Presentation on Opioids for the Prodigy #refresh21 free online refresher.

1. Opioids

2. Who am I
• Steve Cole
• 30+ years in EMS
• Work in SW Idaho
• EMS Training Captain
• Adjunct faculty at local university
• No financial disclosures

3. Questions
and
Objectives
• What are the types of opioids?
• Identify common natural, semi synthetic, and synthetic
opioids
• How do Opioids work?
• Describe the basic pharmacological mechanisms of
opioids
• What does a patient experiencing an opioid
overdose look like??
• Recognize the common effects (Toxidrome) of
opioids
• How do people abuse opioids?
• Describe methods of abuse
• Describe contributing factors for an opioid overdose
• How to I care for a patient with an opioid overdose?
• Describe common treatment strategies for a patient
experiencing opioid overdose
• Are there any reasons I shouldn’t use Naloxone?
• Describe special considerations with naloxone use in an
opioid overdose

4. Disclaimer
• This presentation is not a
substitute for basic clinical
judgment.
• Medicine evolves, so should
your practice of medicine.

5. Educate Yourself

6. EMS Textbooks SUCK!

10. HOW DO OPIOIDS WORK?
Describe the basic pharmacological mechanisms of opioids

11. The Opium Poppy
•Use/Abuse goes back At least to 4000
BC
•The poppy contains numerous opioid
alkaloids
•The most common Opioid Alkaloids
are:
• Morphine
• Codeine
• Thebaine
• Oripavine

12. Opioid Receptors
Source: http://www.iuphar-db.org/DATABASE/FamilyIntroductionForward?familyId=50

13. WHAT DOES A PATIENT EXPERIENCING
AN OPIOID OVERDOSE LOOK LIKE??
Recognize the common effects (Toxidrome) of Opioids

14. What is a Toxidrome?

15. What is a Toxidrome?
syn·drome (ˈsinˌdrōm/)
noun
1. a group of symptoms that
consistently occur together or a
condition characterized by a set
of associated symptoms.
tox·i·drome (ˈtäksiˌdrōm/)
noun
1. a group of signs and
symptoms constituting the basis
for a diagnosis of poisoning.
In other words: A toxidrome is a “syndrome” that specifically relates to a
specific toxin
Be cautious, many syndromes/toxidromes are subtle and overlap their
symptoms. Thorough assessment is essential

16. Opioid Toxidrome
• The Opiate Toxidrome consists of:
– Altered mental status
– Miosis*
– Unresponsiveness
– Shallow respirations
– Slow respiratory rate
– Decreased bowel sounds
– Hypothermia
– Hypotension*
• * these symptoms are very subjective, and may not be present in
polypharmacy overdoses.

17. KEY POINT:
Miosis and
Hypotension are not
definitive for ruling in
or ruling out a opioid
overdose.
•Opioids
•Organophosphates
•Hemorrhagic
Strokes (Pons)

18. End Tidal CO2 and
Opioid OD
• Since most opioid ODs result in significant
respiratory depression prior to
succumbing, many of these will be in a
profound respiratory acidosis.
• This often results in extreme elevated
ETCO2.
• Some ETCO2 in excess of 110-120 mm
Hg have been reported
• Do not hyperventilate these patients to
“bag down” the ETCO2. Instead control
the airway, support other vital functions,
and let the body’s buffer systems take
over.
Photo Credit: Bindu, B., Singh, G., Jain, V., & Chaturvedi, A.
(2019). A Persistently High End-Tidal Carbon Dioxide Value: Can
This Be Spurious? Journal of Neuroanaesthesiology and Critical
Care, 07. https://doi.org/10.1055/s-0039-1679133

19. HOW DO PEOPLE ABUSE
OPIOIDS?
Describe methods of abuse and Describe contributing factors for an opioid overdose

20. Methods of use:
• Shooting
• Skin Popping
• Muscle Popping
• Chasing the dragon
• Freebasing
• Plugging and Shelving
• Dirty Hit
• Tea
– With Grapefruit Juice
• Tincture
– Laudanum and Perigoric

