Jan;9(1):63-88.
4. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010 Jan 19;152(2):85-92.
5. LaForge KS, Yuferov V, Kreek MJ. Opioid receptor and peptide gene polymorphisms: potential implications for addictions. Eur J Pharmacol. 2000 Dec 27;410(2-3):249-268.
6. Kreek MJ, Bart G, Lilly C, LaForge KS, Nielsen DA. Pharmacogenetics and human molecular genetics of opiate and cocaine addictions and their treatments. Pharmacol Rev. 2005 Mar;57(1):1-26.
7. Caffrey CR, Lank PM. When good times go bad: managing 'legal high' complications in the emergency department. Open Access Emerg Med. 2018;10:9-23.
8. Brady JE, Giglio R, Keyes KM, DiMaggio C, Li G. Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis. Inj Epidemiol. 2017 Dec;4(1):24.
9. Huang X, Keyes KM, Li G. Increasing Prescription Opioid and Heroin Overdose Mortality in the United States, 1999-2014: An Age-Period-Cohort Analysis. Am J Public Health. 2018 Jan;108(1):131-136.
10. Massey J, Kilkenny M, Batdorf S, Sanders SK, Ellison D, Halpin J, Gladden RM, Bixler D, Haddy L, Gupta R. Opioid Overdose Outbreak - West Virginia, August 2016. MMWR Morb Mortal Wkly Rep. 2017 Sep 22;66(37):975-980.
11. Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician. 2012 Jul;15(3 Suppl):ES67-92.
12. Borgundvaag B, McLeod S, Khuu W, Varner C, Tadrous M, Gomes T. Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. CMAJ Open. 2018 Mar 01;6(1):E110-E117.
13. Gnanadesigan N, Espinoza RT, Smith R, Israel M, Reuben DB. Interaction of serotonergic antidepressants and opioid analgesics: Is serotonin syndrome going undetected? J Am Med Dir Assoc. 2005 Jul-Aug;6(4):265-9.
14. Sporer KA. Acute heroin overdose. Ann Intern Med. 1999 Apr 06;130(7):584-90.
15. Panchal SJ, Müller-Schwefe P, Wurzelmann JI. Opioid-induced bowel dysfunction: prevalence, pathophysiology and burden. Int J Clin Pract. 2007 Jul;61(7):1181-7.
16. Wanger K, Brough L, Macmillan I, Goulding J, MacPhail I, Christenson JM. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med. 1998 Apr;5(4):293-9.
17. LoVecchio F, Pizon A, Riley B, Sami A, D'Incognito C. Onset of symptoms after methadone overdose. Am J Emerg Med. 2007 Jan;25(1):57-9.
18. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med. 1996 Jul;3(7):660-7.
19. Owusu Obeng A, Hamadeh I, Smith M. Review of Opioid Pharmacogenetics and Considerations for Pain Management. Pharmacotherapy. 2017 Sep;37(9):1105-1121.
20. Ciejka M, Nguyen K, Bluth MH, Dubey E. Drug Toxicities of Common Analgesic Medications in the Emergency Department. Clin Lab Med. 2016 Dec;36(4):761-776.
21. Melanson SE, Baskin L, Magnani B, Kwong TC, Dizon A, Wu AH. Interpretation and utility of drug of abuse immunoassays: lessons from laboratory drug testing surveys. Arch Pathol Lab Med. 2010 May;134(5):735-9.
22. Stotts AL, Dodrill CL, Kosten TR. Opioid dependence treatment: options in pharmacotherapy. Expert Opin Pharmacother. 2009 Aug;10(11):1727-40.
23. Kosten TR, Kleber HD. Strategies to improve compliance with narcotic antagonists. Am J Drug Alcohol Abuse. 1984;10(2):249-66.
24. Wong F, Edwards CJ, Jarrell DH, Patanwala AE. Comparison of lower-dose versus higher-dose intravenous naloxone on time to recurrence of opioid toxicity in the emergency department. Clin Toxicol (Phila). 2019 Jan;57(1):19-24.
25. Pauly JB, Vartan CM, Brooks AT. Implementation and evaluation of an opioid overdose education and naloxone distribution (OEND) program at a Veterans Affairs Medical Center. Subst Abus. 2018;39(2):206-210.
26. Sivilotti ML. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol. 2016 Mar;81(3):428-36.
27. Saloner B, McGinty EE, Beletsky L, Bluthenthal R, Beyrer C, Botticelli M, Sherman SG. A Public Health Strategy for the Opioid Crisis. Public Health Rep. 2018 Nov/Dec;133(1_suppl):24S-34S.
28. Wiese B, Wilson-Poe AR. Emerging Evidence for Cannabis' Role in Opioid Use Disorder. Cannabis Cannabinoid Res. 2018;3(1):179-189.
29. Metfessel BA, Mentel MD, Phanel A, Dimartino MA, Allen M, Ho S. Opioid Use is Associated with Higher Severity-Adjusted Episode Costs in Patients with Conservatively Managed Degenerative Joint Disease of the Back and Neck. Pharmacoeconomics. 2019 Mar;37(3):419-433.
30. Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med. 2013 Jul;125(4):115-30.
31. Langham S, Wright A, Kenworthy J, Grieve R, Dunlop WCN. Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among Heroin Users in the United Kingdom. Value Health. 2018 Apr;21(4):407-415.