Maria G. Tanzi, PharmD
As opioid misuse has risen across the United States, so has opioid-associated out-of-hospital cardiac arrest, which has unique clinical features and management implications, according to a new scientific statement from the American Heart Association (AHA).
“Opioid-associated cardiac arrests have a distinct pathophysiology and require different care compared with traditional events as a result of an ischemia or heart failure,” said Cameron Dezfulian, MD, vice chair of the AHA scientific statement and senior faculty in the departments of critical care and adult coronary heart disease at Texas Children’s Hospital.
“Pharmacists can bring awareness to the care team of patients who are known to have an issue with opioids and can play an active role in the appropriate management of these patients at the time of discharge.”
Risk factors
The scientific statement, which was published in Circulation in March 2021, is divided into the prehospital management and postresuscitation care of patients with opioid-associated cardiac arrest. AHA noted that opioid-associated cardiac arrests are more likely to happen at home, to be unwitnessed, and to occur in younger adults between the ages of 20 to 59 years.
The statement includes a list of risk factors for opioid-associated out-of-hospital cardiac arrest (see sidebar). These events result from brain hypoxia, with progressive hypoxia thought to precede the cessation of cardiac output.
This has important implications for CPR, as current CPR recommendations focus on a compression-only method, which would not be beneficial for those in whom reoxygenation is essential. Therefore, rescue breaths in addition to high-quality chest compressions are preferable in the resuscitation of patients with opioid-associated out-of-hospital cardiac arrest.
The role of naloxone is also discussed for these patients.
Interventions at discharge and beyond
Dezfulian discussed the various ways pharmacists can take an active role in the care of patients after opioid-associated cardiac arrest. He noted that many patients with opioid use disorders lose their tolerance to the drug in the acute hospitalization period and are at an extremely high risk of dying after discharge if they misuse similar doses of opioids again. “Pharmacists should be aware of this ‘loss of tolerance’ and work with the care team at the time of discharge,” said Dezfulian.
Dezfulian suggested that pharmacists start the patient on an agent like buprenorphine and naloxone (Suboxone—Indivior) or methadone—although methadone is much less safe, according to Dezfulian—or refer the patient immediately to a substance abuse program.
Dispensing naloxone and training family members on its proper use is another intervention that pharmacists should consider, Dezfulian said.
In a section on increasing awareness of naloxone and its potential life-saving ability, the statement recommends that providers 1) determine whether their state permits pharmacists to prescribe naloxone or dispense it under a standing order (i.e., without a patient-specific order) or under a collaborative practice agreement; 2) prescribe naloxone to those who are at an increased risk of an opioid overdose and to their family and friends; and 3) determine whether naloxone is covered by insurance or is available at low or no cost to their patients.
Although no data exist on providing basic life support education to families of these patients (with an emphasis on the need to provide rescue breathing), this would be another reasonable intervention.
Pharmacists can also take an active role in identifying factors that increase a patient’s risk for opioid overdose, ensure providers are following guidelines for prescribing opioids, and make the most of prescription drug programs.