Sections

Presentation

History

Pertinent history may be obtained from bystanders, family, friends, or emergency medical services (EMS) providers. Pill bottles, drug paraphernalia, or eyewitness accounts may assist in the diagnosis.

Occasionally, a trial of naloxone administered by EMS is helpful to establish the diagnosis in the prehospital setting.

Ingestion time, quantity, and co-ingestants are important aspects of the history and should be ascertained.

Physical Examination

Patients with opioid toxicity characteristically present with a depressed level of consciousness. Opiate toxicity should be suspected when the clinical triad of central nervous system (CNS) depression, respiratory depression, and pupillary miosis are present. It is important for the clinician to be aware that opioid exposure does not always result in miosis (pupillary constriction) and that respiratory depression is the most specific sign. Drowsiness, conjunctival injection, and euphoria are seen frequently.

Needle tracks are observed occasionally, depending on the route of abuse. Street users commonly use heroin and morphine by subcutaneous ("skin popping") and intravenous ("mainlining") injection. Raw opium usually is eaten or smoked, and sometimes the powder is sniffed ("snorted"). Transdermal opioid patches, such as fentanyl, also may produce toxicity.

Other important presenting signs are ventricular arrhythmias, acute mental status changes, and seizures. Reliance on pupillary miosis to diagnose opioid intoxication can be misleading. If sufficiently severe, hypertension and pupillary dilation may be present because of CNS hypoxia. Morphine, meperidine, pentazocine, diphenoxylate/atropine (Lomotil), and propoxyphene sometimes are associated with mydriasis or midpoint pupils.

The respiratory effort frequently is impaired in opiate intoxication. Both bradypnea and hypopnea are observed. Rates as slow as 4-6 breaths per minute often are observed with moderate-to-severe intoxication. The body retains the hypoxic drive to breathe but this may be overridden by the CNS sedative effects of a severe overdose.

Mild peripheral vasodilation may occur and result in orthostatic hypotension. However, persistent or severe hypotension should raise the suspicion of co-ingestants and prompt reevaluation. Opioids prolong GI transit times, possibly causing delayed and prolonged absorption. Initial tendencies for nausea and emesis are transient. Pink frothy sputum, muscular rigidity, dyspnea, hypoxia and bronchospasm strongly suggest acute lung injury.

Nightmares, anxiety, agitation, euphoria, dysphoria, depression, paranoia, and hallucinations are encountered infrequently, mainly with high doses. Pruritus, flushed skin, and urticaria may arise because of histamine release. Generalized seizures are infrequent; they occur most commonly in infants and children because of initial CNS excitation. In contrast, seizure activity in adults is suggestive of meperidine or propoxyphene ingestions; tramadol may lower the seizure threshold, and so may rarely lead to seizures at therapeutic doses as well as in overdoses. Hearing loss has been associated with heroin and alcohol but is generally considered recoverable.

Propoxyphene, a frequently prescribed narcotic often paired with acetaminophen, was withdrawn from the US market on November 19, 2010 because of the risk of serious cardiac toxicity, even when used at therapeutic doses.^[30]Nevertheless, as recently as 2018, rare cases of exposure to acetaminophen plus propoxyphene continued to be reported.^[18]

