Heroin Toxicity Medication

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

Medication Summary

The goals of pharmacotherapy are to reduce absorption of the drug, to prevent complications, and to reduce morbidity.

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Narcotic antagonists

Class Summary

Naloxone is a pure opioid antagonist that has been in use since the 1970s. Naloxone has an ultrarapid onset of action (1 min) and a short half-life (20 min). Duration of action is 20-60 minutes.

Nalmefene is a new narcotic antagonist that is effective in the termination of respiratory and CNS depression associated with heroin overdose. Has a considerably longer duration of action (lasts 4-8 h after IV injection) than naloxone. Duration of action makes it ideal in patients who are not dependent on opiates and who present with respiratory depression, thus reducing the incidence of resedation.

Naloxone has an excellent safety record, especially when used appropriately. Doses of up to 100 mg have been administered to patients with spinal injury, without untoward effects.

Naloxone reverses the characteristic respiratory depression and the analgesia, coma, and miosis that occur with heroin overdose. It may also reverse the cardiovascular effects of an overdose and reduce immediate and delayed mortality of patients.

Reports that link the use of naloxone to the development of NCPE, convulsions, and death have not been substantiated because these complications have also been noted in patients with other opiates in the absence of naloxone and may be due to hypoxia.

Naloxone use in patients who are dependent on narcotics may precipitate withdrawal syndrome (33% of cases) characterized by abdominal discomfort, vomiting, diarrhea, lacrimation, rhinorrhea, yawning, and piloerection. In patients with polydrug overdose, naloxone may unmask the effects of other substances (eg, cocaine), leading to confusion and restlessness in up to 32% of cases, and, rarely, more serious events.

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Naloxone (Narcan)

 

In suspected narcotic overdose, small increments (0.1 mg) may be used IV until the desired effect is obtained or until 10 mg have been administered with no response. Small increments are used rather than a large bolus injection in order to prevent narcotic withdrawal in the patient who is dependent on opioids. Large bolus injections of naloxone may also unmask adverse effects of co-ingestants (eg, scopolamine, amphetamines, cocaine), resulting in a sympathetic or an anticholinergic crisis. When desired effect is obtained and patient requires continuous infusion, a drip solution is mixed so that two thirds of the originally effective dose is administered qh. To prepare drip, add 40 mg naloxone to 1 L D5W or NS and infuse at 10 mL/h (0.4 mg/h).

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Nalmefene (Revex)

 

Prevents or reverses opioid effects (eg, hypotension, respiratory depression, sedation), possibly by displacing opiates from their receptors.

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GI decontaminants

Class Summary

These agents are used to minimize systemic absorption of the toxin.

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Activated charcoal (Liqui-Char)

 

Emerging as the decontamination method of choice. Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal absorbs 100-1000 mg of drug per gram of charcoal. Indicated for orally ingested narcotics and co-ingestions, but no benefit exists in pure heroin overdose.

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Polyethylene glycol (GoLytely, Colyte)

 

Laxative with strong electrolyte and osmotic effects that has cathartic actions in GI tract. Accomplished whole-bowel irrigation.

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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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