9.11. POISONING/OVERDOSAGE WITH OPIOID DRUGS

Related titles

Carfentanil, drug abuse, fentanyl, heroin, hydrocodone, hydromorphone, methadone, morphine, naloxone, opiates, opioids, overdose, oxycodone, suboxone.

Purpose of assistance

1. Rapid recognition and intervention in clinically severe cases of poisoning or overdose with opioid drugs.
2. Prevention of respiratory and/or cardiac arrest.

Inclusion criteria

Patients with existing miosis (constricted pupils), impaired consciousness, respiratory depression of all age groups with existing or potential opioid poisoning/abuse.

Exclusion criteria

Patients with impaired consciousness due to other causes (for example, head injury, hypoglycemia).

Management of the patient

1. Use special protective equipment.
2. Perform therapeutic interventions to support the patency of the airways, breathing and circulation before administering naloxone.
3. If possible, identify the specific drug taken (including release time, short or long), time of administration, dose, amount.
4. Collect the anamnesis of diseases of the cardiovascular system and drugs prescribed for other diseases.
5. Be aware that there may be unprotected used needles at the scene if a patient injects, so there is a high risk of injury during care, as this patient population has a high susceptibility to contact-borne diseases with blood.
6. Naloxone, an opioid antagonist, should be administered for respiratory depression in confirmed or potential opioid overdose.
7. IV administration of naloxone gives wider possibilities in matters of dosage and titration.
8. Administration of naloxone intravenously or intranasally or in the form of a nebulizer solution are additional ways of administering the drug.
9. If naloxone was administered before the EMD ambulance arrived, find out the dose and, if possible, take with you the device that administered naloxone, as well as other drugs at the scene.

Status assessment

1. Assess airway, breathing, circulation, state of consciousness.
2. Maintain patency of the patient’s airways, administer oxygen therapy, ventilation with an AMBU bag, if necessary.
3. Evaluate the patient for other etiologies of altered consciousness, including hypoxia (pulse oximetry below 94%), hypoglycemia, hypotension, and TBI.
4. Legal opioid drugs are also available in the form of special patches, if found on the body, remove the patch.

Treatment and intervention

1. Emergency resuscitation (opening and/or maintaining an airway, providing oxygen, ensuring adequate circulation) should be performed before naloxone administration.

2. If the patient has respiratory distress due to a confirmed or potential opioid overdose, administer naloxone.
Initial or subsequent doses of naloxone may be gradually titrated and administered until normal breathing is restored.

3. Naloxone can be administered intravenously, intramuscularly, nasally, or through an endotracheal tube:

a) adults: the typical initial dose varies between 0.4-2 mg IV, IM or through an endotracheal tube or up to 4 mg nasally;
b ) children: the children’s dose of naloxone is 0.1 mg/kg intravenously, intravenously, nasally or through an endotracheal tube:

• • • • maximum dose of 2 mg IV, IV or through an endotracheal tube;
      • maximum nasal dose is 4 mg;

c) Naloxone dispensed to the general public or to non-physicians referred through community programs or appointments may be provided as a pre-measured dose in an auto-injector or nasal spray or in pre-measured various doses and/or concentrations in a needleless syringe with an automated device for spraying on mucous membranes;
d) naloxone auto-injectors contain 0.4 mg/0.4 ml or 2 mg/0.4 ml:

• • • • sets issued to ordinary persons contain two auto-injectors and one training one;

g) naloxone nasal spray is produced in the form of a single-use spray bottle containing 4 mg/0.1 ml;
e) when using naloxone nasally with a syringe (preferably with a special dispenser at the end), try to evenly divide the dose between the nostrils (maximum dose – up to 1 ml in each nostril);
e) the dose of naloxone can be titrated until reaching restoration of normal breathing, in the case of using such routes of administration – intravenously, intravenously, nasally or through an endotracheal tube.

4. Strong opioids (see Key Points) may require larger and/or more frequent doses of naloxone to restore normal breathing and/or maintain adequate breathing.

5. Regardless of the dose of naloxone administered, airway control with adequate oxygenation and ventilation is the primary concern in patients with confirmed or suspected opioid overdose.

Patient safety

1. Clinical duration of action of naloxone:

a) duration of action is limited and may end within an hour of administration, whereas opioids often last 4 or more hours;
b) watch for recurrence suppression of breathing and changes in consciousness.

