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General Reference ⬇

OD—Ann IM 1999;130:584

Pathophys and Cause ⬆ ⬇

Cause:Opium derivatives and synthetic opioids including propoxyphene (Darvon)

Pathophys:Psychic dependence much greater problem than the very real, though less common physical dependence (Nejm 1983;308:1096)

Epidemiology ⬆ ⬇

Increased prevalence in urban areas, physicians (Nejm 1970;282:365)

Signs and Symptoms ⬆ ⬇

Sx:Of withdrawal, in 1st 48 h restless, yawning, chills, increased pilomotor activity ("cold turkey"), progresses over 24 h to cramps, diarrhea, sweating, vomiting, tachycardia, hyperventilation, hypertension, seizures (neonates)

Si:

of OD: small pupils, somnolence, and hypoventilation (if all 3 present, 92% sens, 76% specif); needle tracks

of withdrawal: jerky respirations leading to muscle twitching

Complications ⬆ ⬇

Hepatitis B; pulmonary edema (Ann IM 1972;77:29); endocarditis especially right-sided (Ann IM 1973;78:25); nephrotic syndrome and renal failure (Nejm 1974;290:19)

of OD: hypostatic pneumonia, pulmonary edema

Lab and Xray ⬆ ⬇

Lab: Urine:opiate screen, r/o false pos results from quinolone antibiotics (Jama 2002;286:3115); will miss methadone, oxycodone, and propoxyphene, which require "confirmation" gas chromatography

Treatment ⬆

Rx: (Ann IM 1999;130:584)

of OD: observe, rx depressed respirations w naloxone (Narcan) 0.4 mg or less challenge test if addiction suspected, if no w/drawal then 2 mg iv/im/sc/et then 2 mg iv q 2-3 min up to 10 (in children, 0.01 mg/kg iv/io or et; repeat q 3 min until respond, then q 20 min); or more expensive nalmefene (Revex) (Med Let 1995;37:95) 0.5 mg iv then 1 mg 2-5 min later, use 0.1-mg challenge dose 1st if suspect addiction

of withdrawal sx: clonidine 0.1 mg bid-qid helps gi NV + D and cramps (Ann IM 1984;101:331), but methadone 1st choice at 40-100 mg po qd (Jama 1999;281:1000)

of addiction (Nejm 2000;343:1290) (available through addiction treatment clinics):

  • Methadone 80-120 mg qd po results in less severe withdrawal sx; helps up to 50% come off, better than rehab (Jama 2000;283:1303, 1337, 1343); 50 mg po qd may be enough for maintenance (Ann IM 1993;119:23)
  • Naltrexone 100-150 mg tiw, $2/50 mg, Antabuse approach, blocks narcotic effect (Med Let 1985;27:11); or iv × 8 h w general anesthesia then discharge w sc naltrexone pellet being done in for-profit detox clinics (Jama 1998;279:229, 1997;277:363 vs. 2005;294:903)
  • Buprenorphine (Subutex) 8-32 mg sl qd-tiw;
    or as combined buprenorphine-naloxone (16 mg/4 mg) (Suboxone) sl (Nejm 2006;355:365; 2003;349:928, 949;348:82; Med Let 2003;45:13; Am J Drug Alcohol Abuse 2002;28:231); naloxone prevents iv abuse, 50% 1 yr "cures"; FDA approved w 8 h CME (http://buprenorphine.samhsa.gov, or 866-287-2728); $5-$10/d
    or 3 mg sl qd × 3, then clonidine 0.1-0.2 mg po q 4 h prn sx, plus naltrexone 25 mg po qd × 2, 80% successful OP detox at 1 wk (Ann Im 1998;127:526); $300/mo
  • Diacetylmorphone (Nejm 2009;361:377) sc b-tid may help some methadone failures. Is active agent in heroin, so really just heroin maintenance