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Opiate Poisoning, Emergency Medicine

Basics

Description

- Bind to Ό, Ί, and ΄ opiate receptors in the CNS and peripheral nervous system (PNS) - Physical and psychological dependence occurs. - Peak plasma levels: - PO: 1 " 2 hr - Intramuscular: 0.5 " 1 hr - Intravenous or intranasal: Seconds to minutes

- GI: - Nausea - Vomiting - Constipation

- Cardiovascular: - Hypotension - Bradycardia - Palpitations

- Pulmonary: - Respiratory depression - Bronchospasm - Pulmonary edema - Apnea

- Neonatal withdrawal: - Infants born to addicted mothers - Onset: 12 " 72 hr after birth - Irritability, tremors, poor feeding, and dehydration

- Treat opiate withdrawal with clonidine or methadone. - Hypotension: - 0.9% normal saline IV fluid bolus - Trendelenburg test - Initiate dopamine for resistant hypotension.

  • Bind to Ό, Ί, and ΄ opiate receptors in the CNS and peripheral nervous system (PNS)
  • Physical and psychological dependence occurs.
  • Peak plasma levels:PO: 1 " 2 hrIntramuscular: 0.5 " 1 hrIntravenous or intranasal: Seconds to minutes

Etiology

  • Overuse or abuse of oral prescription analgesics for moderate to severe pain
  • Street preparations of opiate analogs may contain adulterants:CocaineClenbuterolPhencyclidineStrychnineDextromethorphanQuinineScopolamine

Diagnosis

Signs and Symptoms

  • CNS:CNS depressionComaSeizures
  • GI:NauseaVomitingConstipation
  • Cardiovascular:HypotensionBradycardiaPalpitations
  • Pulmonary:Respiratory depressionBronchospasmPulmonary edemaApnea
  • Other:
  • Withdrawal:HTNTachycardiaTachypneaAbdominal crampsDiarrheaPiloerectionYawning
  • Neonatal withdrawal:Infants born to addicted mothersOnset: 12 " 72 hr after birthIrritability, tremors, poor feeding, and dehydration
  • Diphenoxylate (Lomotil): Toxicity more severe in children than adults and may be fatal

Essential Workup

Monitor vital signs and pulmonary status with significant exposure:

  • Pulse oximetry or arterial blood gases
  • CXR if persistent hypoxia or possible aspiration
  • Abdominal radiograph if body packing suspected
  • Perform a complete exam for occult sticky patches (e.g., fentanyl).

Diagnosis Tests & Interpretation

Lab

  • Plasma opiate levels not clinically useful:Treatment based on clinical presentation, not opiate level
  • Urine toxicity screen for opiates may not identify some synthetic opioids (e.g., methadone).
  • Acetaminophen level for overuse or abuse of oral prescription analgesic products

Differential Diagnosis

  • Clonidine overdose
  • Barbiturate overdose
  • Benzodiazepine overdose
  • ³-hydroxybutyrate (GHB) overdose
  • Neuroleptic overdose
  • Occult head injury

Treatment

Pre-Hospital

  • Transport all pills/pill bottles involved in overdose for identification in ED.
  • Provide respiratory support.
  • Administer naloxone.

Initial Stabilization/Therapy

  • Check ABCs:Airway control is essential.Administer supplemental oxygen.
  • Administer naloxone:Reverses respiratory depression and coma in opiate overdosesIntubate if naloxone does not reverse respiratory depression.

Ed Treatment/Procedures

  • Naloxone administration:Start with low doses for opiate-habituated patients.High doses (10 mg) may be required to reverse the effects of propoxyphene, methadone, and fentanyl.Administer repeated doses that reversed symptoms, as needed every 20 " 60 min.For long-acting opioids, consider an hourly infusion of 2/3 of the dose needed to reverse symptoms.
  • Decontamination:Administer activated charcoal for oral ingestion.Administer whole-bowel irrigation with polyethylene glycol for asymptomatic body packers.
  • Treat opiate withdrawal with clonidine or methadone.
  • Hypotension:0.9% normal saline IV fluid bolusTrendelenburg testInitiate dopamine for resistant hypotension.
  • Seizures:Treat initially with diazepam.Administer phenobarbital for persistent seizures.

