Friday, October 15, 2010

Opioid Overdose Rescue: Can Hands-Only CPR Help?

Hands-Only CPRWith growing concerns about overdose deaths involving opioid analgesics, it is time for healthcare providers, patients, and family caregivers to assume greater responsibility for life-saving measures that might avert such tragedies. New research stresses the practicality and effectiveness of “Hands-Only CPR” but there may be questions about its appropriateness in opioid overdose. However, any CPR may be better than no CPR.

According to the most current data, in 2007 there were nearly 12,000 overdose deaths in the United States alone from opioid-analgesics; nearly twice the number for cocaine and more than 5 times the number involving heroin [CDC 2010]. The primary cause of such fatalities is respiratory depression due to adverse opioid effects leading to respiratory failure and cardiac arrest; survival depends on prompt action to resuscitate the victim.

For years, the standard for out-of-hospital resuscitation by laypersons (whether family, friends, or bystanders) has been chest compressions with rescue ventilation (called Cardiopulmonary Resuscitation or CPR), requiring mouth-to-mouth breathing plus rapid and forceful chest compressions. More recently, however, research has found that foregoing rescue breaths and doing only chest compressions — called “Chest-Compression-Only CPR” or, more commonly, “Hands-Only CPR” — offers comparable benefits in sustaining life until emergency personnel arrive.

Very recent studies and commentary published in the Journal of the American Medical Association (JAMA) [Bobrow et al. 2010; Cone 2010] and The Lancet [Hüpfl et al. 2010; Nolan and Soar 2010] confirm the practicality, importance, and effectiveness of Hands-Only CPR. Analyses of available data suggest that standard CPR and the Hands-Only approach produce at least similar outcomes in terms of ultimate survival. Moreover, Hands-Only CPR is easier for laypersons to learn and perform by simply following a “push hard, push fast, don’t stop” mantra. Consequently, this approach has been embraced by both the American Heart Association and the Red Cross.

There are some caveats worth considering…
  • Both forms of CPR have limitations and survival benefits are modest. The overall likelihood of survival-to-hospital-discharge reported in one study was 13.3% for Hands-Only CPR compared with 7.8% for standard CPR [Cone 2010]. A meta-analysis pooling data from 3,000 patients in randomized trials reported survival rates of 14% versus 12%, for Hands-Only versus standard CPR, respectively, while observational studies have shown mutually equivalent survival rates of 8% [Hüpfl et al. 2010].

  • In most analyses, Hands-Only CPR conferred a favorable absolute increase in survival, with an NNT=41 (ie, for every 41 patients treated with the new Hands-Only approach one additional life would be saved as compared with standard CPR).

  • Of importance for opioid overdose, the studies to date have excluded cases of cardiac arrest involving trauma, children, episodes secondary to drowning or asphyxiation, and cases with prolonged “downtimes” and depletion of oxygen stores. Extreme respiratory depression associated with opioid overdose might fit into the latter categories of asphyxiation or oxygen depletion; so, benefits of Hands-Only CPR compared with CPR that also provides rescue breathing in overdose situations has not been confirmed and might be questioned.

  • Editorialists in The Lancet noted that to deal with cases of cardiac arrest associated with oxygen depletion laypersons should continue to be trained in standard CPR. However, “any CPR is better than no CPR,” they emphasized. “Compression-only CPR has an important role in increasing the rate of bystander CPR by those who are untrained, who have only a minimum of time for training, or who are unwilling or unable to provide rescue breathing” [Nolan and Soar 2010].
Therefore, many otherwise fatal cases of opioid overdose might benefit from the timely application of Hands-Only CPR. This is especially important because many people are uncomfortable with giving rescue breaths even to a close family member (especially if there is vomiting) or they have not been trained in giving mouth-to-mouth ventilation. In many cases, even trained bystanders do not start standard CPR because they panic, or fear that they will cause harm, or do CPR incorrectly. However, the evidence suggests that bystander CPR is an important life-saving intervention and Hands-Only CPR can be easily learned and performed by almost anyone.

COMMENTARY: Our recent launch of the Opioids911-Safety website ( focuses on preventing opioid overdose in the first place and on what to do in emergency situations (see Resource listings below). Opioid overdose is not a sudden catastrophic event; that is, there usually are alerting signals of opioid overmedication followed by warning signs of overdose toxicity, particularly increased respiratory distress that may take hours to develop fully. Patients and family caregivers (or friends who may help to monitor patients) can learn to identify these adverse effects and take life-saving actions — if they are appropriately educated. Healthcare providers who prescribe opioids could and should be responsible for providing access to the necessary education; although, indications are that this is not a standard component of care in most clinical practices.

Furthermore, as we have noted previously [here], a more complete and effective solution for the prescription-opioid overdose crisis would include the widespread distribution of the antidote — naloxone — for at-home rescue. This antagonist drug, which reverses opioid effects, can be safely administered intranasally (without the hazards of needle-tipped syringes) by any family member or friend while awaiting arrival of emergency services personnel. More promptly administered naloxone, combined with CPR if there is cardiac arrest, could significantly increase the odds of surviving opioid overdose. Thus far, however, and for unknown reasons, there has been no interest in this expressed by federal or state government agencies or national organizations in the pain care community.

  • For a patient-information handout from — titled, “Overdose Emergency Procedures - What to Do Until Help Comes” — including CPR instructions [click here].

  • Further instructions on dealing with opioid-overdose emergencies, including where to get CPR training and information on Hands-Only CPR, are available at [here]

  • For an excellent video from Arizona Health Sciences Center on “Hands-Only CPR” [click here].

  • Listings of further information on naloxone for overdose rescue are available [here].
> Bobrow BJ, Spaite DW, Berg RA, et al. Chest Compression–Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest. JAMA. 2010;304(13):1447-1454. [
abstract here].
> CDC (Centers for Disease Control and Prevention). Unintentional Drug Poisoning in the United States. 2010(Jul) [
PDF available here].
> Cone DC. Compression-Only CPR: Pushing the Science Forward. JAMA. 2010;304(13):1493-1495. [
extract here]
> Hüpfl M, Selig HF, Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. The Lancet. 2010(Oct 15); online ahead of print [
abstract here]
> Nolan JP, Soar J. Dispatcher-assisted bystander CPR: a KISS for a kiss [comment]. The Lancet. 2010(Oct 15); online ahead of print [no summary abstract].