Opioid toxicity: Difference between revisions

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==Background==
==Background==
*Obtain acetaminophin levels in all cases of combination opioid-acetaminophen overdoses
[[File:2 milligrams of fentanyl on pencil tip. A lethal dose for most people. US Drug Enforcement Administration.jpg|thumb|A two milligram dose of fentanyl powder (on pencil tip).]]
*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
*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)<ref>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.</ref>
*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)<ref>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.</ref>
*Consider contributing to the DAWN database for public ED research benefit (Drug Abuse Warning Network)
*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.
*Other than common co-ingestions, consider adulterants such as amphetamines, anticholinergics, hypnotics, heavy metals, etc.
*In the year after an ED visit for an opioid overdose, greater than 5% die & greater than 19% will experience another opioid overdose. <ref>Davis, C., Carr, D., Glenn, M., & Samuels, E. (2021). Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder. Annals of Emergency Medicine, 78(1), 102–107. </ref>


==Clinical Features==
==Clinical Features==
===Common===
===Common===
*Miosis  
*Miosis  
*N/V
*[[Nausea/vomiting]]
*Respiratory depression
*Respiratory depression
*Mental status depression
*Mental status depression
===Uncommon===
===Uncommon===
*QT prolongation (methadone)
*[[QT prolongation]] ([[methadone]])
*Seizure (tramadol)
*[[Seizure]] ([[tramadol]])
*Acute lung injury
*Acute lung injury
*Bowel obstruction, rupture (body packers)
*[[Bowel obstruction]], rupture (body packers)
*Noncardiogenic pulmonary edema (1-2% of heroin overdoses)<ref>Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.</ref>
*[[Noncardiogenic pulmonary edema]] (1-2% of heroin overdoses)<ref>Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.</ref>
**Within 2-4 hrs of overdose
**Within 2-4 hrs of overdose
**Increased RR, cough, pink frothy sputum, CXR with b/l infiltrates
**Increased RR, cough, pink frothy sputum, CXR with bilateral infiltrates
**Resolves in 24-48 hrs with respiratory supportive care
**Resolves in 24-48 hrs with respiratory supportive care


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*Postictal state
*Postictal state
*[[CVA]] - pontine hemorrhage (miosis, coma)
*[[CVA]] - pontine hemorrhage (miosis, coma)
*ARDS
*[[ARDS]]
*DKA, hyperosmolar coma
*[[DKA]], [[hyperosmolar coma]]
{{Sedatve/hypnotic toxicity types}}
*Phencyclidine toxicity  
*Phencyclidine toxicity  
*Phenothiazine toxicity
*Phenothiazine toxicity
{{Sedatve/hypnotic toxicity types}}


==Treatment==
==Evaluation==
*Typically clinical
**Consider [[Utox]]
 
==Management==
===Airway protection and ventilatory management===
===Airway protection and ventilatory management===
*BVM and naloxone administration may prevent need for intubation
*BVM and naloxone administration may prevent need for intubation
===[[Naloxone]] (Narcan)===
===[[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)
''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====
====Dosing====
*If apneic or near-apneic - 2mg IV   
*If apneic or near-apneic - 2mg IV   
*If opioid-naive with minimal respiratory depression - 0.4mg IV
*If opioid-naive with minimal respiratory depression - 0.4mg IV
*If opioid-dependent with minimal respiratory depression - 0.05mg IV
*If opioid-dependent with minimal respiratory depression - 0.05mg IV ("push dose Narcan")
*Infusion
*Infusion
**Only give if the patient responded to the bolus and required repeat administration
**Only give if patient responded to the bolus and requiring repeat administration
**Step 1: Determine the "wake-up dose" or bolus required to wake the pt
**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
**Step 2: Give 2/3 of the "wake-up dose" per hr; mix in 1L D5W
====GI decontamination====
====GI decontamination====
*[[Activated charcoal]] x1 if opioid ingestion occurred within 1hr
*[[Activated charcoal]] x1 if opioid ingestion occurred within 1hr
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==Disposition==
==Disposition==
===Heroin intoxication===
===Heroin intoxication===
*Can consider discharge 1-2hr after naloxone administration if all are true:
*Can consider discharge 1-2hr<ref>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.</ref> after naloxone administration if all are true:
**Ambulatory without assistance
**Ambulatory without assistance
**O2 sat >92% (room air)
**O2 sat >92% (room air)
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**Normal temp
**Normal temp
**GCS 15
**GCS 15
===Non-heroin intoxication===
===Non-heroin intoxication===
*Consider discharge after 4-6hr obs
*Consider discharge after 4-6hr observation
*Consider discharge with prescription for [[Naloxone]] depending on your jurisdiction
*[[Methadone]] toxicity: observe for 12-24hr (longer half-life)
**Naloxone 2 mg/2 mL prefilled syringe and intranasal atomizer device with instructions: ''to spray one-half of syringe (1 mL) into each nostril upon signs of opioid overdose. May repeat X 1. Call 911.''
 
