Overdose Survivors: Medical and Addiction Challenges

Many people assume that most individuals addicted to opioids are young or middle-aged, and generally, they’re right. But there’s also a significant population of 65+ addicted adults, reported by the Wall Street Journal. Alcohol use disorder (AUD) is the most common substance use disorder (SUD) in this group, followed by prescription drug abuse (primarily opioids and benzodiazepines). The reporter interviewed Jerry S., who started heroin at age 15 and has experienced five decades of illicit drug use, crime to support his drug use, and emotional pain from the overdose losses of friends. Jerry’s multi-decade polydrug use compromised his liver, lungs, teeth, and health as he dodged treatment and sobriety. He is one of 2 million people ages 65+ addicted to drugs. Many have survived multiple overdoses and now experience life-compromising consequences of their addiction.

In this post, we look at potential consequences of overdoses and missed opportunities for change, as well as treatments known to work, such as medication-assisted treatment (MAT), and key reasons for refusing treatment or MAT.

Surviving overdose is a major sentinel event with significant short- and long-term consequences, depending on the substance involved, severity of the overdose, and timeliness and effectiveness of medical intervention. Sometimes, an overdose is sufficiently life-changing to motivate someone to enter treatment for opioid use disorder (OUD), take MAT, and change their lives. Most times, however, it is a lost opportunity, and overdoses and addiction continue.

Acute Effects of Overdose

Neurological damage is typical in overdoses but rarely evaluated the same way as traumatic brain injury or stroke. For example, opioid overdose with loss of consciousness and depressed respiration can mean severe oxygen deprivation (hypoxia). This can result in cognitive impairments, memory problems, or permanent brain injury-related disability. Stroke or seizures may also occur during overdose, especially when cocaine or amphetamines are involved. Survivors also may develop pneumonia, pulmonary edema, or long-term respiratory dysfunction. Cardiovascular damage may occur, mainly if associated with speedballing (taking a depressant and a stimulant at the same time) or a sole stimulant. Psychostimulants may cause arrhythmias, heart attacks, stroke, or chronic cardiovascular disease. Overdoses also can lead to kidney or liver failure, sometimes requiring long-term dialysis or transplantation.

Long-Term Consequences of Overdoses

Physical injuries sustained during the overdose, such as fractures, head injuries, or burns, may cause long-term disabilities. Other injuries may cause chronic pain.

Many overdose survivors face long-term health issues, including liver disease, endocarditis (heart infection acquired by intravenous use), depression, and PTSD. Most overdoses contribute to cognitive decline and accelerate age-related memory problems. Brain damage from repeated overdoses can lead to ongoing difficulties with attention, decision-making, and emotional regulation.

Risks for More Overdoses

One study showed that five years later, up to 40% of individuals who overdosed experienced one or more overdoses. Each subsequent overdose has a higher likelihood of being fatal. Individuals who began medication-assisted treatment with buprenorphine, methadone, or naltrexone have significantly better outcomes. However, only 20-50% of the patients continue MAT treatment. Relapses are common without continuous support and treatment, especially the first year after an overdose.

Experts believe 5-15% of people who overdose die within five years since mortality rates for opioid overdose survivors are higher than the general population. Death results from repeated overdoses, suicide, accidents, and infections (endocarditis, HIV, hepatitis C).

Estimates of What Happens to 100 Opioid Overdose Survivors of All Ages

When 100 overdose survivors are considered, the following estimated numbers are affected:

• 20-30 engage in treatment, and many achieve sustained recovery. Some slip or relapse. They reintegrate into society with improved health/quality of life.

• 30-40 experience another overdose. Most survive but remain at high risk without intervention.

• 10-15 die prematurely: Overdose and health complications are the leading causes.

• 15-25 struggle with chronic relapsing addiction.

Treatment works but should be timely and include access to MAT and treatment of other medical and psychiatric diseases. Many factors contribute to relapses, such as poverty, homelessness, unemployment, chronic pain, and stigma against people addicted to drugs, perpetuating cycles of substance use and continued vulnerability. Taking MATs reduces death rates by up to 70% compared to the untreated. Methadone has the best record for treatment retention.

Family, community support, NA, AA, 12-step meetings, and availability of naloxone or nalmefene (opioid reversal agents) are all protective factors that improve outcomes significantly.

Expanding Use of Injectables

Aside from methadone maintenance, one pharmacological solution to reducing risks of further overdoses is using long-acting injectable forms of MAT, such as buprenorphine (Sublocade, Brixadi). For example, using monthly Sublocade, rather than daily oral buprenorphine, has the potential for greater efficacy compared to patients having to remember and comply with taking daily medications. Brixadi is another extended-release buprenorphine injection and is administered weekly or monthly.

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Studies show patients receiving long-acting injectables are likelier to adhere to treatment compared to those taking daily oral medications. Long-acting formulations also provide steady medication levels, avoiding dosage peaks and troughs associated with daily oral dosing. This form reduces withdrawal symptoms and cravings, improving overall stability. Monthly injections simplify treatment for patients with chaotic lifestyles who may struggle with daily routines. Some studies suggest higher retention rates in MAT programs with long-acting formulations compared to oral alternatives. We have used long-acting naltrexone (Vivitrol), especially with physicians with addiction and selected patients with alcohol and opioid use disorders.

One problem with injectable MAT is cost. It is more expensive than oral formulations. For example, Sublocade costs approximately $1,600–$2,000 per monthly dose. Insurance reimbursement is another challenge for injectables. In contrast, oral suboxone or methadone are reimbursed by private insurance, Medicaid, and Medicare.

Clinics and providers must purchase and then store (such as refrigerate) injectable medication. This makes injectables less convenient for clinics compared to oral options. In addition, both patients and providers may be unaware of the availability and benefits of injectable MAT. Some patients fear injections or prefer to self-administer oral medications.

One suggestion to expand the use of injectables is to increase coverage by Medicaid, Medicare, and other insurance. For example, policy changes could mandate coverage of injectable MAT without prior authorization. Another solution is to prove there are better 5-year outcomes compared to daily buprenorphine, which could help convince insurance companies to pay.

Summary

Surviving an overdose is a critical time for intervention, whether the patient is 18 or 70. It is an emergency and teachable moment ideal for an organized intervention, education, and treatment initiation ASAP. I recommend giving patients and their loved ones take-home naloxone or nalmefene to prevent future opioid overdose fatalities and also to start the patient on MAT treatment. MAT treatment with oral buprenorphine or methadone works equally well to reduce mortality, but more patients discontinue buprenorphine. Injectable buprenorphine may help improve results. Medical professionals should also evaluate and treat the whole person for other illnesses and disorders.