Opioid toxicity


  • Natural derivatives: Heroin, Morphine, Codeine, Hydrocodone, Oxycodone (+ UDS)
  • Synthetic: Fentanyl, Hydromorphone, Buprenorphine, Methadone, Meperidine, Dextromethorphan (- UDS)
  • Obtain acetaminophen levels in all cases of combination opioid-acetaminophen (Percocet) overdoses
  • Respiratory depression is the cause of all mortality from opioid toxicity
  • When prescribing opioid pain relievers in the ED, remember to have a discussion of co-ingestion of other depressants (alcohol involved in 1/5 of opioid related deaths)[1]
  • Consider contributing to the DAWN database for public ED research benefit (Drug Abuse Warning Network)
  • Other than common co-ingestions, consider adulterants such as amphetamines, anticholinergics, hypnotics, heavy metals, etc.

Clinical Features


  • Miosis
  • Nausea/vomiting
  • Respiratory depression
  • Mental status depression


  • QT prolongation (methadone)
  • Seizure (tramadol)
  • Acute lung injury
  • Bowel obstruction, rupture (body packers)
  • Noncardiogenic pulmonary edema (1-2% of heroin overdoses)[2]
    • Within 2-4 hrs of overdose
    • Increased RR, cough, pink frothy sputum, CXR with bilateral infiltrates
    • Resolves in 24-48 hrs with respiratory supportive care

Differential Diagnosis

Sedative/hypnotic toxicity


  • Typically clinical


Airway protection and ventilatory management

  • BVM and naloxone administration may prevent need for intubation

Naloxone (Narcan)

May repeat Naloxone q3min up to max dose 10mg. It has an almost immediate onset of action with a duration of action = 20-90min (depending on the drug ingested, most overdoses especially from heroin will require repeat dosing of Naloxone)


  • If apneic or near-apneic - 2mg IV
  • If opioid-naive with minimal respiratory depression - 0.4mg IV
  • If opioid-dependent with minimal respiratory depression - 0.05mg IV
  • Infusion
    • Only give if the patient responded to the bolus and required repeat administration
    • Step 1: Determine the "wake-up dose" or bolus required to wake the patient
    • Step 2: Give 2/3 of the "wake-up dose" per hr; mix in 1L D5W

GI decontamination


Heroin intoxication

  • Can consider discharge 1-2hr[3] after naloxone administration if all are true:
    • Ambulatory without assistance
    • O2 sat >92% (room air)
    • RR >10bpm
    • HR >50
    • Normal temp
    • GCS 15

Non-heroin intoxication

  • Consider discharge after 4-6hr observation
  • Methadone toxicity: observe for 12-24hr (longer half-life)

Narcan Prescription

  • Many states (31) offer protection again criminal liability for prescribing and distributing naloxone to laypeople
  • A new California law requires providers to offer Naloxone autoinjector prescriptions to certain patients at risk for overdose
ManufacturerRoute and DoseCost/Dose
Adapt PharmaPrefilled IN 4mg$33
AmphastarSelf-assemble IN 2mg$33
HospiraSelf-assemble IM 0.4mg$15.83
KaleoAutoinjector 0.4mg$287.50
  • Example Prescription
    • Naloxone 4mg/0.1mL prefilled syringe and intranasal atomizer device
    • Deliver 1 spray to nostril upon signs of opioid overdose. May repeat X 1. Call 911.


  • Discharged from the ED after opioid intoxication or poisoning
  • Receiving high doses of opioids or undergoing chronic pain management
  • Receiving rotating opioid medication regimens
  • Having a legitimate need for analgesia combined with a history of substance abuse
  • Using extended/long-acting opioid preparations
  • Completing mandatory opioid detoxification or abstinence programs
  • Recent release from incarceration and past abuser of opioids

See Also


  1. Jones CM, Paulozzi LJ, Mack KA. Alcohol Involvement in Opioid Pain Reliever and Benzodiazepine Drug Abuse–Related Emergency Department Visits and Drug-Related Deaths — United States, 2010. CDC MMWR. October 10, 2014 / 63(40);881-885.
  2. Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.
  3. Willman MW, Liss DB, Schwarz ES, and Mullins ME. Do heroin overdose patients require observation after receiving naloxone? Clin Toxicol (Phila). 2016; Nov 16:1-7.
  4. ACEP Policy Statement. "Naloxone Prescriptions by Emergency Physicians." Approved by ACEP Board of Directors October 29, 2015.
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