===Narcan Prescription===
===Narcan Prescription===
*Many states (31) offer protection again criminal liability for prescribing and distributing naloxone to laypeople
*Many states (31) offer protection again criminal liability for prescribing and distributing naloxone to laypeople
*A new California law requires providers to offer [[Naloxone]] autoinjector prescriptions to certain patients at risk for overdose
{| class="wikitable"
{| class="wikitable"
|-
|-
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| Kaleo || Autoinjector 0.4mg || $287.50
| 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'''<ref>ACEP Policy Statement. "Naloxone Prescriptions by Emergency Physicians." Approved by ACEP Board of Directors October 29, 2015.</ref>
*Discharged from the ED after opioid intoxication or poisoning
*Receiving high doses of opioids or undergoing chronic pain management
*Receiving rotating opioid medication regimens
*Having a legitimate need for analgesia combined with a history of substance abuse
*Using extended/long-acting opioid preparations
*Completing mandatory opioid detoxification or abstinence programs
*Recent release from incarceration and past abuser of opioids


==See Also==
==See Also==
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==External Links==
==External Links==
*[http://www.mdcalc.com/opioid-risk-tool-ort-for-narcotic-abuse/ MDCalc - Opioid Risk Tool (ORT) for Narcotic Abuse]
*[http://www.mdcalc.com/opioid-risk-tool-ort-for-narcotic-abuse/ MDCalc - Opioid Risk Tool (ORT) for Narcotic Abuse]
*[https://gallery.mailchimp.com/e35e5fa1ba46b6de2508eeb46/files/60d37229-1c34-4f56-91af-2bfceb71c0bc/3_Opioid_Safety_and_Naloxone_for_Patients.pdf?utm_source=CA+Providers+%28ED%2C+Hospitalists+%26+ICU%29+ICs%2BAPCs&utm_campaign=3a63f208f9-EMAIL_CAMPAIGN_2018_12_31_08_01&utm_medium=email&utm_term=0_4c468cb1a3-3a63f208f9-157631691 Narcan autoinjection instructions (English)]
*[https://gallery.mailchimp.com/e35e5fa1ba46b6de2508eeb46/files/0d8baa2d-7785-4304-8b1b-d2702f21954b/4_Opioid_Safety_and_Naloxone_for_Patients_Spanish.pdf?utm_source=CA+Providers+%28ED%2C+Hospitalists+%26+ICU%29+ICs%2BAPCs&utm_campaign=3a63f208f9-EMAIL_CAMPAIGN_2018_12_31_08_01&utm_medium=email&utm_term=0_4c468cb1a3-3a63f208f9-157631691 Narcan autoinjection instructions (Spanish)]


==References==
==References==

Latest revision as of 19:50, 24 April 2024

Background

A two milligram dose of fentanyl powder (on pencil tip).
  • 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.
  • In the year after an ED visit for an opioid overdose, greater than 5% die & greater than 19% will experience another opioid overdose. [2]

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 ("push dose Narcan")
  • Infusion
    • Only give if patient responded to the bolus and requiring 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[4] 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
  • A new California law requires providers to offer Naloxone autoinjector prescriptions to certain patients at risk for overdose
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[5]

  • Discharged from the ED after opioid intoxication or poisoning
  • Receiving high doses of opioids or undergoing chronic pain management
  • Receiving rotating opioid medication regimens
  • Having a legitimate need for analgesia combined with a history of substance abuse
  • Using extended/long-acting opioid preparations
  • Completing mandatory opioid 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. ↑ Davis, C., Carr, D., Glenn, M., & Samuels, E. (2021). Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder. Annals of Emergency Medicine, 78(1), 102–107.
  3. ↑ Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.
  4. ↑ 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.
  5. ↑ ACEP Policy Statement. "Naloxone Prescriptions by Emergency Physicians." Approved by ACEP Board of Directors October 29, 2015.
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