Opioid toxicity

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Background

  • Natural derivatives: Heroin, Morphine, Codeine, Hydrocodone, Oxycodone (+ UDS)
  • Synthetic: Fentanyl, Hydromorphone, Buprenorphine, Methadone, Meperidine, Dextromethorphan (- UDS)
  • Obtain acetaminophen levels in all cases of combination opioid-acetaminophen (Percocet) overdoses
  • Respiratory depression is the cause of all mortality from opioid toxicity
  • When prescribing opioid pain relievers in the ED, remember to have a discussion of co-ingestion of other depressants (alcohol involved in 1/5 of opioid related deaths)[1]
  • Consider contributing to the DAWN database for public ED research benefit (Drug Abuse Warning Network)
  • Other than common co-ingestions, consider adulterants such as amphetamines, anticholinergics, hypnotics, heavy metals, etc.

Clinical Features

Common

Uncommon

Differential Diagnosis

Sedative/hypnotic toxicity

Evaluation

  • Typically clinical

Management

Airway protection and ventilatory management

  • BVM and naloxone administration may prevent need for intubation

Naloxone (Narcan)

May repeat Naloxone q3min up to max dose 10mg. It has an almost immediate onset of action with a duration of action = 20-90min (depending on the drug ingested, most overdoses especially from heroin will require repeat dosing of Naloxone)

Dosing

  • If apneic or near-apneic - 2mg IV
  • If opioid-naive with minimal respiratory depression - 0.4mg IV
  • If opioid-dependent with minimal respiratory depression - 0.05mg IV
  • Infusion
    • Only give if the patient responded to the bolus and required repeat administration
    • Step 1: Determine the "wake-up dose" or bolus required to wake the patient
    • Step 2: Give 2/3 of the "wake-up dose" per hr; mix in 1L D5W

GI decontamination

Disposition

Heroin intoxication

  • Can consider discharge 1-2hr[3] after naloxone administration if all are true:
    • Ambulatory without assistance
    • O2 sat >92% (room air)
    • RR >10bpm
    • HR >50
    • Normal temp
    • GCS 15

Non-heroin intoxication

  • Consider discharge after 4-6hr observation
  • Methadone toxicity: observe for 12-24hr (longer half-life)

Narcan Prescription

  • Many states (31) offer protection again criminal liability for prescribing and distributing naloxone to laypeople
Manufacturer Route and Dose Cost/Dose
Adapt Pharma Prefilled IN 4mg $33
Amphastar Self-assemble IN 2mg $33
Hospira Self-assemble IM 0.4mg $15.83
Kaleo Autoinjector 0.4mg $287.50
  • Example Prescription
    • Naloxone 4mg/0.1mL prefilled syringe and intranasal atomizer device
    • Deliver 1 spray to nostril upon signs of opioid overdose. May repeat X 1. Call 911.

Indications[4]

  • Discharged from the ED after opioid intoxication or poisoning
  • Receiving high doses of opioids or undergoing chronic pain management
  • Recieving rotating opioid medication redgimens
  • Having a legitimate need for analgesia combined with history of substance abuse
  • Using extended/long-acting opioid preparations
  • Completing mandatory opiooid detoxification or abstinence programs
  • Recent release from incarceration and past abuser of opioids

See Also

External Links

References

  1. ↑ Jones CM, Paulozzi LJ, Mack KA. Alcohol Involvement in Opioid Pain Reliever and Benzodiazepine Drug Abuse–Related Emergency Department Visits and Drug-Related Deaths — United States, 2010. CDC MMWR. October 10, 2014 / 63(40);881-885.
  2. ↑ Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.
  3. ↑ Willman MW, Liss DB, Schwarz ES, and Mullins ME. Do heroin overdose patients require observation after receiving naloxone? Clin Toxicol (Phila). 2016; Nov 16:1-7.
  4. ↑ ACEP Policy Statement. "Naloxone Prescriptions by Emerency Physicians." Approved by ACEP Board of Directors October 29, 2015.
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