Opioid Toxicity Workup
- Author: Everett Stephens, MD; Chief Editor: Asim Tarabar, MD more...
Drug screens are widely available but rarely alter clinical management in uncomplicated overdoses. Drug screens are most sensitive when performed on urine. Positive results are observed up to 36-48 hours postexposure, but wide variations are possible depending upon test sensitivity, dose, route, and the patient's metabolism.
In patients with moderate-to-severe toxicity, performing the following baseline studies is appropriate:
- Complete blood cell count
- Comprehensive metabolic panel
- Creatine kinase level
- Arterial blood gas determinations
Obtain chest radiographs if acute lung injury is suspected. Abdominal films may be helpful when evaluating a suspected body stuffer or body packer. Although the body stuffer (ie, a person who quickly swallows drug packages in an effort to hide evidence from police) is more prone to toxicity from hasty preparation, body packers (ie, individuals who carefully seal large amounts of drugs in packages and then swallow them for transport) have much larger amounts of drug liberated should their packages leak. Films suggestive of ingestion are helpful in making a diagnosis, but films negative for drug packages do not rule out potentially life-threatening ingestions.
An ECG should be obtained on all patients with intentional overdose (possible cardiotoxic co-ingestants) or those with significant toxicity.
Dart RC, Surratt HL, Cicero TJ, Parrino MW, Severtson SG, Bucher-Bartelson B, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015 Jan 15. 372(3):241-8. [Medline].
Brauser D. Prescription Opioid Abuse Waning. Medscape Medical News. Available at http://www.medscape.com/viewarticle/838538. Accessed: January 23, 2015.
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].
Joranson DE, Gilson AM. Wanted: a public health approach to prescription opioid abuse and diversion. Pharmacoepidemiol Drug Saf. 2006 Sep. 15(9):632-4. [Medline].
Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: concerns and strategies. Drug Alcohol Depend. 2006 Feb 1. 81(2):103-7. [Medline].
Ray WA, Chung CP, Murray KT, Hall K, Stein CM. Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain. JAMA. 2016 Jun 14. 315(22):2415-23. [Medline].
Atluri S, Sudarshan G, Manchikanti L. Assessment of the trends in medical use and misuse of opioid analgesics from 2004 to 2011. Pain Physician. 2014 Mar-Apr. 17(2):E119-28. [Medline]. [Full Text].
Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Available at http://www.samhsa.gov/data/2k13/DAWN127/sr127-DAWN-highlights.htm. Accessed: January 7, 2015.
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].
Centers for Disease Control and Prevention,National Center for Health Statistics, National Vital Statistics System. Number and Age-Adjusted Rates of Drug-poisoning Deaths Involving Opioid Analgesics and Heroin: United States, 2000–2014. Mortality File. Atlanta, GA: 2015. [Full Text].
National Drug Early Warning System. Fentanyl and Fentanyl Analogs. Available at http://pub.lucidpress.com/NDEWSFentanyl/#0uATvewBep_i . December 7, 2015; Accessed: July 13, 2016.
Byard RW, Gilbert JD. Narcotic administration and stenosing lesions of the upper airway--a potentially lethal combination. J Clin Forensic Med. 2005 Feb. 12(1):29-31. [Medline].
Backmund M, Schuetz C, Meyer K, Edlin BR, Reimer J. The risk of emergency room treatment due to overdose in injection drug users. J Addict Dis. 2009. 28(1):68-73. [Medline].
Propoxyphene: Withdrawal - Risk of Cardiac Toxicity. U.S. Food and Drug Administration. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm234389.htm. Accessed: January 7, 2015.
Peles E, Schreiber S, Adelson M. Tricyclic antidepressants abuse, with or without benzodiazepines abuse, in former heroin addicts currently in methadone maintenance treatment (MMT). Eur Neuropsychopharmacol. 2008 Mar. 18(3):188-93. [Medline].
Hutchins KD, Pierre-Louis PJ, Zaretski L, Williams AW, Lin RL, Natarajan GA. Heroin body packing: three fatal cases of intestinal perforation. J Forensic Sci. 2000 Jan. 45(1):42-7. [Medline].
Olmedo R, Nelson L, Chu J, Hoffman RS. Is surgical decontamination definitive treatment of "body-packers"?. Am J Emerg Med. 2001 Nov. 19(7):593-6. [Medline].
Pinto A, Reginelli A, Pinto F, Sica G, Scaglione M, Berger FH, et al. Radiological and practical aspects of body packing. Br J Radiol. 2014 Apr. 87(1036):20130500. [Medline]. [Full Text].
Kerr D, Kelly AM, Dietze P, Jolley D, Barger B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009 Dec. 104(12):2067-74. [Medline].
