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Heroin Toxicity Treatment & Management

  • Author: Rania Habal, MD; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Jul 08, 2016
 

Medical Care

The direct effects of heroin on the central nervous system (CNS) are quickly reversible with naloxone. Naloxone may be given intravenously, intramuscularly, subcutaneously, or via endotracheal tube; the newer intranasal formulation has proved especially convenient for first responders and laypersons.

A response to naloxone should be expected within 5 minutes. The effects from naloxone generally last 20-40 minutes. Resedation occurs when large doses of heroin are used, when continuous absorption from a ruptured transport bag occurs, or in the presence of a long-acting narcotic agent. The absence of a response to naloxone should prompt a search for another cause of the clinical presentation, such as hypoglycemia. Respiratory support should be instituted early, when necessary.

Gastric lavage in the setting of oral heroin overdose is generally not recommended because it has no documented value. Furthermore, gastric lavage is contraindicated in body packers and body stuffers because the procedure may rupture a package.

Activated charcoal is becoming increasingly controversial because of the risk of aspiration and charcoal pneumonitis. It may be indicated for orally ingested narcotics with large enterohepatic circulation (eg, propoxyphene, diphenoxylate) but is of no value in pure heroin overdose.

Body packers and body stuffers also generally require whole-bowel irrigation, except in the presence of intestinal obstruction or perforation. Whole-bowel irrigation may be accomplished with an oral polyethylene glycol (GoLYTELY) solution at a rate of 2 L/h until stools are watery and clear.

Admission to the hospital is rarely necessary and generally limited to complications of heroin overdose and intravenous drug use. Admission to the intensive care unit is also rarely required and is indicated for patients who require respiratory support and those with life-threatening arrhythmias, shock, and recurrent convulsions, as well as those who require continuous naloxone infusions (rebound coma, respiratory depression).

Pulmonary edema

Noncardiogenic pulmonary edema (NCPE), which affects 0.3-2.4% of heroin overdoses, generally lasts 24-48 hours and responds to supportive care. In most instances, hypoxia improves with mask oxygen ventilation only, but noninvasive positive-pressure ventilation (NIPPV) and endotracheal intubation may be required. Endotracheal intubation is indicated for airway protection, severe hypoxia, acidosis, and cardiovascular instability.

Convulsions

The presence of recurrent convulsions in a patient with heroin overdose should prompt a search for causes of seizures, such as hypoxia, CNS injury, adulterants, or co-ingestions (eg, tricyclic antidepressants, cocaine, amphetamines).

Some narcotics, such as meperidine (Demerol), pentazocine (Talwin), diphenoxylate, and fentanyl (Actiq), may cause seizures. Seizures caused by these narcotics, excluding diphenoxylate and atropine (Lomotil), are usually of short duration and do not progress to status epilepticus.

Heroin and narcotic-related convulsions respond to conventional benzodiazepine therapy.

Rhabdomyolysis

Prolonged coma and convulsions may contribute to the development of rhabdomyolysis, which is treated conventionally, with large amounts of crystalloid solutions, alkalinization of the urine, and forced diuresis.

Infusion of large amounts of crystalloids in patients with narcotic overdose may require close monitoring of hemodynamic parameters because these patients are also at risk for pulmonary edema.

Special considerations

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.

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Surgical Care

Surgery is indicated for body packers with bowel obstruction or bowel perforation. Surgery is also indicated in patients with ruptured packets resulting in life-threatening symptoms not responding to naloxone infusions or when the ruptured packets contain cocaine and other life-threatening drugs. Unruptured heroin packages that remain in the stomach for longer than 48 hours without obstruction may be managed expectantly.

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Consultations

Consultation with a toxicologist or the regional poison control center may be indicated if multiple ingestions have occurred.

Consultation with a surgeon is indicated when heroin packets cause a body packer or body stuffer to experience a bowel obstruction, intestinal rupture, and peritonitis and when compartment syndrome is suspected.

Consultation with a psychiatrist is indicated for patients with an intentional suicidal overdose (extremely rare).

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Diet

Patients with ileus and GI obstruction should be kept on a nothing-by-mouth status.

