Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
MORPHINE TOXICITY
Joey Tabula,MD
Internal Medicine
Objectives
 To present a case of multidrug toxicity with focus on
morphine toxicity
 To discuss pharmacologic and toxico...
General Data
 CASE DELETED IN SLIDESHARE
Present Working Impression
 Substance abuse to morphine, diazepam, methamphetamine,
nicotine
 Poisoning by morphine, dia...
Toxidrome: Narcotics and opiates
Coma Desaturation
Hypotension
Pinpoint
pupils
Morphine and Diazepam
Toxidrome History
Drug
Testing
(bedside and
semiquantitative)
Manifestations
Morphine
• Coma
• Respiratory
depression
• Hypotension
• Pinpoint pupils
• Bronchial
hypersecretion
Diazepa...
Drug interactions
 Diazepam + Morphine
 increase side effects such as dizziness, drowsiness, and
difficulty concentratin...
Opioids
 psychoactive analgesic drugs for pain relief and palliative
care
 addictive potential
 controlled prescription...
Opioid receptor transduction mechanisms
Opioid receptor subtypes
Euphoria
Clinical Effects of Opioids
Morphine
 isolated between 1803 and 1805 by Friedrich Sertürner
 first isolation of an active ingredient from a plant
 ...
Duration of effect of oral opiates
Onset and Duration of Action in Therapeutic Dosing
and Overdose of Selected Opioid Analgesic Agents
Boyer, 2012
Opioid Lipophilicity
Lipophilic
Hydrophilic
Sufentanil
Buprenorphine
Fentanyl
Methadone
Hydromorphone
Hydrocodone
Morphine...
Opioid “Liking” Phenomenon
Higher
Lower
Oxycodone
Hydromorphone
Levorphanol
Hydrocodone
Methadone
Morphine
Fentanyl
Oxymor...
Opioid acute withdrawal syndrome symptoms
Cardiac disorders
Tachycardia
Gastrointestinal disorders
Diarrhea
Nausea
Vomitin...
Cooked Morphine
 It is common for many
injecting drug users to
prepare injections from
tablets that are designed
for oral...
Cigarette filter + Commercial syringe filter
 Pulmonary embolism
 Pulmonary
granulomas
 Pulmonary edema
 Emphysema
 P...
Naloxone
 competitive antagonist to opioids in the central nervous
system
 approved as a prescription medication in the ...
Naloxone: mechanism of action
Goal of naloxone
is not necessarily
complete arousal but
adequate spontaneous ventilation.
Adverse effects after naloxone in reversal
of opioid depression
Cardiac disorders
Cardiac arrest
Tachycardia
Ventricular f...
Five-step process first responder on
suspected opioid overdose
1. Check for signs of opioid overdose (unconscious and unar...
Naloxone spray
 spraying naloxone injection into the nasal cavity as a
needle-free means of administering naloxone, thus
...
Naloxone at home
 Overdose training and take-home naloxone for opiate users:
prospective cohort study of impact on knowle...
Case Reports
 Morphine-induced cardiogenic shock in a 44-year old
woman (Feeney C, et al 2011)
 Morphine-induced constip...
Three-pronged Treatment: prioritization
Morphine
Naloxone
Diazepam
Flumazenil
MDAC
Methamphetamine
MDAC
Thank you!
Morphine toxicity (edited)
Morphine toxicity (edited)
Morphine toxicity (edited)
Upcoming SlideShare
Loading in …5
×

Morphine toxicity (edited)

2,869 views

Published on

morphine toxicity, cooked morphine

Published in: Health & Medicine
  • Be the first to comment

Morphine toxicity (edited)

