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

Etiology

Overuse or abuse of oral prescription analgesics for moderate to severe pain
Street preparations of opiate analogs may contain adulterants:
- Cocaine
- Clenbuterol
- Phencyclidine
- Strychnine
- Dextromethorphan
- Quinine
- Scopolamine

Diagnosis

Signs and Symptoms

CNS:
- CNS depression
- Coma
- Seizures
GI:
- Nausea
- Vomiting
- Constipation
Cardiovascular:
- Hypotension
- Bradycardia
- Palpitations
Pulmonary:
- Respiratory depression
- Bronchospasm
- Pulmonary edema
- Apnea
Other:
- Miosis
- Hypothermia
Withdrawal:
- HTN
- Tachycardia
- Tachypnea
- Abdominal cramps
- Diarrhea
- Piloerection
- Yawning

Neonatal withdrawal:
- Infants born to addicted mothers
- Onset: 12 " 72 hr after birth
- Irritability, 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 overdoses
- Intubate 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 bolus
- Trendelenburg test
- Initiate 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)

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