Heroin Toxicity Follow-up

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

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.
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Further Outpatient Care

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

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

About 3-10% of patients treated for heroin overdose require admission to the hospital because of complications such as pneumonia, noncardiogenic pulmonary edema (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.[7] 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, shown in the image belowEndocarditis-related septic pulmonary emboli in a Endocarditis-related septic pulmonary emboli in a heroin user.
  • Valvular insufficiency
  • Skin and soft tissue infections (eg, abscesses, cellulitis, suppurative thrombophlebitis, necrotizing fasciitis, shown in the image below)Necrotizing fasciitis in a heroin user. Necrotizing fasciitis in a heroin user.
  • 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.

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Prognosis

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

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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.

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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

References

  1. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies. Results from the 2009 National Survey on Drug Use and Health: National Findings. September 2010. Available at http://www.oas.samhsa.gov/nsduh/2k8nsduh/2k8Results.pdf. Accessed January 2011.

  2. United Nations Office on Drugs and Crime. World Drug Report 2009. Available at http://www.unodc.org/documents/wdr/WDR_2009/WDR2009_eng_web.pdf. Accessed December 11, 2009.

  3. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). EMCDDA Annual report 2009: the state of the drugs problem in Europe. November 2009. Available at http://www.emcdda.europa.eu/situation/analysis. Accessed December 11, 2009.

  4. Bronstein AC, Spyker DA, Cantilena LR Jr, et al. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol (Phila). Dec 2010;48(10):979-1178. [Medline].

  5. National Institute for Drug Addiction (NIDA). Research on the Nature and Extent of Drug Use in the United States.

  6. Hoffman RS, Kirrane BM, Marcus SM. A descriptive study of an outbreak of clenbuterol-containing heroin. Ann Emerg Med. Nov 2008;52(5):548-53. [Medline].

  7. Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema : a case series. Chest. Nov 2001;120(5):1628-32. [Medline].

  8. Atypical reactions associated with heroin use--five states, January-April 2005. MMWR Morb Mortal Wkly Rep. Aug 19 2005;54(32):793-6. [Medline].

  9. Bikell WH, Benar O. Life-threatening opioid toxicity. Prob Crit Care. 1987;1:106.

  10. Bryant WK, Galea S, Tracy M, et al. Overdose deaths attributed to methadone and heroin in New York City, 1990-1998. Addiction. Jul 2004;99(7):846-54. [Medline].

  11. Buajordet I, Naess AC, Jacobsen D, et al. Adverse events after naloxone treatment of episodes of suspected acute opioid overdose. Eur J Emerg Med. Feb 2004;11(1):19-23. [Medline].

  12. Coffin PO, Galea S, Ahern J, et al. Opiates, cocaine and alcohol combinations in accidental drug overdose deathsin New York City, 1990-98. Addiction. Jun 2003;98(6):739-47. [Medline].

  13. Darke S, Hall W, Weatherburn D, et al. Fluctuations in heroin purity and the incidence of fatal heroin overdose. Drug Alcohol Depend. Apr 1 1999;54(2):155-61. [Medline].

  14. Darke S, Zador D. Fatal heroin 'overdose': a review. Addiction. Dec 1996;91(12):1765-72. [Medline].

  15. Davidson PJ, McLean RL, Kral AH, et al. Fatal heroin-related overdose in San Francisco, 1997-2000: a case for targeted intervention. J Urban Health. Jun 2003;80(2):261-73. [Medline].

  16. Davoli M, Perucci CA, Forastiere F, et al. Risk factors for overdose mortality: a case-control study within a cohort ofintravenous drug users. Int J Epidemiol. Apr 1993;22(2):273-7. [Medline].

  17. Dietemann JL, Botelho C, Nogueira T, et al. [Imaging in acute toxic encephalopathy.]. J Neuroradiol. Sep 2004;31(4):313-26. [Medline].

  18. DOHMH. Investigation into Contaminated Heroin. New York City Department of Health and Mental Hygiene. 2005;Health Alert #6..

  19. Ellenhorn MJ. The Opiates. In: Ellenhorn's Medical Toxicology: Diagnosis and Treatment of Human Poisoning. Baltimore, Md: Lippincott, Williams & Wilkins; 1997:405-447.

  20. Gable RS. Comparison of acute lethal toxicity of commonly abused psychoactive substances. Addiction. Jun 2004;99(6):686-96. [Medline].

  21. Gaeta TJ, Capodano RJ, Spevack TA. Potential danger of nalmefene use in the emergency department. Ann Emerg Med. Jan 1997;29(1):193-4. [Medline].

  22. Garrick TM, Sheedy D, Abernethy J, et al. Heroin-related deaths in Sydney, Australia. How common are they?. Am J Addict. Spring 2000;9(2):172-8. [Medline].

  23. Gossop M, Griffiths P, Powis B, et al. Frequency of non-fatal heroin overdose: survey of heroin users recruited innon-clinical settings. BMJ. Aug 17 1996;313(7054):402. [Medline].

  24. Gupta R, Haydock T. Severe hypercapnia caused by acute heroin overdose. Ann Emerg Med. May 2004;43(5):665-6. [Medline].

  25. Gutstein HB, Akil H. Goodman, Gilman, eds. Opioid analgesics. The Pharmacological Basis of Therapeutics. Joel Gri: 2001:569-620.

  26. Handal KA, Schauben JL, Salamone FR. Naloxone. Ann Emerg Med. Jul 1983;12(7):438-45. [Medline].

  27. Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. Mar 1991;20(3):246-52. [Medline].

