Notes – Opioid Poisoning/Overdose

Opioid Poisoning/Overdose

Patient Safety Considerations

  1. Clinical duration of naloxone
    1. The clinical opioid reversal effect of naloxone is limited and may end within an hour whereas opioids often have a duration of 4 hours or longer
    2. Monitor the patient for recurrent respiratory depression and decreased mental status
  2. Opioid withdrawal
    1. Patients with altered mental status secondary to an opioid overdose may become agitated or violent following naloxone administration due to opioid withdrawal therefore the goal is to use the lowest dose as possible to avoid precipitating withdrawal
    2. Be prepared for this potential scenario and take the appropriate measures in advance to ensure and maintain scene safety
  3. EMS providers should be prepared to initiate airway management before, during, and after naloxone administration and to provide appropriate airway support until the patient has adequate respiratory effort

Notes /Educational Pearls

Key Considerations

  1. The essential feature of opioid overdose requiring EMS intervention is respiratory depression or apnea
  2. Some opioids have additional toxic effects (e.g. methadone can produce QT prolongation, and tramadol can produce seizures)
  3. Overuse and abuse of prescribed and illegal opioids has led to an increase in accidental and intentional opioid overdoses
  4. DEA and Opioids:
    1. Legally prescribed opioids are controlled under the Drug Enforcement Administration (DEA)
    2. Opioids have a high potential for abuse, but have an accepted medical use in patient treatment and can be prescribed by a physician
    3. Frequent legally prescribed opioids include codeine, fentanyl, hydrocodone, morphine, hydromorphone, methadone, morphine, oxycodone, and oxymorphone
    4. Opioid derivatives, such as heroin, are illegal in the United States
  5. Opioid combinations:
    1. Some opioids are manufactured as a combination of analgesics with acetaminophen, acetylsalicylic acid (aspirin), or other substances
    2. In the scenario of an overdose, there is a potential for multiple drug toxicities
    3. Examples of opioid combination analgesics:
      1. Vicodin® is a combination of acetaminophen and hydrocodone
      2. Percocet® is a combination of acetaminophen and oxycodone
      3. Percodan® is a combination of aspirin and oxycodone
      4. Suboxone® is a combination of buprenorphine and naloxone
  6. High-potency opioids:
    1. Fentanyl is 50-100 times more potent than morphine – it is legally manufactured in an injectable and oral liquid, tablet, and transdermal (worn as a patch) forms however much of the fentanyl adulterating the heroin supply are illegal fentanyl analogs such as acetyl fentanyl
    2. Carfentanil is 10,000 times more potent than morphine
      1. It is legally manufactured in a liquid form – however, a powder or tablet is the most common form of this drug that is illegally produced
      2. In the concentration in which it is legally manufactured (3 mg/mL), an intramuscular dose of 2 mL of carfentanil will sedate an elephant
    3. Synthetic opioids (e.g. W-18, are 10,000 times more potent than morphine) – many synthetic opioids are not detectable by routine toxicology screening assays
  7. The IN route has the benefit of no risk of needle stick to the provider
  8. Patients with opioid overdose from fentanyl or fentanyl analogs may rapidly exhibit chest wall rigidity and require positive end expiratory pressure (PEEP), in addition to multiple and/or larger doses of naloxone, to achieve adequate ventilation
  9. PPE that provides additional cutaneous, respiratory, or ocular protection may be considered when providing care in jurisdictions experiencing an increased incidence of overdose from high potency opioids

Pertinent Assessment Findings

  1. The primary clinical indication for the use of opioid medications is analgesia
  2. In the opioid overdose scenario, signs and symptoms include:
  3. Miosis (pinpoint pupils)
  4. Respiratory depression
  5. Decreased mental status
  6. Additional assessment precautions:
    1. The risk of respiratory arrest with subsequent cardiac arrest from an opioid overdose as well as hypoxia (pulse oximetry 94%), hypercarbia, and aspiration may be increased when other substances such as alcohol, benzodiazepines, or other medications have also been taken by the patient
    2. Pediatric Considerations: The signs and symptoms of an opioid overdose may also be seen in newborns who have been delivered from a mother with recent or chronic opioid use. Neonates who have been administered naloxone for respiratory depression due to presumed intrauterine opioid exposure may be narcotic dependent and should be monitored closely for seizures

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914219 – Medical-Opioid Poisoning/Overdose

Key Documentation Elements

  • Rapid and accurate identification of signs and symptoms of opioid poisoning
  • Pulse oximetry (oxygen saturation) and, if available, capnometry or capnography
  • Blood glucose assessment
  • Naloxone dose and route of administration
  • Clinical response to medication administration
  • Number of doses of naloxone to achieve a clinical response

Performance Measures

  • Clinical improvement after prehospital administration of naloxone
  • Frequency of patients who develop adverse effects or complications (recurrent respiratory depression or decreased mental status, aspiration pneumonia or pulmonary edema)
  • Number of patients who refuse transport following naloxone administration

References

  1. American College of Medical Toxicology and the American Academy of Clinical Toxicology, Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders, http://www.acmt.net/_Library/Fentanyl_Position/Fentanyl_PPE_Emergency_Responders_.pdf. Accessed August 29, 2017.
  2. Burns G, DeRienz RT, Baker DD, Casavant M, Spiller HA. Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse? Clin Toxicol. 2016;54(5):420-3.
  3. Drug Approval Package, EVZIO (Naloxone hydrochloride) Injection. Accessdata.fda.gov. https://www.accessdata.fda.gov/drugsatfda_docs/nda/2014/205787Orig1s000TOC.cfm. Created December 18, 2014. Accessed August 28, 2017.
  4. Drugs@FDA: FDA Approved Drug Products. FDA.gov. https://www.accessdata.fda.gov/scripts/cder/daf/. New Drug Application (NDA) #208411. Accessed August 28, 2017.
  5. Drugs@FDA: FDA Approved Drug Products. FDA.gov. https://www.accessdata.fda.gov/scripts/cder/daf/. New Drug Application (NDA) #209862. Accessed August 28, 2017.
  6. Fentanyl: Preventing Occupational Exposure to Emergency Responders. Atlanta, GA: Centers for Disease Control and Prevention, the National Institute for Occupational Safety and Health; Updated November 28, 2016.
  7. Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s Toxicologic Emergencies, 10th Edition. China: McGraw-Hill Education; 2015.
  8. Marx JA et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 2014 2052-2056
  9. Nelson, LS et al. Goldfrank’s Toxicologic Emergencies, 2014, 559-578
  10. Title 21 United States Code (USC) Controlled Substance Act, Section 812. Springfield, VA: US Department of Justice, Drug Enforcement Administration.