2. Stopping the action of opioid drugs:

a) patients with an altered state of consciousness due to an overdose may become aggressive and agitated after administration of naloxone due to withdrawal of opioids, so the main challenge is to use the lowest possible dose to avoid a withdrawal reaction;< br />b) be prepared for such cases and apply appropriate security measures at the scene in advance.

3. The EMD team must be prepared to initiate airway control before, during, and after administration of naloxone to ensure airway maintenance until adequate breathing is restored.

Useful information for training

Key points

1. The main symptom of an opioid overdose that requires intervention from the EMD is respiratory depression or apnea.

2. Some opioid drugs have toxic side effects (for example, methadone can cause QT prolongation and tramadol can cause seizures).

3. The overuse and abuse of licensed and illegal opioid drugs has led to an increase in intentional overdoses.

4. Drug and Opioid Administration:

a) permitted and prescription opioid drugs are controlled by the Drug Enforcement Administration;
b) opioids have a high potential for abuse, however, are permitted for medical use and can be prescribed by physicians ;
c) the most popular authorized opioid drugs are codeine, fentanyl, hydrocone, morphine, hydromorphone, methadone, oxycodone, oxymorphone;
d) opiate derivatives such as heroin are prohibited in the USA.

5. Combinations of opioids

a) some opioid drugs are released in the form of a combination of analgesics with paracetamol, acetylsalicylic acid or other substances;
b) in case of overdose, there is a probability of intoxication with several substances at once;
c) examples of the combination of opioid analgesics:

• • • • a combination of paracetamol and hydrocodone;
      • a combination of paracetamol and oxycodone;
      • a combination of acetylsalicylic acid and oxycodone;
      • a combination of buprenorphine and naloxone.

6. Strong opioids:

a) fentanyl is 50-100 times more potent than morphine, it is legally produced in the form of liquids, tablets, transdermal patches. However, most alternative forms of the fentanyl combination (used as heroin substitutes) are banned, such as acetylfentanyl;
b) carfentanil is 10,000 times stronger than morphine:

• • • • it is legally produced in the form of a liquid, however, most often this product is sold illegally in the form of tablets or powder;
      • at the concentration in which it is legally manufactured (3 mg/ml), an intramuscular dose of 2 ml of carfentanil can put an elephant to sleep;

c) synthetic opioids (eg W-18, 10,000 times stronger than morphine) – many synthetic opioids cannot be detected by routine toxicology screening tests.

7. The nasal route of administration is advantageous due to the absence of risk of damage to the larynxwho is the savior himself.

8. Overdose with fentanyl or its analogs can rapidly cause chest wall rigidity and require positive expiratory pressure ventilation in addition to multiple and/or large doses of naloxone to ensure adequate ventilation.

9. Protective equipment to protect the skin, respiratory organs, and eyes may be required in areas with a high number of overdoses of potent opioid drugs.

Corresponding evaluation results

1. The main clinical indication for the use of opioid drugs is analgesia.

2. In the event of an opioid overdose, signs and symptoms include:

a) miosis (narrowed pupils);
b) suppression of breathing;
c) suppression of consciousness.

3. Additional precautions during assessment:

a) the risk of respiratory arrest followed by cardiac arrest due to an overdose of opioid drugs, as well as hypoxia (pulse oximetry below 94%), hypercarbia and aspiration increases in case of additional use of other substances, such as alcohol, benzodiazepines, or other medications the patient is taking;
b) caution when working with children: signs and symptoms of overdose may occur in newborns whose mothers have recently used or are chronically using opioid drugs. If naloxone has been administered to an infant for respiratory depression due to potential opioid poisoning in utero, it is necessary to closely monitor the possible occurrence of seizures due to possible drug addiction.

Key elements of documentation

1. Quick and qualitative recognition of signs and symptoms of opioid poisoning.
2. Indicators of pulse oximetry and, if possible, capnometry or capnography.
3. Glucose level.
4. Dose and route of administration of naloxone.
5. Clinical response to the administered drug.
6. Number of naloxone doses to achieve a clinical response.

Criteria for the effectiveness of aid provision

1. Clinical improvement after administration of naloxone at the pre-hospital stage.
2. Frequency of occurrence of adverse effects and complications (repeated worsening of breathing or worsening of consciousness, aspiration pneumonia or pulmonary edema).
3. The number of patients who refused to be transported after the administration of naloxone.