Narcan Nasal Spray (naloxone intranasal) [package insert]. Radnor, PA: Adapt Pharma, Inc. November, 2015. Available at [Full Text].
FDA News Release. FDA moves quickly to approve easy-to-use nasal spray to treat opioid overdose. U.S. Food and Drug Administration. Available at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm473505.htm. 2015 Nov 18; Accessed: November 18, 2015.
Sutter ME, Gerona R, Davis MT, Roche BM, Colby DK, et al. Fatal Fentanyl: One Pill Can Kill. Acad Emerg Med. June 2016. [Medline].
[Guideline] Thanacoody R, Caravati EM, Troutman B, Hojer J, Benson B, Hoppu K, et al. Position paper update: Whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila). 2015 Jan. 53(1):5-12. [Medline].
Yokell MA, Zaller ND, Green TC, McKenzie M, Rich JD. Intravenous use of illicit buprenorphine/naloxone to reverse an acute heroin overdose. J Opioid Manag. 2012 Jan-Feb. 8(1):63-6. [Medline].
Palmiere C, Brunel C, Sporkert F, Augsburger M. An unusual case of accidental poisoning: fatal methadone inhalation. J Forensic Sci. 2011 Jul. 56(4):1072-5. [Medline].
Vital signs: risk for overdose from methadone used for pain relief - United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2012 Jul 6. 61(26):493-7. [Medline].
[Guideline] Chou R, Cruciani RA, Fiellin DA, Compton P, Farrar JT, Haigney MC, et al. Methadone safety: a clinical practice guideline from the American Pain Society and College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society. J Pain. 2014 Apr. 15(4):321-37. [Medline].
Lim JK, Bratberg JP, Davis CS, Green TC, Walley AY. Prescribe to Prevent: Overdose Prevention and Naloxone Rescue Kits for Prescribers and Pharmacists. J Addict Med. 2016 Jun 3. [Medline].
Coffin PO, Behar E, Rowe C, Santos GM, Coffa D, Bald M, et al. Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain. Ann Intern Med. 2016 Jun 28. [Medline].
Bachyrycz A, Shrestha S, Bleske BE, Tinker D, Bakhireva LN. Opioid Overdose Prevention Through Pharmacy-based Naloxone Prescription Program: Innovations in Healthcare Delivery. Subst Abus. 2016 May. 10:[Medline].
Kerr D, Dietze P, Kelly AM. Intranasal naloxone for the treatment of suspected heroin overdose. Addiction. 2008 Mar. 103(3):379-86. [Medline].
Beletsky L, Ruthazer R, Macalino GE, Rich JD, Tan L, Burris S. Physicians' knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities. J Urban Health. 2007 Jan. 84(1):126-36. [Medline]. [Full Text].
Porter R, O'Reilly H. Pulmonary hemorrhage: a rare complication of opioid overdose. Pediatr Emerg Care. 2011 Aug. 27(8):742-4. [Medline].
Weiner AL, Bayer MJ, McKay CA Jr, DeMeo M, Starr E. Anticholinergic poisoning with adulterated intranasal cocaine. Am J Emerg Med. 1998 Sep. 16(5):517-20. [Medline].
Brewer C, Streel E. Recent developments in naltrexone implants and depot injections for opiate abuse: the new kid on the block is approaching adulthood. Adicciones. 2010. 22(4):285-91. [Medline].
FDA Okays Handheld Autoinjector for Opioid Overdose. April 3, 2014. Medscape. Available at http://www.medscape.com/viewarticle/823039. Accessed: July 8, 2016.
Gaeta TJ, Capodano RJ, Spevack TA. Potential danger of nalmefene use in the emergency department. Ann Emerg Med. 1997 Jan. 29(1):193-4. [Medline].
Iqbal N. Recoverable hearing loss with amphetamines and other drugs. J Psychoactive Drugs. 2004 Jun. 36(2):285-8. [Medline].
Kelly AM, Koutsogiannis Z. Intranasal naloxone for life threatening opioid toxicity. Emerg Med J. 2002 Jul. 19(4):375. [Medline]. [Full Text].
Sachdeva DK, Jolly BT. Tramadol overdose requiring prolonged opioid antagonism. Am J Emerg Med. 1997 Mar. 15(2):217-8. [Medline].
Tyndale R. Drug addiction: a critical problem calling for novel solutions. Clin Pharmacol Ther. 2008 Apr. 83(4):503-6. [Medline].
Jones CM, Baldwin GT, Manocchio T, White JO, Mack KA. Trends in Methadone Distribution for Pain Treatment, Methadone Diversion, and Overdose Deaths — United States, 2002–2014. MMWR. July 8, 2016. 65:667-671. [Medline]. [Full Text].