Heroin Toxicity Treatment & Management

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

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), 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.
Next

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).
Previous
Next

Diet

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

Previous
Proceed to Medication
 
 
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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.