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Contributor Information and Disclosures
Author

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

Rania Habal, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Chair of the Clinical Competency Committee, Pulmonary and Critical Care Fellowship Program, Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Health System; Chair, Guideline Oversight Committee, American College of Chest Physicians

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

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Laurie Robin Grier, MD Medical Director of MICU, Professor of Medicine, Emergency Medicine, Anesthesiology and Obstetrics/Gynecology, Fellowship Director for Critical Care 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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

References
  1. Yaksh TL, Wallace MS. Opioid Analgesia and Pain Management. Brunten LL, ed. Goodman & Gilman's The Pharmacologic Basis of Therapeutics. 12th ed. New York, NY: McGraw Hill Medical; 2010. 481-524.

  2. US Substance Abuse and Mental Health Services Administration. Results from the 2014 National Survey on Drug Use and Health: Summary of National Findings and Detailed Tables. Substance Abuse and Mental Health Services Administration. Available at http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Accessed: July 7, 2016.

  3. United Nations Office on Drugs and Crime. World Drug Report 2014. Available at http://www.unodc.org/wdr2014/. Accessed: October 1, 2014.

  4. European Monitoring Centre for Drugs and Drug Addiction. EMCDDA Annual Report 2014. European Monitoring Centre for Drugs and Drug Addiction. Available at http://www.emcdda.eu.int/. Accessed: October 1, 2014.

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

  6. Centers for Disease Control and Prevention. Atypical reactions associated with heroin use--five states, January-April 2005. MMWR Morb Mortal Wkly Rep. 2005 Aug 19. 54(32):793-6. [Medline].

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

  8. Bryant WK, Galea S, Tracy M, Markham Piper T, Tardiff KJ, Vlahov D. Overdose deaths attributed to methadone and heroin in New York City, 1990-1998. Addiction. 2004 Jul. 99(7):846-54. [Medline].

  9. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths--United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016 Jan 1. 64 (50-51):1378-82. [Medline]. [Full Text].

  10. National Institute on Drug Abuse. Data and Statistics. Available at http://www.drugabuse.gov/. Accessed: October 7, 2013.

  11. Rudd RA, Paulozzi LJ, Bauer MJ, Burleson RW, Carlson RE, et al. Increases in heroin overdose deaths - 28 States, 2010 to 2012. MMWR Morb Mortal Wkly Rep. 2014 Oct 3. 63 (39):849-54. [Medline]. [Full Text].

  12. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015. 53 (10):962-1147. [Medline]. [Full Text].

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

  14. Coffin PO, Galea S, Ahern J, Leon AC, Vlahov D, Tardiff K. Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98. Addiction. 2003 Jun. 98(6):739-47. [Medline].

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

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

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

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

  19. New York City Department of Health and Mental Hygiene. Health department investigating hospitalizations possibly related to contaminated heroin. Available at http://www.nyc.gov/html/doh/html/pr/pr014-05.shtml. Accessed: October 7, 2013.

  20. Centers for Disease Control and Prevention. Wound botulism among black tar heroin users--Washington, 2003. MMWR Morb Mortal Wkly Rep. 2003 Sep 19. 52(37):885-6. [Medline].

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

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

  23. Seelye KQ. Heroin Epidemic Is Yielding to a Deadlier Cousin: Fentanyl. NY Times. March 16, 2016. Available at http://www.nytimes.com/2016/03/26/us/heroin-fentanyl.html?_r=0.

  24. Fentanyl and Fentanyl Analogs. National Drug Early Warning System. Available at http://pub.lucidpress.com/NDEWSFentanyl/#0uATvewBep_i. December 7, 2015; Accessed: July 7, 2016.

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

  26. Vagi SJ, Sheikh S, Brackney M, et al. Passive multistate surveillance for neutropenia after use of cocaine or heroin possibly contaminated with levamisole. Ann Emerg Med. 2013 Apr. 61(4):468-74. [Medline].

  27. Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. Substance Abuse and Mental Health Services Administration. 2013. Available at http://www.samhsa.gov/data/2k13/DAWN2k11ED/DAWN2k11ED.htm.

 
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