Case Definition: Opioids (Fentanyl, Etorphine, or Others)

Clinical description

Exposure to opioids typically occurs through ingestion but also can result from transdermal absorption, inhalation via aerosolization, or injection. Clinical effects of opioid poisoning result from central nervous system and respiratory system depression manifesting as lethargy or coma, decreased respiratory rate, miosis, bradypnea, and possibly apnea (1-3).

Laboratory criteria for diagnosis

• Biologic: A case in which opioids are detected in a biological fluid such as urine by hospital or commercial laboratory tests. Fentanyl derivatives and certain other synthetic and semi-synthetic opioids (e.g., oxycodone) might not be detected by routine toxicologic screens available in most hospitals. (1)

- OR-

• Environmental: Detection of opioids in environmental samples. (4-7)

Case classification

• Suspected: A case in which a potentially exposed person is being evaluated by health-care workers or public health officials for poisoning by a particular chemical agent, but no specific credible threat exists.
• Probable: A clinically compatible case in which a high index of suspicion (credible threat or patient history regarding location and time) exists for opioid exposure, or an epidemiologic link exists between this case and a laboratory-confirmed case.
• Confirmed: A clinically compatible case in which laboratory tests have confirmed exposure.

The case can be confirmed if laboratory testing was not performed because either a predominant amount of clinical and nonspecific laboratory evidence of a particular chemical was present or a 100% certainty of the etiology of the agent is known.

Additional resources

1. Nelson L, Olson D. Chapter 38: Opioids. In: Nelson LS, Lewin NA, Howland MA, Hoffman RS, Goldfrank LR, Flomenbaum NE, eds. Goldfrank's Toxicologic Emergencies. 9th ed. New York, NY: McGraw-Hill; 2011:559-74.
2. Sporer KA. Acute heroin overdose. Ann Intern Med 1999;130:584-90.
3. Boyer EW. Management of Opioid Analgesic Overdose. N Engl J Med. 2012 Jul 12; 367(2):146-55.
4. NIOSH. NIOSH manual of analytical methods [online]. 2003. [cited 2013 Apr 5]. Available from URL: http://www.cdc.gov/niosh/docs/2003-154/.
5. OSHA. Sampling and analytical methods [online]. 2010. [cited 2013 Apr 5]. Available from URL: http://www.osha.gov/dts/sltc/methods/index.html.
6. FDA. Food: Laboratory methods [online]. 2013. [cited 2013 Apr 5]. Available from URL: http://www.fda.gov/Food/FoodScienceResearch/LaboratoryMethods/default.htm.
7. EPA. Selected analytical methods: chemical methods query [online]. 2013. [cited 2013 Apr 5]. Available from URL: http://www.epa.gov/sam/searchchem.htm.