1. Opioids Objectives Understand opioids overdose pathophysiology.
Presentations of opioids toxicity
Diagnostic strategies of opioids toxicity
Management of opioids toxicity
Diagnosis and Management of opioids withdrawal
Zohair Al Aseri MD,FRCPC EM & CCM

2. PERSPECTIVE
Opioid applies to all natural, synthetic, and semi synthetic agents with morphine-likeactions.
narcotic refers to any agent that induces sleep and is non specific
Zohair Al Aseri MD,FRCPC EM & CCM

3. Misuse of pharmaceutical opioid
PERSPECTIVE
Misuse of pharmaceutical opioid
Injection is the most common route, followed by inhalation, smoking and ingestion.
Zohair Al Aseri MD,FRCPC EM & CCM

4. Pathophysiology and Pharmacology Toxicity
Although different opioids have receptor preferences in therapeutic or low doses, this specificity is lost at higher doses.
Zohair Al Aseri MD,FRCPC EM & CCM

5. Pathophysiology and Pharmacology Toxicity
Opioids are well absorbed after GI (oral and rectal) or parenteral administration but also through nasal, buccal, pulmonary, and transdermal routes, depending on the lipid solubility of the specific opioid.
Heroin is usually abused through intravenous and subcutaneous routes, but it is also absorbed after nasal administration because it is lipid soluble.
Zohair Al Aseri MD,FRCPC EM & CCM

6. Pathophysiology and Pharmacology Toxicity
With therapeutic doses, absorption is complete within 1 or 2 hours.
Absorption and clinical effects of toxicity may be prolonged after overdose, however, because gastric emptying is delayed.
Most opioids have a large volume of distribution.
Zohair Al Aseri MD,FRCPC EM & CCM

7. Pathophysiology and Pharmacology Toxicity
Heroin
peaks in the serum within 1 minute of intravenous injection, 3 to 5 minutes of intranasal administration, and 10 minutes of subcutaneous injection.
Heroin's lipophilic nature allows for rapid transport across the blood-brain barrier into the CNS.
Zohair Al Aseri MD,FRCPC EM & CCM

8. CLINICAL FEATURES Toxicity The toxidrome of opioid toxicity is
CNS depression
Respiratory depression
Miosis
Zohair Al Aseri MD,FRCPC EM & CCM

9. Neurologic CNS depression
Well-recognized manifestation of opioid toxicity.
Hypoxia from CNS depression and respiratory depression also causes many neurologic complications.
Dysphoria and acute psychosis may occur with an agonist-antagonist opioid.
Zohair Al Aseri MD,FRCPC EM & CCM

10. Neurologic
Seizures
Meperidine-related seizures are probably caused by accumulation of normeperidine with repeated doses
Seizures may also result from hypoxia with overdose of any opioid.
Zohair Al Aseri MD,FRCPC EM & CCM

11. Neurologic Parkinsonian symptoms In intravenous drug abusers
The syndrome is irreversible in some patients
Zohair Al Aseri MD,FRCPC EM & CCM

12. Serotonin syndromeis a clinical triad of
Neurologic
Serotonin syndromeis a clinical triad of
mental status changes
autonomic instability
neuromuscular changes
May be fatal.
Meperidine and dextromethorphan have serotoninergic properties and have been associated with serotonin syndrome.
Zohair Al Aseri MD,FRCPC EM & CCM

13. Respiratory Decrease respiratory rate and tidal volume
Overdose of an agonist-antagonist agent produces less significant respiratory depression
Bronchospasm is rare with heroin use in asthmatic and nonasthmatic patients and occurs mostly after inhalational exposure.
Acute lung injury occurs with therapeutic opioid use but is much more common after overdose
Zohair Al Aseri MD,FRCPC EM & CCM

14. In more than 90% of heroin overdoses, results in miosis.
Ophthalmologic
In more than 90% of heroin overdoses, results in miosis.
Gastrointestinal
Nausea and vomiting are common with therapeutic opioid use and also with overdose.
Severe cases may develop ileus
Genitourinary
Urinary retention from urethral sphincter spasm and decreased detrusor tone.
Zohair Al Aseri MD,FRCPC EM & CCM

15. Opioids cause mild hypotension and relative bradycardia.
Cardiovascular
Opioids cause mild hypotension and relative bradycardia.
Zohair Al Aseri MD,FRCPC EM & CCM

16. Dermatologic
Pruritus, flushing, and urticaria occur after administration of certain opioids that release histamine (e.g., morphine)
Zohair Al Aseri MD,FRCPC EM & CCM

17. Metabolic Hypoglycemia occurs, mechanismis unclear.
Hypothermia has been reported
Zohair Al Aseri MD,FRCPC EM & CCM

18. Withdrawal
Increased sympathetic discharge and adrenergic hyperactivity are responsible for the clinical symptoms and signs.
Withdrawal is associated with CNS excitation, tachypnea, and mydriasis.
Pulse and blood pressure are also increased. Although these can be uncomfortable, they are typically not life-threatening.
Zohair Al Aseri MD,FRCPC EM & CCM

19. Withdrawal
Nausea, vomiting, diarrhea, and abdominal cramps are common in withdrawal.
They can be significant and lead to dehydration and electrolyte abnormalities.
Zohair Al Aseri MD,FRCPC EM & CCM

20. DIAGNOSTIC STRATEGIES
History and physical examination
Hypoglycemia
Abdominal radiograph may identify packets of opioids or other illicit substances in a body packer.
acetaminophen and salicylate levels should be checked because many prescription opioids are available in combination products.
Zohair Al Aseri MD,FRCPC EM & CCM

21. DIAGNOSTIC STRATEGIES
As with opioid toxicity, no diagnostic test exists for opioid withdrawal.
Zohair Al Aseri MD,FRCPC EM & CCM

22. If reversal is not achieved with antidote
MANAGEMENT
airway, oxygenation, and ventilation is of vital importance in patients with opioid toxicity.
If reversal is not achieved with antidote
Zohair Al Aseri MD,FRCPC EM & CCM

23. MANAGEMENT
Circulatory support usually does not require more than a crystalloid infusion.
Most opioids have a large volume of distribution and cannot be cleared by dialysis.
Zohair Al Aseri MD,FRCPC EM & CCM

24. Gastrointestinal Decontamination
MANAGEMENT
Gastrointestinal Decontamination
is often unnecessary because the antidote can reverse the effects.
Zohair Al Aseri MD,FRCPC EM & CCM

25. MANAGEMENT
Antidote
Naloxone a pure opioid antagonist is the antidote most frequently used to reverse opioid toxicity.
Naloxone has a rapid onset of action.
Naloxone is indicated for patients with opioid intoxication who have significant CNS or respiratory depression.
Zohair Al Aseri MD,FRCPC EM & CCM

26. DISPOSITION
Toxicity
Patients with opioid toxicity are usually treated successfully in the emergency department, sometimes in conjunction with the emergency department observation unit.
Patients who receive naloxone should be observed for 2 hours to assess the extent of re- sedation.
Zohair Al Aseri MD,FRCPC EM & CCM

27. Zohair Al Aseri MD,FRCPC EM & CCM