Opioid toxicity

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

Miosis
Nausea/vomiting
Respiratory depression
Mental status depression

Uncommon

QT prolongation (methadone)
Seizure (tramadol)
Acute lung injury
Bowel obstruction, rupture (body packers)
Noncardiogenic pulmonary edema (1-2% of heroin overdoses)^[3]
- Within 2-4 hrs of overdose
- Increased RR, cough, pink frothy sputum, CXR with bilateral infiltrates
- Resolves in 24-48 hrs with respiratory supportive care

Differential Diagnosis

Clonidine toxicity
Organophosphate toxicity
CO poisoning
Hypoglycemia
Postictal state
CVA - pontine hemorrhage (miosis, coma)
ARDS
DKA, hyperosmolar coma
Phencyclidine toxicity
Phenothiazine toxicity

Sedative/hypnotic toxicity

Evaluation

Typically clinical
- Consider Utox

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

Activated charcoal x1 if opioid ingestion occurred within 1hr

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

External Links

References

↑ 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.
↑ 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.
↑ Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.
↑ 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.
↑ ACEP Policy Statement. "Naloxone Prescriptions by Emergency Physicians." Approved by ACEP Board of Directors October 29, 2015.

Authors:

[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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