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Prevention of Opioids-Involved Overdose Deaths among adults 18-64 y.o. in Maryland

Prevention of Opioids-Involved Overdose Deaths among adults 18-64 y.o. in Maryland

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Prevention of Opioids-Involved Overdose Deaths among adults 18-64 y.o. in Maryland


Opioids are a class of natural or synthetic drugs that are used to manage moderate to severe pain in the acute care setting or through long-term treatment. However, these drugs have serious and potentially life-threatening health risks and adverse effects. An estimated 200 million prescriptions of opioid analgesics are dispensed to patients in the United States every year. Opioid drugs that are commonly prescribed to manage pain include:

  • Oxycodone
  • Morphine
  • Hydrocodone
  • Methadone
  • Buprenorphine
  • Codeine (CDC, 2020).

Fentanyl is a synthetic opioid analgesic that has superior pain-relieving effects compared to other opioids and is more effective in the management of severe pain. Illicit injectable analogs of the drug, such as alpha-Methyl fentanyl and 3-Methylfentanyl, are produced and distributed in various parts of the U.S. Tramadol is an opiate medication that acts through a similar mechanism as opioids (Schiller & Mechanic, 2019). On the other hand, some substances like heroin are illicit opioid drugs and are mainly used recreationally (CDC, 2020).

Prescription opioids are commonly prescribed to reduce pain after surgery or severe injury. The drugs are also used to manage chronic cancer pain to improve patients’ quality of life. Fentanyl is particularly useful in the treatment of severe cancer pain. Similarly, opioid analgesics are also prescribed for the management of chronic non-cancer pain, including chronic back pain and debilitating pain associated with musculoskeletal disorders such as osteoarthritis (CDC, 2020). One out of five patients with non-cancer pain receives an opioid prescription (Maryland Department of Health, 2020).

Opioids have major side effects, such as a significantly high potential for addiction and abuse, which precipitate opioid use disorder. However, opioid overdose and overdose death are by far the most serious side effects of opioid drugs. Long-term opioid therapy and opioid use disorder increase the potential for opioid overdose (Babu et al., 2019).

Opioid Overdose Landscape in the U.S.

The opioid overdose death epidemic in the U.S. has worsened in recent years, with a three-fold increase in the incidence of fatal and non-fatal opioid overdose in the last decade only (Chen et al., 2019).

The number of deaths due to opioid overdose increased four times between 1999 and 2018, with a total of 450,000 deaths between the two years.

Out of more than 67,000 drug overdose deaths in the U.S. in 2018, 70% of the deaths were opioid-related (CDC, 2020).

Between 2015 and 2018, opioid overdose deaths caused by synthetic opioids, particularly fentanyl, increased significantly (Scholl et al., 2019).

Notably, illicit opioids, including heroin and illegally produced fentanyl analogs, cause the majority of opioid overdose deaths.

Out of the nearly 12,000 opioid overdose deaths that occurred between July 2016 and July 2017, 58.7% of the deaths resulted from illicit opioids (Mattson et al., 2018).

Co-administration or co-ingestion of other psychotropic drugs is associated with an increased risk of fatal opioid overdose

(Lyons et al., 2017).

Benzodiazepines such as Diazepam have been linked to more than 51% of prescription opioid deaths. Gabapentin contributes to nearly 22% of prescription opioid deaths. Similarly, Cocaine contributes to nearly 35% of deaths due to prescription and illicit opioid overdose (Mattson et al., 2018).

Opioid Overdose Landscape in Maryland

In 2018, Maryland was among 6 U.S. states with the highest age-adjusted rates of drug-overdose deaths, with a death rate of 37.2% (Hedegaard et al., 2020).

There were 2143 opioid-related deaths in Maryland in 2018, compared to 504 in 2010. Fentanyl-related overdose deaths have rapidly driven the opioid death epidemic in Maryland since 2010. Increased use of synthetic fentanyl in Maryland has resulted from decreased accessibility of prescription opioids due to strict regulation.

Deaths due to fentanyl increased from 39 deaths in 2010 to 1888 deaths in 2018 (Maryland Department of Health, 2020).

Although prescription opioid-related deaths in Maryland decreased from 413 in 2017 to 379 in 2018, the opioid prescribing rate in the state was 45.1 per 100 providers in 2018, indicating increased exposure of State residents to the risk of opioid overdose (CDC, 2020; Maryland Department of Health, 2020).

Individuals over the age of 25 represented more than 94% of the opioid-related deaths in the state in 2018, with the highest proportion of deaths occurring among individuals over the age of 45.

Similarly, Baltimore city reports the highest opioid overdose death rate, with 1172 overdose deaths reported in the city in 2018 (Maryland Department of Health, 2020).

Opioid overdose deaths commonly occur among individuals with a known history of opioid use disorder or a previous history of non-fatal overdose.

Additionally, the majority of overdose deaths occur in the home setting (CDC, 2020; Schiller & Mechanic, 2019)).

Causes of Opioid Overdose

  • Unintentional opioid overdose typically involving prescription opioids.
  • Intentional opioid overdose associated with mental illnesses such as depression.
  • Medication errors usually in the hospital setting.
  • Complications of opioid use disorder (Schiller & Mechanic, 2019).

Increased risk of opioid overdose can result from:

  • Escalation of the usual dose of a prescribed opioid.
  • Reinstitution of opioid use after discontinuing use.
  • Mental illness
  • Concurrent use of opioids and sedative drugs such as Diazepam (Schiller & Mechanic, 2019).