Differential Diagnoses

Opioid Overdose: Data Overview. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/drugoverdose/data/index.html. March 19, 2020; Accessed: June 6, 2020.
Opioid Overdose: Understanding the Epidemic. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/drugoverdose/epidemic/index.html. March 19, 2020; Accessed: June 6, 2020.
Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths - United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019 Jan 4. 67 (5152):1419-1427. [Medline]. [Full Text].
Ahmad FB, Escobedo LA, Rossen LM, Spencer MR, Warner M, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. Available at https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. 2020; Accessed: June 6, 2020.
Fentanyl. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/drugoverdose/opioids/fentanyl.html. March 19, 2020; Accessed: June 6, 2020.
Ludden J. An Even Deadlier Opioid, Carfentanil, Is Hitting The Streets. Shots: Health News from NPR. September 2, 2016. Available at http://www.npr.org/sections/health-shots/2016/09/02/492108992/an-even-deadlier-opioid-carfentanil-is-hitting-the-streets.
Hedegaard H, Miniño AM, Warner M. NCHS Data Brief ■ No. 329 ■ November 2018 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics Drug Overdose Deaths in the United States, 1999–2017. NCHS Data Brief. November 2018. Available at https://www.cdc.gov/nchs/data/databriefs/db329-h.pdf.
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. January 22, 2015; Accessed: June 6, 2020.
Drug Overdose Death Data. Centers for Disease Control and Prevention. Available at https://www.cdc.gov/drugoverdose/data/statedeaths.html. March 19, 2020; Accessed: June 6, 2020.
Hanks S. The law of unintended consequences: when pain management leads to medication errors. P T. 2008 Jul. 33 (7):420-5. [Medline].
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].
Dean L, Pratt V, McLeod H, Dean L, Malheiro A, Rubinstein W. Codeine Therapy and CYP2D6 Genotype. March 16, 2017. [Medline]. [Full Text].
Miotto K, Cho AK, Khalil MA, Blanco K, Sasaki JD, Rawson R. Trends in Tramadol: Pharmacology, Metabolism, and Misuse. Anesth Analg. 2017 Jan. 124 (1):44-51. [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].
Guy GP Jr, Zhang K, Bohm MK, Losby J, Lewis B, Young R, et al. Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017 Jul 7. 66 (26):697-704. [Medline]. [Full Text].
Gummin DD, Mowry JB, Spyker DA, Brooks DE, Beuhler MC, Rivers LJ, et al. 2018 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 36th Annual Report. Clin Toxicol (Phila). 2019 Dec. 57 (12):1220-1413. [Medline]. [Full Text].
Centers for Disease Control and Prevention. Opioid Overdoses Treated in Emergency Departments. CDC Vital Signs. Available at https://www.cdc.gov/vitalsigns/pdf/2018-03-vitalsigns.pdf. March 2018; Accessed: October 1, 2018.
Drug Enforcement Administration. Fentanyl Remains the Most Significant Synthetic Opioid Threat and Poses the Greatest Threat to the Opioid User Market in the United States. Available at https://ndews.umd.edu/sites/ndews.umd.edu/files/fentanyl-remains-most-significant-synthetic-opioid-threat-2018.pdf. May 2018; Accessed: June 6, 2020.
Gladden RM, O'Donnell J, Mattson CL, Seth P. Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines, Cocaine, and Methamphetamine - 25 States, July-December 2017 to January-June 2018. MMWR Morb Mortal Wkly Rep. 2019 Aug 30. 68 (34):737-744. [Medline]. [Full Text].
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].
Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2011–2016. National Vital Statistics Reports. December 12, 2018. Available at https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf.
United Nations Office on Drugs and Crime. World Drug Report 2017. Available at https://www.unodc.org/wdr2017/. Accessed: October 1, 2018.
Mounteney J, Giraudon I, Denissov G, Griffiths P. Fentanyls: Are we missing the signs? Highly potent and on the rise in Europe. Int J Drug Policy. 2015 Jul. 26 (7):626-31. [Medline].
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].
Brooks M. Gabapentin Plus Opioids a Deadly Combination?. Medscape Medical News. Available at http://www.medscape.com/viewarticle/886536. October 4, 2017; Accessed: June 6, 2020.
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].
FDA Okays Handheld Autoinjector for Opioid Overdose. Medscape. Available at http://www.medscape.com/viewarticle/823039. April 3, 2014; Accessed: June 6, 2020.
FDA Drug Safety Communication: FDA recommends against the continued use of propoxyphene. U.S. Food and Drug Administration. Available at https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-recommends-against-continued-use-propoxyphene. November 19, 2010; Accessed: June 6, 2020.
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 https://wayback.archive-it.org/7993/20180125101447/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm473505.htm. 2015 Nov 18; Accessed: June 6, 2020.
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].
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].
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].
Babu KM, Brent J, Juurlink DN. Prevention of Opioid Overdose. N Engl J Med. 2019 Jun 6. 380 (23):2246-2255. [Medline]. [Full Text].
Strang J, McDonald R, Campbell G, Degenhardt L, Nielsen S, Ritter A, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019 Sep. 79 (13):1395-1418. [Medline]. [Full Text].
FDA approves new hand-held auto-injector to reverse opioid overdose. US Food and Drug Administration. Available at http://wayback.archive-it.org/7993/20170112032835/http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm. April 3, 2014; Accessed: June 6, 2020.
Wheeler E, Jones TS, Gilbert MK, Davidson PJ, Centers for Disease Control and Prevention (CDC). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014. MMWR Morb Mortal Wkly Rep. 2015 Jun 19. 64 (23):631-5. [Medline]. [Full Text].
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].
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].
Kerr D, Dietze P, Kelly AM. Intranasal naloxone for the treatment of suspected heroin overdose. Addiction. 2008 Mar. 103(3):379-86. [Medline].

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Author

Everett Stephens, MD Assistant Clinical Professor, Department of Emergency Medicine, University of Louisville School of Medicine

Everett Stephens, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael J Burns, MD Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

Mark Louden, MD Assistant Professor of Clinical Medicine, Division of Emergency Medicine, Department of Medicine, University of Miami, Leonard M Miller School of Medicine

Mark Louden, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

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.

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