Opioid toxicity: Difference between revisions
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*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. | ||
==Clinical Features== | ==Clinical Features== | ||
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===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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**Deliver 1 spray to nostril upon signs of opioid overdose. May repeat X 1. Call 911. | **Deliver 1 spray to nostril upon signs of opioid overdose. May repeat X 1. Call 911. | ||
'''Indications'''<ref>ACEP Policy Statement. "Naloxone Prescriptions by | '''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 | *Discharged from the ED after opioid intoxication or poisoning | ||
*Receiving high doses of opioids or undergoing chronic pain management | *Receiving high doses of opioids or undergoing chronic pain management | ||
* | *Receiving rotating opioid medication regimens | ||
*Having a legitimate need for analgesia combined with history of substance abuse | *Having a legitimate need for analgesia combined with a history of substance abuse | ||
*Using extended/long-acting opioid preparations | *Using extended/long-acting opioid preparations | ||
*Completing mandatory | *Completing mandatory opioid detoxification or abstinence programs | ||
*Recent release from incarceration and past abuser of opioids | *Recent release from incarceration and past abuser of opioids | ||
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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== |
Revision as of 20:24, 22 January 2020
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
- 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)[2]
- 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
- Absinthe
- Barbiturates
- Benzodiazepines
- Chloral hydrate
- Gamma hydroxybutyrate (GHB)
- Baclofen toxicity
- Opioids
- Toxic alcohols
- Xylazine 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
- 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
- Activated charcoal x1 if opioid ingestion occurred within 1hr
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
- 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
- MDCalc - Opioid Risk Tool (ORT) for Narcotic Abuse
- Narcan autoinjection instructions (English)
- Narcan autoinjection instructions (Spanish)
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.
- ↑ 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.