Signs of Opioid Overdose

Opioid overdose should be suspected in an individual who is known to be using prescription or non-prescription opioids and is manifesting the following signs:

  • Signs of altered level of consciousness, such as sleepiness or unresponsiveness, indicating depression of the central nervous system.
  • Slow and shallow pattern of breathing indicating respiratory depression.
  • Limp body with absent spontaneous movement (CDC, 2020; Schiller & Mechanic, 2019).
  • Small and constricted pupils. This sign may be absent in some individuals (Schiller & Mechanic, 2019).
  • Lethargy or euphoria (Schiller & Mechanic, 2019).
  • Signs of choking.
  • Abnormal sounds, such as gurgling or snoring noises (CDC, 2020).
  • Cold, pale, and blue appearance of the skin.
  • Needles track marks on the skin.
  • Patch marks suggesting the use of patch formulations such as fentanyl (Schiller & Mechanic, 2019).

Opioid Overdose and Overdose-death Prevention

Reducing the risk of overdose following initial therapy

The risk of opioid overdose begins with the first episode of exposure to an opioid drug, whether through medical prescription or recreational experimentation (Babu et al., 2019). Prevention of opioid overdose, therefore, begins with curbing the risk of development of opioid use disorder through:

  • Limiting the initial opioid regimen. This involves limitation of the degree of initial exposure through restriction of the dose of the opioid and the duration of use during new opioid use.
  • Initial risk assessment. This involves identifying factors that may predispose an individual to overdose following opioid initiation, such as concurrent use of other medications such as benzodiazepine and a history of substance dependence, followed by careful monitoring.
  • Encouraging the disposal of unused doses of a prescribed opioid. Surplus doses of prescribed opioids increase the risk of overdose by encouraging the diversion of drug use (Babu et al., 2019).

Reducing the risk of overdose during long-term therapy

  • Avoiding the escalation of the current regular dose of the prescription opioid. Fatal opioid overdose risk is dose-dependent.
  • Tapering high-dose prescriptions. Gradual reduction of the opioid dose reduces the dose-dependent risk of overdose.
  • Limiting the use of concurrent medications such as sedatives.
  • Co-prescription of opioid-overdose reversal agents such as Naloxone. This is particularly useful when managing chronic pain using opioid analgesics (Babu et al., 2019).

Treatment of overdose and opioid use disorder

  • Early suspicion and recognition, followed by early administration of reversal agents such as Naloxone (Schiller & Mechanic, 2019).
  • Methadone and buprenorphine treatment programs for individuals with an established opioid use disorder. Involves detoxification and maintenance treatment phases.
  • Extended-release naltrexone regimen as an alternative treatment for opioid use disorder (Babu et al., 2019).

Primary Care and Community Interventions   

  • Community naloxone-distribution programs. Bystander and community-organization-based distribution programs for reversal agents enable immediate intervention to reverse a non-fatal overdose before it becomes fatal (Babu et al., 2019).
  • Community training and health education programs on the risk factors and signs of opioid overdose to encourage early recognition and intervention before the overdose causes death.
  • Screening for opioid use disorders during primary care visits to enhance the detection of opioid dependence.
  • Reducing restrictions on the accessibility of reversal agents and drugs for opioid use disorder, such as Naloxone and buprenorphine (Chen et al., 2019). This can be achieved through the introduction of standing orders at supply stores and increasing access to the agents by frontline responders such as law enforcement and emergency response personnel (CDC, 2020).
  • Harm reduction interventions for high-risk individuals such as supervised injection programs, reduction of needle sharing, and increased regulation of public opioid use (Babu et al., 2019).
  • Institution of measures to control the supply of illegally produced opioids such as fentanyl analogs (Chen et al., 2019).


Babu, K. M., Brent, J., & Juurlink, D. N. (2019). Prevention of Opioid Overdose. New England Journal of Medicine, 2246-2255.

CDC. (2020, June 10). Opioid Overdose. Retrieved from Centers for Disease Control and Prevention:

CDC. (2020, June 10). Prescription Opioids. Retrieved from Centers for Disease Control:

Chen et al. (2019). Prevention of prescription opioid misuse and projected overdose deaths in the United States. JAMA network open, e187621-e187621.

Hedegaard, H., Miniño, A. M., & Warner, M. (2020, June 10). Drug Overdose Deaths in the United States, 1999–2018. Hyattsville, MD: National Center for Health Statistics. Retrieved from Centers for Disease Control and Prevention:

Lyons et al. (2017). Association between opioid and benzodiazepine use and clinical deterioration in ward patients. Journal of hospital medicine.

Maryland Department of Health. (2020, June 10). Opioid Overdose Landscape. Retrieved from Maryland Department of Health:

Mattson, C. L., O’Donnell, J., Kariisa, M., Seth, P., Scholl, L., & Gladden, R. M. (2018). Opportunities to prevent overdose deaths involving prescription and illicit opioids, 11 states, July 2016–June 2017. Morbidity and Mortality Weekly Report, 945.

Schiller, E. Y., & Mechanic, O. J. (2019). Opioid overdose. In StatPearls. StatPearls Publishing.

Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G. (2019). Drug and opioid-involved overdose deaths—United States, 2013–2017. Morbidity and Mortality Weekly Report, 1419.


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Prevention of Opioids-Involved Overdose Deaths among adults 18-64 y.o. in Maryland

This should be an educational material for patients in the primary care office. The format is a brochure. Inside the paper, the bullet points can be made to emphasize the important things and facilitate reading. The writing has to contain facts about the disease (prescribed and non-prescribed opioids overdose), symptoms, and prophylaxis; the context should be understandable for patients. The sources may include CDC, Maryland local healthcare department, and article materials to prove the facts. 1-2 charts/graphs are preferable to visualize the material. 2-3 sources are enough.

Prevention of Opioids-Involved Overdose Deaths among adults 18-64 y.o. in Maryland

Prevention of Opioids-Involved Overdose Deaths among adults 18-64 y.o. in Maryland

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