  1. 1. MORPHINE TOXICITY Joey Tabula,MD Internal Medicine
  2. 2. Objectives  To present a case of multidrug toxicity with focus on morphine toxicity  To discuss pharmacologic and toxicologic effects of morphine  To discuss the management of morphine toxicity
  3. 3. General Data  CASE DELETED IN SLIDESHARE
  4. 4. Present Working Impression  Substance abuse to morphine, diazepam, methamphetamine, nicotine  Poisoning by morphine, diazepam, methamphetamine  Acute respiratory failure, resolving  Encephalopathy, resolved  Distributive shock, resolved  Ischemic acute tubular necrosis, resolving  Ischemic hepatitis, resolving  Rhabdomyolysis  Acute bilateral globus pallidus infarcts  Possible fall resulting to trauma to the cervical spine (quadriplegia)  Complicated UTI  Hypertension
  5. 5. Toxidrome: Narcotics and opiates Coma Desaturation Hypotension Pinpoint pupils
  6. 6. Morphine and Diazepam Toxidrome History Drug Testing (bedside and semiquantitative)
  7. 7. Manifestations Morphine • Coma • Respiratory depression • Hypotension • Pinpoint pupils • Bronchial hypersecretion Diazepam • Coma • Bronchial hypersecretion • Nystagmus • Hypothermia MAP • Coma • Mydriasis • Tremors • Hyperpyrexia • Hypertension • Flushing
  8. 8. Drug interactions  Diazepam + Morphine  increase side effects such as dizziness, drowsiness, and difficulty concentrating  No interactions with Methamphetamine
  9. 9. Opioids  psychoactive analgesic drugs for pain relief and palliative care  addictive potential  controlled prescriptions  needed to avoid misuse and dependence
  10. 10. Opioid receptor transduction mechanisms
  11. 11. Opioid receptor subtypes
  12. 12. Euphoria
  13. 13. Clinical Effects of Opioids
  14. 14. Morphine  isolated between 1803 and 1805 by Friedrich Sertürner  first isolation of an active ingredient from a plant  Sertürner originally named the substance morphium after the Greek god of dreams, Morpheus, for its tendency to cause sleep.
  15. 15. Duration of effect of oral opiates
  16. 16. Onset and Duration of Action in Therapeutic Dosing and Overdose of Selected Opioid Analgesic Agents Boyer, 2012
  17. 17. Opioid Lipophilicity Lipophilic Hydrophilic Sufentanil Buprenorphine Fentanyl Methadone Hydromorphone Hydrocodone Morphine Codeine Propoxyphene
  18. 18. Opioid “Liking” Phenomenon Higher Lower Oxycodone Hydromorphone Levorphanol Hydrocodone Methadone Morphine Fentanyl Oxymorphone Codeine Tapentadol Tramadol Buprenorphine
  19. 19. Opioid acute withdrawal syndrome symptoms Cardiac disorders Tachycardia Gastrointestinal disorders Diarrhea Nausea Vomiting General disorders and administration site conditions Asthenia Chills Pain Pyrexia Investigations Blood pressure increased Nervous system disorders Tremor Psychiatric disorders Nervousness Restlessness Respiratory, thoracic and mediastinal disorders Rhinorrhea Sneezing Yawning Skin and subcutaneous tissue disorders Hyperhidrosis Piloerection
  20. 20. Cooked Morphine  It is common for many injecting drug users to prepare injections from tablets that are designed for oral administration
  21. 21. Cigarette filter + Commercial syringe filter  Pulmonary embolism  Pulmonary granulomas  Pulmonary edema  Emphysema  Pulmonary fibrosis  Hypertension
  22. 22. Naloxone  competitive antagonist to opioids in the central nervous system  approved as a prescription medication in the US since 1971  generally devoid of activity unless opioids are present in a person
  23. 23. Naloxone: mechanism of action
  24. 24. Goal of naloxone is not necessarily complete arousal but adequate spontaneous ventilation.
  25. 25. Adverse effects after naloxone in reversal of opioid depression Cardiac disorders Cardiac arrest Tachycardia Ventricular fibrillation Ventricular tachycardia Gastrointestinal disorders Nausea Vomiting Investigations Blood pressure increased Nervous system disorders Convulsion Tremor Psychiatric disorders Withdrawal syndrome Respiratory, thoracic and mediastinal disorders Pulmonary edema Skin and subcutaneous tissue disorders Hyperhidrosis
  26. 26. Five-step process first responder on suspected opioid overdose 1. Check for signs of opioid overdose (unconscious and unarousable, slow or absent breathing, pale, clammy skin, slow or no heart beat). 2. Call EMS to access immediate medical attention. 3. Administer naloxone. 4. Rescue breathe if patient not breathing. 5. Stay with the person and monitor their response until emergency medical assistance arrives. After 5 minutes, repeat the naloxone dose if person is not awakening or breathing well enough. A repeat dose may be needed 30–90 minutes later if sedation and respiratory depression recur. Wermeling, 2015
  27. 27. Naloxone spray  spraying naloxone injection into the nasal cavity as a needle-free means of administering naloxone, thus reducing the risk of needle stick injury Barton et al, 2002
  28. 28. Naloxone at home  Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdose (Strang J, 2015)  239 opiate users  Pre-training and post-training questionnaire on overdose management  3-month follow-up, re-interviewed  18 overdoses  Naloxone used in 12 occasions, successful reversal  1 death in 6 overdoses where naloxone was not used
  29. 29. Case Reports  Morphine-induced cardiogenic shock in a 44-year old woman (Feeney C, et al 2011)  Morphine-induced constipation treated with methylnatrexone (Feeney KT, et al 2012)  Morphine-induced muscle rigidity in a 2-day old term neonate (van der Lee R, et al 2009)  Morphine-induced rhabdomyolysis and hyperkalemia (Feldman R, et al 2001)  Near-fatal intoxication in a 46-year old depressed woman reversed with naloxone (Westerling D, et al 1998)
  30. 30. Three-pronged Treatment: prioritization Morphine Naloxone Diazepam Flumazenil MDAC Methamphetamine MDAC
  31. 31. Thank you!

×