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Conversations with Iranian toxicology nurses about care of patients with methadone overdoses

Nurses working in toxicological emergency department, wards and ICUs

Location: Loghman-Hakim Hospital Tehran, Iran

Date: September 2021

Nurses’ wards:  

SectionMean ± SD age (yrs)Mean± SD experience (yrs)Estimated annual methadone overdose cases
Toxicological emerg dept nurses (8)36± 810±92,100±1,590
Toxicological ward nurses (7)37± 712±62,240±1,220
Toxicological ICU nurses (17)34± 410±5675±250
All nurses (32)35± 610±51,590±1,320

Key question points and summary of findings:

  1. Problems using naloxone for opioid overdose patients:

Nurses reported their experience using naloxone for opioid dependent patients who overdose:

  • ED nurses: 50% of nurses said naloxone is an acceptable antidote, while 37% found it a challenging medication because patients needed a lot of attention, and threats to nurses were common (due to withdrawal). A nurse explicitly said it is perfect for naïve patients and challenging for opioid dependents.
  • Ward nurses: more than half of the nurses said it’s a difficult antidote because of the withdrawal it may induce and the apnea that may occur if the infusions is stopped. Again, one nurse noted that she was happy using it for non-dependent patients.
  •  ICU nurses: Almost half of nurses were happy using naloxone in ICU setting. 30% pointed to administration challenges for dependent patients. About 25% thought it a difficult antidote for intubated patients in ICU, due to agitation and general difficulty in managing patients. 

2. Annual number of methadone cases compared to the past: Estimations regarding the number of methadone overdose cases cared for each year varied by ward area (see estimated annual case load in table). Most nurses believed that the case number had increased dramatically over the previous 5 years; only one nurse reported no difference in case number.  Four nurses were new employees and did not know the trend of methadone overdose case load.

3. Causes of methadone overdose: there was a wide range of opinion on the causes of overdose from a nursing perspective. Some nurses elaborate more than one reason:

  • Easy access to methadone (63% of nurses)
  • Low education (20% of nurses)
  • High level of addiction in the society (16% of nurses)
  • Sale by herbal stores (16% of nurses)
  • Offered by peers (12% of nurses)
  • Release from MMT clinics (12% of nurses)
  • Socioeconomical problems (12% of nurses)
  • High demand for detoxification and further withdrawal that may cause overdose (6% of nurses)
  • Poverty (6% of nurses)
  • Low cost of methadone (6% of nurses)
  • Active black market (6% of nurses)
  • Easy use of methadone (6% of nurses)
  • Mental health problems (3% of nurses)
  • Lack of job (3% of nurses)
  • Euphoria (3% of nurses)
  • Low number of referral to MMT clinics (3% of nurses)
  • Expensive access to distracting pleasurable activities (3% of nurses)
  • Low welfare facilities (3% of nurses)
  • Mistake due to lack of color and odor in methadone syrup (3% of nurses)
  • Familial conflicts (3% of nurses)
  • Withdrawal states (3% of nurses)

    4. Reported issues in care of methadone overdose cases with naloxone: the experiences of nurses were different based on their work location.
  • Cardiac ischemic events and even cardiac arrest (in older patients; mostly reported by ICU nurses) (28%)
  • Withdrawal syndrome (20%)
  • Apnea due to short half-life of naloxone (reported by ED and ward nurses) (20%)
  • Long tapering duration of naloxone infusion (ward nurses) (12%)
  • Difficult i.v. access (a nurse in ICU)
  • Not enough monitoring (two nurses in ICU)

    5. Increasing the capacity of care for better service of opioid overdose cases:
  • Dedicated specific wards/ICUs for care of drug overdose cases (47%)
  • Recruiting experienced nurses (31%)
  • Accessing more monitors and ventilators (31%)
  • Recruiting more nurses (16%)
  • More beds (13%)
  • Educational program for potential patients (6%)
  • MMT services (3%)

    6. Advantages and disadvantages of buprenorphine versus naloxone antidotes:Nine nurses had been involved in a trial of buprenorphine versus naloxone and had opinions on the advantages and disadvantages of buprenorphine. The main advantages were:
  • Long-acting duration of BUP compared to naloxone (78%)
  • Shorter hospital stay (67%)
  • Less withdrawal syndrome compared to naloxone (44%)
  • More security/safety for staff (due to less withdrawal) (33%)
  • Lower mortality rate compared to naloxone (22%)
  • Lower cost of treatment (11%)
  • Rapid reversal of BUP (11%)

The main disadvantage reported (4 nurses) was the lack of a complete response in some methadone overdose patients.

7. Recommendations for further implementation of buprenorphine in our setting:

  • Greater availability of buprenorphine as a therapeutic option (56%)
  • Need to identify rescue therapies if buprenorphine does not reverse the patient’s overdose (33%)
  • Need to identify maintenances dose regimens of buprenorphine (not just one bolus loading doses; 11%)