eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Heroin: Follow-up

Author: Rania Habal, MD, Assistant Professor, Department of Emergency Medicine, New York Medical College
Contributor Information and Disclosures

Updated: Aug 12, 2008

Follow-up

Further Inpatient Care

  • Further inpatient care may be needed for patients with medical complications that require prolonged specialist care (eg, development of pneumonia, septic emboli, endocarditis, cellulitis, osteomyelitis, subdural abscess, compartment syndrome, cerebrovascular accident).
  • Monitor patients for opioid withdrawal symptoms.
  • Psychiatric support and therapy must be provided concomitantly with medical therapy for all intentional overdoses.

Further Outpatient Care

  • Psychiatric support and therapy for all intentional overdoses
  • Social support for addiction (eg, Narcotics Anonymous, detoxification programs)
  • Methadone maintenance programs

Inpatient & Outpatient Medications

  • Consider methadone programs.
  • Long-term antibiotics may be required for certain infections such as osteomyelitis.

Transfer

  • Transfer to a nonmonitored bed is indicated when the patient's condition is stable and requires further medical therapy.
  • Transfer to a psychiatric service may be indicated for intentional overdoses.

Deterrence/Prevention

  • Enrollment in deterrence programs (eg, Narcotics Anonymous, detoxification programs) may be beneficial for some patients.
  • Reduction in supply has been shown to reduce heroin use and heroin-related deaths in Australia and other countries.
  • Heroin overdose deaths may be prevented by training users and those close to them to respond quickly to the overdose. In as many as 32% of heroin-related deaths, the patients were not alone, and the others who were present failed to recognize the seriousness of the overdose or were reluctant to respond because of legal repercussions.

Complications

About 3-10% of patients treated for heroin overdose require admission to the hospital because of complications such as pneumonia, NCPE, persistent hypoxia/hypoventilation, persistent altered mental status, trauma, rhabdomyolysis, compartment syndrome, and infectious complications.

NCPE affects 0.3-2.4% of heroin overdose cases and has been reported in 50-90% of autopsies performed on patients who overdosed on heroin and were found dead at the scene. NCPE may occur with any narcotic but is encountered most commonly in cases that involve overdoses of heroin, methadone, propoxyphene, or codeine. Typically, heroin-related NCPE occurs in males with a Glasgow Coma Scale of less than 5 and severe respiratory depression that requires naloxone.

In a retrospective chart review, Sporer and Dorn reported that 74% of patients ultimately diagnosed with heroin-induced NCPE were hypoxic upon presentation to the ED, 22% of patients developed severe hypoxia during the first hour, and 4% of patients developed hypoxia in the 4 hours following the overdose.2 None of these patients was hypoventilating upon arrival to the ED; the average respiratory rate was 24 breaths per minute (range, 16-44 breaths per min). The patients' average initial oxygen saturation level on room air was 76% (range, 47-89%).

Most patients (66%) responded to oxygen via nonrebreather face mask and to observation only. Mechanical ventilation was required to achieve adequate oxygenation in 33% of patients. Hypoxia resolved in most patients (74%) within 24 hours, several within 8 hours. In the remainder of patients (22%), hypoxia resolved over the next 48 hours. Most intubated patients were extubated within 24 hours.

Although the cause of NCPE remains uncertain, hypoxia-induced lung damage likely plays a major role in the development of pulmonary edema. Other mechanisms that have been suggested as causes of pulmonary edema include acute anaphylaxis, neurogenic effects, humoral effects, immune-complex deposition, and depressed myocardial contractility.

Long-term use of narcotics leads to narcotic addiction, a condition marked by a constant craving for narcotics and an extremely uncomfortable withdrawal syndrome. This syndrome is characterized by yawning, piloerection, lacrimation, salivation, nasal congestion, vomiting, diarrhea, and general body aches. Clonidine may be used to control the symptoms of opiate withdrawal.

Complications that relate to the intravenous injection of heroin and other drugs include the following:  

  • Septic emboli
  • Foreign body embolization
  • Endocarditis
  • Valvular insufficiency
  • Skin and soft tissue infections (eg, abscesses, cellulitis, suppurative thrombophlebitis, necrotizing fasciitis)
  • Wound botulism
  • Sepsis
  • Osteomyelitis
  • Subdural abscess
  • Cerebrovascular accident
  • Mycotic aneurysm
  • AIDS
  • Hepatitis
  • Fungal infections
  • Tuberculosis
  • Complications that relate to inhalation include pneumothorax, pneumomediastinum, and toxic leukoencephalopathy.

Patients may present with complications related to adulterants of street drugs. Street drugs are combined with inert or toxic substances to increase the mass and street value of the original product. Common heroin adulterants include talc, sugars, quinine, local anesthetics, flour, sodium bicarbonate, amphetamines, lysergic acid diethylamide (LSD), phencyclidine, cocaine, and scopolamine. Recently, a number of deaths due to clenbuterol toxicity were reported in patients who used heroin in the northeastern United States. Talc may cause pulmonary injury. Quinine, local anesthetics, amphetamines, and cocaine may be cardiotoxic and cause cardiac arrhythmias.

Prognosis

Prognosis is directly related to the duration of hypoxia and the rapid identification and management of complications.  Survival after cardiac arrest is limited.

Patient Education

For excellent patient education resources, visit eMedicine's Substance Abuse Center and Mental Health and Behavior Center. Also, see eMedicine's patient education articles Substance Abuse, Drug Dependence & Abuse, Club Drugs, Narcotic Abuse, Substance Abuse, and Activated Charcoal.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider co-ingestions (eg, acetaminophen, aspirin) in the evaluation and management of any overdose
  • Failure to consider other diagnoses (eg, CNS infection or bleed, hypoglycemia, carbon monoxide poisoning) in the evaluation and treatment of presumed narcotic overdoses
  • Failure to consider concomitant trauma
  • Failure to identify and treat complications
  • Failure to evaluate efficacy and complications of therapy

Special Concerns

  • Pregnant patients
    • Heroin addiction in the pregnant patient is grossly underestimated.
    • Heroin readily crosses the placenta and the blood-brain barrier of the fetus, leading to narcotic dependence in the fetus.
    • Heroin overdose results in hypoxia, which, in turn, causes placental vasoconstriction, thus causing further injury to the fetus.
    • Complications in the mother can lead to additional and similar complications in the fetus.
  • Childhood heroin overdose: This is rare and does not differ clinically from an adult overdose. Similarly, treatment of pediatric heroin overdose would not differ from that of an adult. In all cases of pediatric heroin overdose, social services should be involved.
 


More on Toxicity, Heroin

Overview: Toxicity, Heroin
Differential Diagnoses & Workup: Toxicity, Heroin
Treatment & Medication: Toxicity, Heroin
Follow-up: Toxicity, Heroin
Multimedia: Toxicity, Heroin
References
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Further Reading

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Keywords

heroin toxicity, heroin, heroin poisoning, heroin overdose, heroin addiction, heroin use, heroin dependence, dope, smack, skag, junk, mud, shill, big H, horse, white stuff, brown sugar, black tar, Lady Jane, body stuffers, body packers, intravenous drug use, intravenous drug abusers, IVDA, skin-popping, diacetylmorphine, narcotic, mainlining, opioid

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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.

Medical Editor

Laurie Robin Grier, MD, Medical Director of MICU, Associate Professor of Medicine, 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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint 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, Academic Affairs, 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, 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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