Heroin Toxicity Clinical Presentation

  • Author: Rania Habal, MD; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Apr 15, 2011
 

History

In general, when it is the sole agent used, the clinical presentation of heroin poisoning and its diagnosis hold little challenge for the experienced health care practitioner. The diagnosis of heroin poisoning should be suspected in all comatose patients, especially in the presence of respiratory depression and miosis.

Symptoms generally develop within 10 minutes of intravenous heroin injection. Patients who survive heroin poisoning commonly admit to having used more than their usual dose, having used heroin again after a prolonged period of abstinence, or having used a more concentrated street sample.

Heroin toxicity shares common clinical characteristics with other medical or toxicologic conditions. For example, clonidine administration in a patient with pontine hemorrhage may cause coma, respiratory depression, and miosis similar to opioid intoxication. Phencyclidine, certain phenothiazines, and organophosphates may also cause miosis with altered mental status.

The clinical presentation of heroin poisoning may be altered by a number of the following factors:

  • Concomitant conditions: The presence of CNS disease, traumatic injuries, hypoxia, hypoglycemia, hypovolemia, acidosis, or metabolic disease may alter the clinical presentation of heroin poisoning.
  • Co-ingestions: The most commonly co-ingested substance is alcohol, followed by benzodiazepines, cocaine, and amphetamines.
  • Contaminants: Street heroin samples are often contaminated with agents that have their own toxicity profile, eg, sedative hypnotics, amphetamines, local anesthetics, anticholinergic agents, quinine, strychnine, arsenic, and, most recently, clenbuterol[6] .
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Physical

Coma, respiratory depression, and miosis are the hallmarks of opioid overdose. According to Hoffman and colleagues, the presence of these hallmarks (ie, coma, respiratory depression, miosis) has a 92% sensitivity and 76% specificity for heroin overdose.

The clinical presentation and depth of coma may be altered in patients with co-ingestions and in the presence of concomitant medical conditions such as hypoxia, trauma, hypoglycemia, and shock or with concomitant ingestion of other toxins such as amphetamines, cocaine, and anticholinergics. In these circumstances, patients may exhibit delirium, tachypnea, and mydriasis. Delirium may also be noted in overdoses with prescription narcotics such as dextromethorphan, meperidine, and codeine. Convulsions occur with overdoses of meperidine, fentanyl, pentazocine, or propoxyphene.

Mild hypotension and mild bradycardia are commonly observed with heroin use. These are attributable to peripheral vasodilation, reduced peripheral resistance and histamine release, and inhibition of baroreceptor reflexes. In the setting of heroin poisoning, hypotension remains mild. The presence of severe hypotension should prompt a search for other causes of hypotension, such as hemorrhage, hypovolemia, sepsis, pulmonary emboli and other causes of shock.

Respiratory depression, due to heroin's effect on the brain's respiratory centers is a hallmark. However, the presence of tachypnea should prompt the search for complications of heroin use such as pneumonia, pulmonary edema, pneumothorax; or an alternative diagnosis such as shock, acidosis or CNS injury. Tachypnea may also be seen in overdoses of pentazocine or meperidine.

Examination of the skin may also reveal patterns of heroin use such as track marks (shown in the image below), fresh puncture wounds, and "skin-popping" marks.

Track marks in a heroin intravenous drug user. Track marks in a heroin intravenous drug user.
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Causes

The most common scenarios for a significant heroin overdose are the use of a higher dose, the accidental injection of highly concentrated solution in the unsuspecting user, or the use of heroin after a prolonged period of abstinence. Intentional (ie, suicidal) overdoses are rare. Other scenarios include body packing and body stuffing.

"Body packers," also called "mules," are people who pack their GI tract with bags of heroin in order to smuggle the illegal drug from one country to another. In these persons, the drugs are carefully packaged for safe passage. Persons may become symptomatic when a heroin-containing package ruptures or when the packages cause GI obstruction or rupture. Body packing should be suspected in persons who are found unconscious at airports, during international flights, or soon after a trip to endemic countries.

"Body stuffers," on the other hand, are people who ingest all the drugs in their possession in order to conceal the evidence from the police. Because these packages are typically not designed for safe GI transport, they easily rupture and frequently cause poisoning. The clinical presentation is often atypical because multiple substances may have been ingested.

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Contributor Information and Disclosures
Author

Rania Habal, MD  Assistant Professor, Department of Emergency Medicine, New York Medical College

Disclosure: Nothing to disclose.

Specialty Editor Board

Laurie Robin Grier, MD  Medical Director of MICU, Professor of Medicine, Department of Emergency Medicine, Anesthesiology and OBGYN, Section of Pulmonary and Critical Care Medicine, Louisiana State University Health Science Center at Shreveport

Laurie Robin Grier, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Society for Parenteral and Enteral Nutrition, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Daniel R Ouellette, MD, FCCP  Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Astra Zeneca Honoraria Speaking and teaching

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM  Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair of Academic Affairs, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center

Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, European Society of Intensive Care Medicine, Shock Society, and Society of Critical Care Medicine

Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

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Heroin-related noncardiogenic pulmonary edema.
Track marks in a heroin intravenous drug user.
Necrotizing fasciitis in a heroin user.
Endocarditis-related septic pulmonary emboli in a heroin user.
 
 
 
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