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Toxicity, Heroin: Treatment & Medication
Updated: Aug 12, 2008
- Overview
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Treatment
Medical Care
The direct effects of heroin on the CNS are quickly reversible with naloxone. Naloxone may be given intravenously, intramuscularly, subcutaneously, or through the endotracheal tube. A response 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, which is indicated for orally ingested narcotics, especially those with large enterohepatic circulation (eg, propoxyphene, diphenoxylate) 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
- NCPE affects 0.3-2.4% of heroin overdoses and generally becomes clinically apparent within 2-4 hours of the overdose. NCPE is heralded by the onset of hypoxia, increased respiratory rate, and a cough that produces frothy pink sputum. Chest radiography generally reveals bilateral infiltrates. Heroin-related NCPE generally lasts 24-48 hours and responds to supportive care. In most instances, hypoxia improves with mask oxygen ventilation only, but NIPPV and endotracheal intubation may be required. Endotracheal intubation is indicated for airway protection, severe hypoxia, acidosis, and cardiovascular instability.
- While the cause of NCPE remains uncertain, hypoxia-induced lung damage is likely to play a major role in the development of pulmonary edema. Other causes that have been suggested include acute anaphylaxis, neurogenic effects, humoral effects, immune-complex deposition, and depressed myocardial contractility.
- 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), propoxyphene (Darvon), 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.
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).
Diet
Patients with ileus and GI obstruction should be kept on a nothing by mouth status.
Medication
The goals of pharmacotherapy are to reduce absorption of the drug, to prevent complications, and to reduce morbidity.
Narcotic antagonists
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.
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).
Adult
0.2-2 mg IV/IM q2-3min until desired effect or total of 10 mg reached
Pediatric
<20 kg: 0.1 mg/kg IV/IM q2-3min as needed based on response
>20 kg: Administer as in adults
Decreases analgesic effects of narcotics; may reduce efficacy of clonidine
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in cardiovascular disease; may precipitate withdrawal symptoms in patients dependent on opiates; caution in co-ingestions of sympathomimetics and anticholinergics
Nalmefene (Revex)
Prevents or reverses opioid effects (eg, hypotension, respiratory depression, sedation), possibly by displacing opiates from their receptors.
Adult
0.1 mg IV q2-3min until desired effect or total of 1.5 mg reached
Pediatric
0.25 mcg/kg IV q2-5min until desired effect
Decreases analgesic effects of narcotics
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in cardiovascular disease and co-ingestions of sympathomimetics or anticholinergics
GI decontaminants
These agents are used to minimize systemic absorption of the toxin.
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.
Adult
25-100 g PO, 1 g/kg or 10 times amount of poison ingested as a suspension in 4-8 oz of water
Pediatric
<1 year: Not recommended
>1 year: 1 g/kg PO or 10 times amount of poison ingested as a suspension in 2-4 oz of water
May inactivate syrup of ipecac if used concomitantly; effectiveness of other medications decrease with coadministration; do not mix charcoal with sherbet, milk, or ice cream (decreases absorptive properties of activated charcoal)
Documented hypersensitivity; poisoning or overdosage of mineral acids and alkalies
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administering activated charcoal; after emesis with ipecac, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol gastric lavage, returns will be black
Polyethylene glycol (GoLytely, Colyte)
Laxative with strong electrolyte and osmotic effects that has cathartic actions in GI tract. Accomplished whole-bowel irrigation.
Adult
2 L/h until rectal effluent clear
Pediatric
Not established
Reduces effectiveness and absorption of oral medications
Documented hypersensitivity; colitis; megacolon; bowel perforation; gastric retention; GI obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in ulcerative colitis and hot loop polypectomy
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Further Reading
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