  28. Hoffman RS, Goldfrank LR. The poisoned patient with altered consciousness. Controversies in the use of a 'coma cocktail'. JAMA. Aug 16 1995;274(7):562-9. [Medline].

  29. Howland MA. Opioid antagonists. In: Goldfrank LR, Flomenbaum NR, eds. Goldfrank's Toxicologic Emergencies. 8th ed. New York: McGraw-Hill; 2006:614-615.

  30. Hutchins KD, Pierre-Louis PJ, Zaretski L, et al. Heroin body packing: three fatal cases of intestinal perforation. J Forensic Sci. Jan 2000;45(1):42-7. [Medline].

  31. Infante F, Domínguez E, Trujillo D, et al. Metal contamination in illicit samples of heroin. J Forensic Sci. Jan 1999;44(1):110-3. [Medline].

  32. Lewis N. Opioids. In: Goldfrank LR, Flomenbaum NR, eds. Goldfrank's Toxicologic Emergencies. 8th ed. New York: McGraw-Hill; 2006:590-618.

  33. Longo MC, Henry-Edwards SM, Humeniuk RE, et al. Impact of the heroin 'drought' on patterns of drug use and drug-related harms. Drug Alcohol Rev. Jun 2004;23(2):143-50. [Medline].

  34. McCleave NR. Drug smuggling by body packers. Detection and removal of internally concealed drugs. Med J Aust. Dec 6-20 1993;159(11-12):750-4. [Medline].

  35. McLaughlin SA, Richards ME. Another perspective on "Severe hypercapnia caused by acute heroin overdose". Ann Emerg Med. Dec 2004;44(6):670-1; author reply 671-2. [Medline].

  36. Osterwalder JJ. Naloxone--for intoxications with intravenous heroin and heroin mixtures--harmless or hazardous? A prospective clinical study. J Toxicol Clin Toxicol. 1996;34(4):409-16. [Medline].

  37. Richards RG, Reed D, Cravey RH. Death from intravenously administered narcotics: a study of 114 cases;. J Forensic Sci. Jul 1976;21(3):467-82. [Medline].

  38. Ruttenber AJ, Kalter HD, Santinga P. The role of ethanol abuse in the etiology of heroin-related death. J Forensic Sci. Jul 1990;35(4):891-900. [Medline].

  39. Schauben JL. Opioids. In: Irwin RS, Cerra FB, Rippe JM, eds. Irwin and Rippe's Intensive Care Medicine. Baltimore, Md: Lippincott Williams & Wilkins; 1999:1744-1754.

  40. Schwartz JA, Koenigsberg MD. Naloxone-induced pulmonary edema. Ann Emerg Med. Nov 1987;16(11):1294-6. [Medline].

  41. Scopolamine poisoning among heroin users--New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996. MMWR Morb Mortal Wkly Rep. Jun 7 1996;45(22):457-60. [Medline].

  42. Seaman SR, Brettle RP, Gore SM. Mortality from overdose among injecting drug users recently released from prison: database linkage study. BMJ. Feb 7 1998;316(7129):426-8. [Medline].

  43. Smith DA, Leake L, Loflin JR, et al. Is admission after intravenous heroin overdose necessary?. Ann Emerg Med. Nov 1992;21(11):1326-30. [Medline].

  44. Sporer KA. Acute heroin overdose. Ann Intern Med. Apr 6 1999;130(7):584-90. [Medline].

  45. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med. Jul 1996;3(7):660-7. [Medline].

  46. Steentoft A, Kringsholm B, Hansen AC, et al. [Fatal poisonings among drug addicts in Denmark in 2002]. Ugeskr Laeger. May 2 2005;167(18):1954-7. [Medline].

  47. Steentoft A, Worm K, Pedersen CB, et al. Drugs in blood samples from unconscious drug addicts after the intake of an overdose. Int J Legal Med. 1996;108(5):248-51. [Medline].

  48. Sterrett C, Brownfield J, Korn CS, et al. Patterns of presentation in heroin overdose resulting in pulmonary edema. Am J Emerg Med. Jan 2003;21(1):32-4. [Medline].

  49. US Department of Health and Human Services, Substance Abuse and Mental Health. Drug Abuse Warning Network 2003: Interim National Estimates of Drug-Related Emergency Department Visits. December, 2004.

  50. Utecht MJ, Stone AF, McCarron MM. Heroin body packers. J Emerg Med. Jan-Feb 1993;11(1):33-40. [Medline].

  51. Vilke GM, Buchanan J, Dunford JV, et al. Are heroin overdose deaths related to patient release after prehospital treatment with naloxone?. Prehosp Emerg Care. Jul-Sep 1999;3(3):183-6. [Medline].

  52. Washton AM, Resnick RB. Clonidine in opiate withdrawal: review and appraisal of clinical findings. Pharmacotherapy. Sep-Oct 1981;1(2):140-6. [Medline].

  53. Wetli CV, Rao A, Rao VJ. Fatal heroin body packing. Am J Forensic Med Pathol. Sep 1997;18(3):312-8. [Medline].

  54. Wound botulism among black tar heroin users--Washington, 2003. MMWR Morb Mortal Wkly Rep. Sep 19 2003;52(37):885-6. [Medline].

  55. Zador D, Sunjic S, Darke S. Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances. Med J Aust. Feb 19 1996;164(4):204-7. [Medline].

 
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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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