Opioid toxicity: Difference between revisions

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==Background==
==Background==
*Obtain acetaminophin levels in all cases of combination opioid-acetaminophen overdoses
*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>
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==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


==Differential Diagnosis==
==Differential Diagnosis==
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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}}
==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
*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


==Treatment==
====GI decontamination====
#Airway protection and ventilatory management
*[[Activated charcoal]] x1 if opioid ingestion occurred within 1hr
#*BVM and naloxone administration may prevent need for intubation
#[[Naloxone]] (Narcan)
#*Bolus (May repeat q3min up to max dose 10mg
#**Apneic or near-apneic - 2mg IV 
#**Opioid-naive with minimal respiratory depression - 0.4mg IV
#**Opioid-dependent with minimal respiratory depression - 0.05mg IV
#**Almost immediate onset of action
#**Duration of action = 20-90min ('''may be less than that of the ingested opioid''')
#*Infusion
#**Only give if the pt responded to the bolus and required repeat administration
#**Step 1: Determine the "wake-up dose" or bolus required to wake the pt
#**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==
==Disposition==
#Heroin intoxication:
===Heroin intoxication===
##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:
###Independent mobility
**Ambulatory without assistance
###O2 sat >92% (room air)
**O2 sat >92% (room air)
###RR >10bpm
**RR >10bpm
###HR >50
**HR >50
###Normal temp
**Normal temp
###GCS 15
**GCS 15
#Non-heroin intoxication:
 
##Consider discharge after 4-6hr obs
===Non-heroin intoxication===
#Consider discharge with Rx for [[Naloxone]]
*Consider discharge after 4-6hr observation
#*Naloxone 2 mg/2 mL prefilled syringe and intranasal atomizer device<br/>#2 each<br/>Spray one-half of syringe (1 mL) into each nostril upon signs of opioid overdose. May repeat X 1. Call 911.
*[[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
 
{| class="wikitable"
|-
! 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'''<ref>ACEP Policy Statement. "Naloxone Prescriptions by Emerency 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
*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==
==See Also==
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==External Links==
==External Links==
*[http://www.mdcalc.com/opioid-risk-tool-ort-for-narcotic-abuse/ MDCalc - Opiod 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)]


==Source==
==References==
<references/>
<references/>


[[Category:Tox]]
[[Category:Toxicology]]

Revision as of 21:27, 31 December 2018

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
  • 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[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.