Heroin Toxicity Workup
- Author: Rania Habal, MD; Chief Editor: Asim Tarabar, MD more...
The diagnosis of heroin poisoning is usually made clinically, and laboratory analysis does not alter therapy in the emergent setting. Additional tests and further workup are indicated if the patient's condition does not respond to naloxone or if the patient's course of treatment is complicated.
Qualitative analysis may be helpful in confirming heroin use, as well as concomitant use of other drugs. Co-ingestion of alcohol, benzodiazepines, cocaine, and amphetamines is common and may contribute to morbidity and mortality. Therapeutic drug levels should be obtained if the patient is taking prescription narcotics, as these products commonly contain acetaminophen or aspirin.
Heroin is quickly metabolized to 6-MAM and morphine. Most qualitative toxicologic studies screen for morphine only and use the presence of morphine in the urine as a surrogate for heroin use. In criminal and legal cases, however, testing for specific compounds is necessary, and, because 6-MAM can be generated only from heroin metabolism, the presence of 6-MAM on a drug screen is taken as evidence for heroin use.
In mild-to-moderate heroin overdoses, arterial blood gas (ABG) analysis reveals respiratory acidosis. In more severe overdoses, tissue hypoxia is common, leading to mixed respiratory and metabolic acidosis. The presence of unexplained metabolic acidosis should prompt a search for a co-ingestion or contamination with poisonous substances such as cyanide and clenbuterol.
Hypoglycemia must be diagnosed at the bedside and treated immediately. A complete metabolic panel is indicated if the patient's coma persists despite the infusion of naloxone (Narcan), dextrose, and thiamine (the coma protocol).
Other studies to consider include the following:
Liver function tests (LFTs) and coagulation studies are indicated if hepatitis is suspected and can determine ammonia levels if hepatic encephalopathy is suspected.
Renal function should be monitored in patients with rhabdomyolysis, shock, or prolonged coma and in the setting of sepsis, severe hypertension, and preexisting renal insufficiency.
Complete blood cell (CBC) count is indicated if infection, blood loss, or immunodeficiency is suspected.
Creatine kinase (CK) level determination is indicated when rhabdomyolysis or compartment syndrome is suspected; an elevated CK level may denote cardiac injury in comatose patients.
A pregnancy test should be considered in women of childbearing age.
Cerebrospinal fluid (CSF) analysis is indicated when an infectious process is suspected.
Chest radiography is indicated if the patient remains hypoxic. A chest radiograph may help diagnose many of the pulmonary complications of heroin poisoning, including noncardiogenic pulmonary edema (depicted in the radiograph below), aspiration pneumonitis, atelectasis, and other complications of drug use such as pneumothorax, pneumomediastinum, pneumoperitoneum, septic pulmonary emboli, fungal infections, and aspiration pneumonia. Adulterants may also cause pulmonary abnormalities. Talc, for example, causes granulomatosis and thrombosis of small pulmonary vessels and may appear as a reticulonodular pattern. Long-term talc exposure may also result in pulmonary hypertension.
Abdominal radiographs are helpful in demonstrating the presence of radiopaque substances in the GI tract, such as vials or bags of heroin. The sensitivity of radiographs is only 85-90%.
A noncontrast CT scan of the abdomen and pelvis has a higher sensitivity for foreign body in the GI tract than plain radiographs. CT scanning is also able to demonstrate lack of progression of the foreign body within the GI tract to help pinpoint the site of obstruction and the site of viscus perforation.
A CT scan of the brain is indicated in the presence of focal neurologic findings or when coma persists. A CT scan may reveal space-occupying lesions such as brain abscesses, intracerebral or extracerebral hematomas, and stroke.
MRI of the brain is helpful in establishing the diagnosis of heroin-induced leukoencephalopathy. Findings include white-matter abnormalities in the cerebellum and posterior limb of the internal capsule.
An electrocardiogram (ECG) may show abnormalities in rhythm and rate, which are rare in pure opioid overdoses but common with toxicity from some co-ingestants and adulterants of street drugs. An ECG may also reveal evidence of myocardial ischemia.
Echocardiography is indicated if endocarditis is suspected. An echocardiogram may also help diagnose acute pulmonary hypertension secondary to embolic disease.
Endotracheal intubation is indicated for airway protection and may be required in the management of hypoxia due to NCPE. Endotracheal intubation with ventilation may also be required in the management of increased intracranial pressure and shock.
Pulmonary artery catheterization may be indicated. NCPE secondary to opioid overdose is characterized by a normal pulmonary capillary wedge pressure and mildly increased pulmonary arterial pressure.
Lumbar puncture may be indicated. In the absence of signs of increased intracranial pressure, a lumbar puncture is indicated in comatose patients who have evidence of meningitis or fever without a source. In cases in which bacterial meningitis is suspected, antibiotic therapy should not be delayed by the lumbar puncture.
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.
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.
United Nations Office on Drugs and Crime. World Drug Report 2014. Available at http://www.unodc.org/wdr2014/. Accessed: October 1, 2014.
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.
Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema : a case series. Chest. 2001 Nov. 120(5):1628-32. [Medline].
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].
Bikell WH, Benar O. Life-threatening opioid toxicity. Prob Crit Care. 1987. 1:106.
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].
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].
National Institute on Drug Abuse. Data and Statistics. Available at http://www.drugabuse.gov/. Accessed: October 7, 2013.
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].
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].
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].
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].
Darke S, Zador D. Fatal heroin 'overdose': a review. Addiction. 1996 Dec. 91(12):1765-72. [Medline].
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].
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].
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].
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.
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].
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].
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].
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.
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.
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].
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].
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.