21. Side Note: Bucket List

22. So why do people
overdose?
• IV opioid use
– NOTE: IN Drug use
carries a similar risk
• Poly-pharmacy Overdose
• Returning to opioid use
from abstinence
– Jail?
– Detox?
• The Weekend Warrior
• Using opioids alone
• New supply of Drug

23. Poly-pharm OD
Speedball
(Opioid and a stimulant used IV)

24. Poly-Opioid OD
• Increasingly common practice of
mixing one type of opioid
(typically Heroin) with another ,
more potent opioid.
• This increases the “potency”
(increasing profit) without
increasing the “purity” (i.e. the
cost)
• Retains the eurphoric effects of
some opioids while getting the
heavier nod of others.
Photo credit: NPR.org
Tamika Moore/AL.com/Landov

29. What is Diversion?
• Diversion is the use of prescribed substances (Opioids are
just one drug class that is often diverted) for illicit or
recreational use.
• How are Drugs Diverted?
– Hospice/Home Health Care
– Visitors
– Family
– Health Care providers
– Public Safety Workers
– Professional Patients.

31. TYPES OF OPIOIDS
Identify common natural, semi synthetic, and synthetic opioids

32. Opioids: What are we
talking about?
• Illicit vs. Legal?
• Synthetic vs. naturally occurring opioids?
• Clinical vs Recreational use?

33. Opium

34. Morphine
•Naturally occurring in raw opium
• First isolated in 1804
• First IV opioid in 1857
•The gold standard by which other
opioids are judged
•Potent Respiratory / CNS
depressant
•“Equipotent” euphoria to Heroin,
though slower onset.
•Intermediate Duration (3-6 hours)
•Many “ER” (extended release)
formulations
cc: Dirty Bunny - https://www.flickr.com/photos/34728046@N00

35. Codeine, Hydrocodone
•Codeine naturally occurs
in the poppy plant
•Hydrocodone is a semi-
synthetic derivative of
codeine. Often taken as a
oral tablet or an elixir
• Often co-ingested
with an NSAID (such
as APAP, Motrin or
ASA)
• Norco, Vicodin
cc: compujeramey - https://www.flickr.com/photos/37171504@N00

36. Semi-Synthetic
opioids
• Semi-Synthetic Opioids are opioids
that are synthesized frojm naturally
occurring opioids but are generally
more potent or have other desirable
properties.
• Ex:
– Heroin (Morphine)
– Dilaudid (Morphine)
– Oxycodone (Thebaine)

37. Heroin
• Black Tar
• China White
• Speed Ball
• Homicide, Buick,
super Buick,
twilight sleep

38. Oxycontin/Oxycodone
•Oxycodone is another semi-synthetic
•Derived from Thebaine
•Roughly twice as potent as Morphine
•Also More potent than Hydrocodone
•Most often available in Tablet form
• Like Hydrocodone, often co-ingested with
an NSAID (such as APAP, Morin or ASA)
• Percocet
•Extended release versions known as
Oxycodone
• “Oxy”
• May be crushed, diluted, and injected like
traditional heroin

39. Dilaudid
•Hydromorphone
•Semi-Synthetic Opioid
• Technically found in small
quantities in the poppy plant
• Synthesized in 1924 directly from
Morphine
•Very potent analgesic
•Very Euphoric
•Very potent CNS/ Respiratory
Depressant
•Faster acting than Morphine
(similar to Heroin for rate of onset)
• 10 times more potent than
Morphine
• 5 times more potent than Heroin

40. Synthetic Opioids
• Synthetic opioids are substances that are synthesized in a laboratory , that are not derived from any of the four
naturally occurring opioids, but which target some or all of the various opioid receptors.
– Clinical
– Veterinary
– Industrial
• Ex:
– Fentanyl Analogs
– Methadone
– Loperimide

41. Duragesic: Another form of
Fentanyl

42. Methadone
•Synthetic opioid
•Comparable with Oxycontin and
Dilaudid. Longer acting than most
other Analgesic
• Typically 4-8 hours
•Like other prescription opiates,
WIDELY Available
•One study showed of 18 methadone
related deaths:
• Less than ½ were prescribed methadone
• Only three were prescribed methadone
through a methadone tx program

43. Imodium
Methadone
•Synthetic opioid
•“Lope”, “Poor Mans Methadone”
•Relatively low cost and easy to get
increases addiction potential
•Like Methadone, Loperamide can
prolong sedum blockade and prolong
the QT interval.

