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Narcotic Overdose
Aka: Narcotic Overdose, Opioid Overdose, Opiate Overdose, Narcotic Toxicity, Opioid Toxicity
- See Also
- Opioid
- Opioid Abuse
- Opioid Withdrawal
- Indications: Opioid Overdose management
- Respiratory Depression (Hypoxia, apnea)
- Severe sedation (e.g. comatose)
- Epidemiology
- Opioid Overdose is the leading cause of death in U.S. for those under age 50 years old
- Opioids have been implicated in 16,000 deaths per year in U.S. as of 2013
- (2015) MMWR Morb Mortal Wkly Rep 64(1): 32 [PubMed]
- Risk Factors
- Morphine Equivalents >50 mg/day doubles risk, contrasted with <20 mg/day (e.g. Hydrocodone 5 mg every 6 hours)
- Symptoms
- Constipation
- Nausea
- Vomiting
- Flushing
- Pruritus
- Findings: Symptoms and Signs
- Altered Level of Consciousness (CNS depression or sedation)
- Coma
- Lethargy
- Stupor
- Hypotension
- Miosis (except Demerol which causes Mydriasis)
- Pulmonary Edema
- Respiratory depression
- Seizures
- Precautions
- Close monitoring must be continued after antidote
- Opioid half-life might exceed that of Naloxone
- Consider Very Low Dose Naloxone Protocol
- Indicated for Cancer Pain or Chronic Pain (prevents severe Rebound Pain)
- Heroin and other Illicit Drugs are often adulterated with synthetic Opioids at inconsistent doses
- Fentanyl (most common)
- Alpha-methylfentanyl
- Carfentanil
- Differential Diagnosis: Suspected Opioid Overdose not reversing with Naloxone
- Clonidine Overdose
- Drugs of Abuse often have very high potency
- Krokodil (use Naloxone 2 mg)
- Fentanyl derivative (may require Naloxone up to 10 mg )
- Labs
- Toxicology labs
- See Toxin Ingestion
- Creatinine Phosphokinase (CPK)
- Risk of Rhabdomyolysis
- Diagnostics
- Electrocardiogram
- Certain Opioids (i.e. Methadone) will prolong QTc Interval
- Management: General
- Naloxone
- See doses below (or see Naloxone)
- Not indicated for a mentating patient with normal Vital Signs
- Indicated for hypoventilation <9 breaths/min or increased EtCO2
- Consider for long acting Opioids (Oxycontin, MS Contin, Methadone, Zohydro)
- Naloxone continuous infusion
- Nalmefene (Revex)
- Consider 1 or 2 Nasal Trumpets (Nasopharyngeal Airways)
- Monitoring
- EtCO2 and Oxygen Saturation
- Oxygen Saturation alone is insufficient
- Supplemental Oxygen can result in Apneic Oxygenation with normal O2Sat but rising carbon dioxide
- Observation Stay indications
- Young Children (age <5 years old)
- Long acting Opioid
- Intentional Overdose (and evaluate for psychiatric admission)
- Observe in Emergency Department for at least one hour (some prefer 4 hour observation)
- Naloxone effect lasts 45 minutes (opiod effects may last longer)
- Observe longer for long acting agents (e.g. Methadone) or suspected dual ingestion (e.g. with Fentanyl)
- Shorter observations may be safe with shorter acting agents (e.g. Heroin)
- Willman (2017) Clin Toxicol 55(2): 81-87 +PMID: 27849133 [PubMed]
- Management: Naloxone (Narcan)
- Adults
- Initial
- No respiratory depression: 0.1 to 0.4 mg IV or IM
- Respiratory depression: 1 to 2 mg IV or IM
- Alternative initial protocol
- Very Low Dose Naloxone Protocol (slow titration method)
- Prepare Naloxone 0.4 mg/ml ampule in 10 ml saline (0.04 mg/ml)
- Administer Naloxone in 0.02 to 0.04 mg (0.5 to 1 ml) increments
- Next, if no response or incomplete response (synthetic Opioids may require high Naloxone dose)
- Give 2 mg IV or IM every 3-5 minutes to a total of 10-20 mg
- Infusion
- Naloxone 2 mg in 500 ml D5W or NS (0.004 mg/ml) titrating to response
- Children
- Initial
- No respiratory depression: 0.01 mg/kg IV or IM
- Respiratory depression: 0.1 mg/kg IV or IM
- Next, if no response or incomplete response
- Give 0.1 mg/kg IV or IM
- Complications
- Death
- More than 50,000 Opioid Overdose deaths in 2016 (U.S.)
- Non-fatal Overdose is associated with a 10% mortality within the next year
- Pulmonary Edema
- Typically follows Opioid reversal (unclear etiology)
- May require Endotracheal Intubation
- Prevention: Prescribed Chronic Opioids
- Best prevention is to keep Opioid naive patients naive
- See Emergency Department Pain Management
- Identify alternatives to Opioids in Chronic Pain Management
- Prescribe Home Naloxone in case of Overdose or for those on high dose Opioids
- Keep equianalgesic doses in mind when administering parenteral Opioids
- Hydromorphone (Dilaudid) 1 mg is equivalent to up to 10 mg of Morphine Sulfate
- Exercise caution when combining agents that blunt respiratory drive (e.g. Opioids with Benzodiazepines)
- Benzodiazepines
- Muscle relaxants
- Analgesic tolerance occurs before tolerance to respiratory depression
- Opioid tolerant patients are at increased risk of apnea due to high dose Opioids
- Exercise caution in already compromised respiratory status
- COPD
- Sleep Apnea
- Prevention: Opioid Abuse
- See Opioid Abuse for protocol
- Prescribe Home Naloxone
- Needle exchange program
- Infectious disease screening (e.g. HIV, Hepatitis C, as well as STDs)
- Offer Chemical Dependency treatment
- Treatment is often declined, as patients walk out of ED prior to discharge process
- Reassure patient that the Naloxone withdrawal wears off in one hour
- Offer Opioid Withdrawal symptomatic management (e.g. Clonidine, Ondansetron)
- Patient waiting until withdrawal symptoms subside opens window for discussion of Buprenorphine, prevention
- Non-fatal Opioid Overdose patients are at very high risk that the next Overdose will be fatal
- Sample script (modified from Reuben Strayer, MD, in reference below)
- I know you have a complicated life and wish things could be different
- When you are ready to make a change, we can help
- Come back anytime; we are here all day, every day
- Buprenorphine (Suboxone) prescription
- See Opioid Abuse
- Requires practitioner waiver (X DEA number)
- See Buprenorphine for precautions (including precipitating withdrawal)
- Reframe Buprenorphine for addiction, as similar to Insulin in Diabetes Mellitus
- References
- Mason and Armenian in Herbert (2018) EM:Rap 18(7):8-9
- Strayer in Herbert (2020) EM:Rap 20(6):10-2
- Strayer and Swaminathan in Herbert (2018) EM:Rap 18(9): 3-6
- Swaminathan, Hayes, LaPoint in Herbert (2017) EM:Rap 17(5): 2-3