Analgesic
Narcotic Overdose
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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
Opioid
s 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 Equivalent
s >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
Seizure
s
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 Drug
s are often adulterated with synthetic
Opioid
s 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 )
Management
Gene
ral
Naloxone
See doses below (or see
Naloxone
)
Not indicated for a mentating patient with normal
Vital Sign
s
Indicated for hypoventilation <9 breaths/min or increased
EtCO2
Consider for long acting
Opioid
s (
Oxycontin
, MS Contin,
Methadone
,
Zohydro
)
Naloxone
continuous infusion
Nalmefene
(
Revex
)
Consider 1 or 2
Nasal Trumpet
s (
Nasopharyngeal Airway
s)
Monitoring
EtCO2
and
Oxygen Saturation
Oxygen Saturation
alone is insufficient
Supplemental Oxygen
can result in
Apneic Oxygenation
with normal O2Sat but rising carbon dioxide
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
Opioid
s 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 Opioid
s
Best prevention is to keep
Opioid
naive patients naive
See
Emergency Department Pain Management
Identify alternatives to
Opioid
s in
Chronic Pain Management
Prescribe Home
Naloxone
in case of
Overdose
or for those on high dose
Opioid
s
Keep equianalgesic doses in mind when administering parenteral
Opioid
s
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.
Opioid
s with
Benzodiazepine
s)
Benzodiazepine
s
Muscle relaxants
Analgesic
tolerance occurs before tolerance to respiratory depression
Opioid
tolerant patients are at increased risk of apnea due to high dose
Opioid
s
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
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