44. KEY POINT:
METHADONE AND IMMODIUM (LOPERAMIDE) HAVE CARDIAC
TOXICITY AS WELL
• Like Methadone, Loperamide can
prolong sedum blockade and
prolong the QT interval.
– VT
– TdP
• Case reports of “Ventricular
Tachycardia Storm” refractory to
antiarrhythmics and electrical
therapy
– This is a similar mechanism for
the cardiac effects of Tricyclic
anti-depressants, as well as
calcium channel effects.

45. How to I care for a patient
with an Opioid Overdose?
Describe common treatment strategies for a patient experiencing opioid overdose

46. It is a lot more than
Naloxone

47. REMEMBER: Opioid overdoses are AMS calls first, opioid overdoses last
A - alcohol, alcohol withdrawal, and
anoxia
E -epilepsy and other neurological
disorders
I - insulin (Hyper or Hypo-glycemia)
O - overdose (Poly-pharmacy?)
U - uremia, underdose of current
medications.
T - trauma
I - infection
P - psychiatric
S - stroke, shock states
cc: Wade Morgen - https://www.flickr.com/photos/31845391@N04

48. In order to treat an opioid patient
we need to understand HOW
opioids kill…
Primary Causes of Mortality:
• Respiratory failure
• Airway Failure
Secondary Causes of Mortality
• Aspiration
• (Rarely) hypothermia and hypotension
• Situational Factors
• MIS-TREATMENT by providers
cc: Peter O'Connor aka anemoneprojectors - https://www.flickr.com/photos/58414938@N00

49. THIS IS YOUR FIRST
LINE TREATMENT AT
ALL LEVELS

50. Effect
Time
Potential Respiratory Effect of Certain
Opioids (i.e. Heroin, Dilaudid)
Potential Respiratory Effect of Other
Opioids (i.e. Morphine, Methadone)
NOTE: Sufficient quantities of ANY opioid
may induce respiratory compromise!
Threshold of Respiratory
Arrest/Failure

51. But what
if????
• Remember:
– No one ever died of a
naloxone deficit
– Patient die from Airway
Failure
– Patients die from
Respiratory Failure
– Patients die from
complications of Aspiration
– and rarely heart problems
and blood pressure
problems

52. What is Narcan?
• Generic: Naloxone
• Opioid antagonist
• Effects in 2-3 minutes
• Higher doses needed for
synthetic opioids

53. What is an
antagonist?
Binds to a “receptor” but doesn’t allow it
to be activated.

54. Narcan, OPIOID Withdrawal,
and adverse events?
•OPIOID WITHDRAWAL IS RARELY FATAL.
• WHY DO WE HAVE FATAL EVENTS WITH NARCAN INDUCES WITHDRAWAL?
•Have you ever heard Narcan causing :
• Seizures
• Cardiac Arrest (VT)
• Stroke?
•MOST (not all ) WITHDRAWAL SYNDROMES ARE RELATED DIRECTLY TO THE
EFFECTS OF THE DRUG/SUBSTANCES INVOLVED.
• Then WHY do these S/S occur?
•FOUR REASONS:
• SYNPATHETIC RESPONSE
• HYPOXIA
• HYPERCARBIA
• ACIDOSIS
cc: LendingMemo - https://www.flickr.com/photos/92802060@N06

55. Avoiding BAD OUTCOMES
•SYNPATHETIC RESPONSE
• EPINEPHERINE RELEASE!
•RESPIRATORY DEPRESSION CAUSES:
• HYPOXIA
• HYPERCARBIA
• ACIDOSIS
•We Treat Sympathetic response by SLOWING DOWN NARCAN ADMIN
with SMALLER DOSES
•We treat the RESPIRATORY CAUSES WITH CORRECTIVE BVM THERAPY!
cc: @icandidyou - https://www.flickr.com/photos/24423223@N02

56. Potency vs. Affinity
Potency = How hard the drug punches
Affinity= How hard the drug “handshakes” the receptor site.

57. Indications:
• Unconscious and not responding to any verbal stimuli
– If the patient “mumbles words” or has semi purposeful movement, roll on
side and then monitor closely
• No detectable breathing, OR has poor respiratory effort such as:
– agonal breaths
– loud snoring respirations
– occasional gasping breaths or cyanosis.
• The patient has pinpoint pupils along with the respiratory
depression or arrest (ineffective or absent breathing).