Medication

  • Activated charcoal: 1 " 2 g/kg PO
  • Clonidine: 0.1 " 0.3 mg PO BID for 10 days; 0.1 " 0.2 mg/kg/d transdermal patch
  • Diazepam: 5 " 10 mg IV (peds: 0.2 " 0.5 mg/kg IV) q10 " 15min
  • Dopamine: 2 " 20 Ό/kg/min; titrate to effect.
  • Methadone: 15 " 40 mg/d
  • Naloxone: 0.4 " 2 mg (peds: 0.1 mg/kg; neonate dose same as peds except if suspect neonatal withdrawal use 0.001 mg/kg IV) IV, IM, or nebulized
  • Phenobarbital: 10 " 20 mg/kg IV (loading dose); monitor for respiratory depression
  • Polyethylene glycol: 2 L/h until clear rectal effluent and/or passage of packets

Opioid patches can be abused in various ways (transdermally, orally, smoked, injected). Even used patches still contain a significant dose of drug.

Follow-Up

Disposition

Admission Criteria

  • Symptomatic after oral overdose
  • Repeated naloxone dosing or infusion needed to reverse symptoms
  • Children <5 yr after diphenoxylate ingestion should be observed for 24 hr.
  • Opiate body packers
  • Persistent symptoms from concomitant toxin exposure (e.g., clenbuterol)

Discharge Criteria

  • Asymptomatic 6 hr after oral overdose
  • Asymptomatic 4 hr after naloxone administration
  • Complete elimination of opiate packets

Follow-Up Recommendations

  • Substance abuse referral for patients with oral opiate abuse.
  • Patients with unintentional (accidental) poisoning require poison prevention counseling.
  • Patients with intentional (e.g., suicide) poisoning require psychiatric evaluation.

Pearls and Pitfalls

  • Consider occult acetaminophen poisoning in chronic oral opioid " abusing patients.
  • Buprenorphine may cause prolonged sedation in pediatric patients.
  • Semisynthetic and synthetic opioids will not provide a positive opiate hospital drug screen result.

Additional Reading

  • Bailey JE, Campagna E, Dart RC. The underrecognized toll of prescription opioid abuse on young children. Ann Emerg Med. 2009;53(4):419 " 424.
  • Centers for Disease Control and Prevention (CDC). Vital signs: Overdoses of prescription opioid pain relievers " United States, 1999 " 2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487 " 1492.
  • Enteen L, Bauer J, McLean R, et al. Overdose prevention and naloxone prescription for opioid users in San Francisco. J Urban Health. 2010;87(6):931 " 941.
  • Hoffman RS, Kirrane BM, Marcus SM, et al. A descriptive study of an outbreak of clenbuterol-containing heroin. Ann Emerg Med. 2008;52(5):548 " 553.
  • Weber JM, Tataris KL, Hoffman JD, et al. Can nebulized naloxone be used safely and effectively by emergency medical services for suspected opioid overdose? Prehosp Emerg Care. 2012;16(2):289 " 292.

Codes

ICD9

  • 965.00 Poisoning by opium (alkaloids), unspecified
  • 965.01 Poisoning by heroin
  • 965.02 Poisoning by methadone
  • 965.09 Poisoning by other opiates and related narcotics
  • 965.0 Poisoning by opiates and related narcotics

ICD10

  • T40.1X1A Poisoning by heroin, accidental (unintentional), init encntr
  • T40.3X1A Poisoning by methadone, accidental (unintentional), init
  • T40.601A Poisoning by unsp narcotics, accidental, init
  • T40.4X1D Poisoning by oth synthetic narcotics, accidental, subs
  • F11.23 Opioid dependence with withdrawal

SNOMED

  • 11196001 Poisoning by opiate AND/OR related narcotic (disorder)
  • 60199004 Poisoning by methadone (disorder)
  • 13187008 Poisoning by heroin (disorder)
  • 290201006 Fentanyl poisoning (disorder)
  • 87132004 Opioid withdrawal (disorder)