58. Do you need pinpoint pupils?

59. Can the patient…
• Look at you?
• Swallow on command?
• Cough on command?
• Follow any instructions?
• Hold a cup?
• Sit upright?
• Running around being
agitated?

60. Is the patient?
• Snoring
• Gurgling
• Blue
• Apniec
• Have poor Respiratory
effort?

61. BLS Naloxone?

64. Why Intranasal?

65. Why Intramuscular?

66. Narcan (Naloxone)
for Paramedics and AEMTs
•Ventilation/stimulation first
•Slow admin of Narcan, just enough to make them breath
• ABSOLUTELY NO PUNATIVE ADMINISTRATION!!!
•Adult:
• IV, SL: 0.1-2 mg PRN MAX Single dose of 0.4-0.5 mg.
• Max total dose 10 mg.*
• IN/IM/ETT, IV in cardiac arrest: 2 mg.
•Pediatrics:
• 0.01-0.05 mg/kg IV, IO, IM, SubQ, ET. Repeat PRN.
• MAX 0.4-0.5 mg/dose
•High (total) doses may be needed if drug is synthetic
•Watch for re-sedation due to Narcan’s short duration (about 20-
30 minutes)

67. KEY POINT:
•It should be noted that a response to (or failure to
respond) naloxone is not considered a reliable
diagnostic tool in determining if a patient has
consumed opioids.
•Failure to respond to a total dose of 10 mg of
naloxone usually indicates:
• That poisoning is not due to opioids (or opioids alone);
• Or that hypoxic brain damage has occurred.
• Or that the AMS is not opioid related at all
• (A-E-I-O-U-T-I-P-S)
cc: CarbonNYC [in SF!] - https://www.flickr.com/photos/15923063@N00

68. Naloxone
Infusions?
• Re-administer bolus of 0.1-2mg naloxone and initiate
infusion
• To mix: 4 mg/250 cc
• IV/IO 0.1-10 mg/hour, titrated for effect.
• Initiated at a rate 50-100% equivalent to the initial rescue
dose required to maintain respiratory effort.
• I.E. if 1 mg was initially required for restoration of
respirations, the dose may be initially set at 0.5-1 mg/hour to
maintain that state”

69. Narcan in Cardiac
Arrest
• 2020 AHA Opioid Guidelines
– 2020 - “Because there are no studies
demonstrating improvement in patient
outcomes from administration of
naloxone during cardiac arrest, provision
of CPR should be the focus of initial care.
Naloxone can be administered along
with standard ACLS care if it does not
delay components of high-quality CPR.”
• Probably no harm UNLESS you sacrifice
quality CPR to give it

70. No patient
should suffer
a delay in
care
“waiting for
Narcan to
work”

71. ARE THERE ANY REASONS I
SHOULDN’T USE NALOXONE?
Describe special considerations with naloxone use in an opioid overdose

72. When to avoid Narcan all together
• Semi- Awake
patients
• Pregnancy
• Aspiration
• POLY PHARM OD’s

76. Source: http://www.elephantjournal.com/2013/10/love-it-all-a-husbands-farewell-to-his-
dying-wife-photos/
It is generally unwise to treat these patients with an opioid antagonist unless life threatening
respiratory depression is a reasonable concern..
"Inappropriate use of naloxone in cancer patients with pain.."
J Pain Symptom Manage. 11(2)(1996): 131-134.

77. In the End
•Stay up to date
•Don’t believe the Hype
•Overdose patients are AMS patients first, opioid overdoses last
•CORRECT HYPOXIA, ACIDOSIS , HYPERCARBIA BEFORE NARCAN
•When giving Narcan: SLOW and LOW (Slow Push and Low Doses
repeated)
• Goal is airway and respiratory correction, not to wake them up
cc: jayneandd - https://www.flickr.com/photos/8180853@N07

78. Wrapping up…