2017 opioids dos and donts

2017 Spring Fling
Opioids: Do’s and Don'ts
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"Among the remedies which it has
pleased Almighty God to give to man to
relieve his
sufferings, none is so universal and so
efficacious as opium."
-Thomas Sydenham (1624-1689)
cc: Anne Worner - https://www.flickr.com/photos/28652129@N06

Objectives
• Discuss the basic pharmacology of opioids
• Discuss the epidemiology of illicit opioid use
• Describe common treatment modalities
• Describe treatment variations for uncommon
presentations
• Describe common pitfalls in the emergency care of
opioid overdoses
cc: alexdecarvalho - https://www.flickr.com/photos/51035823282@N01

• Steve Cole
• croaker260@gmail.com
• Ada County Paramedics for 18
years
• EMS for 25 (and counting)
years

Disclaimer
• I have no financial conflicts of interest
• This presentation is not a substitute for
basic clinical judgment.
• Follow your protocols!
cc: karen_neoh - https://www.flickr.com/photos/50266725@N02

Opioid use
• Since 2000
– 200% increase in overdose
deaths with opioids
• 2014
– 61% of overdoses involved
opioids
• Growing epidemic across
U.S.
– May 2016- 30 ODs and 2
deaths in 11 days
– August 15th West Virginia-
27 ODs in 5 hours
– August 29th Cincinnati- 174
ODs in 6 days
– Police exposures
• Only a matter of time

Before we get started…..
• Doing your own research…
• Knowing where to look
• Staying up to date
Educating
Yourself….

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

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.

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 (1-10%)
• Codeine
• Thebaine
• Oripavine
cc: fatboyke (Luc) - https://www.flickr.com/photos/8264376@N03

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

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

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.
KEY POINT:
Miosis and Hypotension are not definitive for ruling in or
ruling out a opioid overdose.

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

So why do people overdose?
• IV opioid use
• Poly-pharmacy Overdose
• Returning to opioid use from abstinence
– Jail?
– Detox?
• The Weekend Warrior
• Using opioids alone
• New supply of Drug

Types of Opioids
cc: karen_neoh - https://www.flickr.com/photos/50266725@N02

Opium
• The raw Latex (sap) of
the poppy plant
• The latex has:
– Morphine
– Thebaine
– Codeine,
– Oripavine
Source: http://www.aaronhuey.com/#/editorial-
archive/afghanistan-drug-war/Opium_032

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

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

Sizzurp(Codeine, ETOH, and Phenergan mixes

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

By Todd Huffman from Phoenix, AZ - Needle Exchange, CC BY 2.0,
https://commons.wikimedia.org/w/index.php?curid=5170947

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

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

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

Duragesic: Another form of
Fentanyl

Poly-Opioid Mixes
• 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

Feb 8th to 9th , 2017
* Normal is 22 opioid a day in this system

Treatment of Opioid
Overdose’s

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

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

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

THIS IS YOUR FIRST LINE TREATMENT AT ALL LEVELS

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

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

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

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

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).

Narcan (Naloxone)
•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)

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

AHA statement
• Naloxone is a potent antagonist of the binding
of opioid medications to their receptors in the
brain and spinal cord. Administration of
naloxone can reverse central nervous system
and respiratory depression caused by opioid
overdose. Naloxone has no role in the
management of cardiac arrest.

Narcan doesn’t help in Cardiac
Arrest, Or does it?
•Poorly studied but very reasonable
•In one AHA study:
• Small study , 36 patients
• Asytole and PEA were predominant rhythm. Down times varied but were typically extended.
• 42% of cardiac arrest patients with a suspected opioid etiology showed improvement in EKG
rhythm s/p Narcan administration
• 27% had ROSC by arrival at ER
• 1% had survival to discharge.
• “…Although we cannot support the routine use of naloxone during cardiac arrest, we recommend
its administration with any suspicion of opioid use. Due to low rates of return of spontaneous
circulation and survival during cardiac arrest, any potential intervention leading to rhythm
improvement is a reasonable treatment modality.”
•Why?
• Inhibits the adverse effects of the opioids in cardiac arrest, specifically hypotension
• Narcan may cause a endogenous sympathetic response (i.e. release of endogenous epinephrine)
in the opioid addicted patient
• May have indirect, poorly understood antiarrhythmic effects
•Source : Resuscitation. 2010 Jan;81(1):42-6. doi: 10.1016/j.resuscitation.2009.09.016.
Epub 2009 Nov 13. Naloxone in cardiac arrest with suspected opioid overdoses. Saybolt
MD1, Alter SM, Dos Santos F, Calello DP, Rynn KO, Nelson DA, Merlin MA.
cc: Bushtick - https://www.flickr.com/photos/67197620@N00

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

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

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

NARCAN Treat & Release
Criteria
• Criteria:
• The patient can mobilize as usual;
• The patient has an oxygen saturation on room air of >92%; 3) have a respiratory
rate >10 breaths/min and <20 breaths/min;
• The patient has a temperature of >35.0°C and <37.5°C;
• The patient has a heart rate >50 beats/min and <100 beats/min; and
• The patient has a Glasgow Coma Scale score of 15.
• Follow up with IM (or SQ) Narcan
•References:
• Christenson J, Etherington J, Grafstein E, et al. Early discharge of patients with
presumed opioid overdose: development of a clinical prediction rule. Acad Emerg
Med 2000;7(10);1110-18.
• Wanger K, Brough L, MacMillan I, et al. Intravenous vs subcutaneous naloxone for
out-of-hospital management of presumed opioid overdose. Acad Emerg Med
1998;5(4);293-9.

LE (can be) quicker than EMS
Myerburg RJ, Fenster J, Velez M, et al. Impact of community-wide police car
deployment of automated external defibrillators on survival from out-of-hospital
cardiac arrest. Circulation. 2002; 106:1058–1064

When to avoid Narcan all together
• Semi- Awake patients
• Pregnancy
• Aspiration
• POLY PHARM OD’s
cc: rishibando - https://www.flickr.com/photos/27590002@N04

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.

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

Questions?
Source: http://paindr.com/wp-content/uploads/2013/04/Poppy-

Links
• https://www.youtube.com/watch?v=1yPrGNr4TQY
• https://www.youtube.com/watch?v=sMuvTlU_mJg
• https://www.youtube.com/watch?v=Mo6cfAnP7sc
• https://www.youtube.com/watch?v=EFZzX9J_wXg
• https://www.youtube.com/watch?v=WaAnGXRvv80
• https://www.youtube.com/watch?v=veomoaFzroc
• https://www.youtube.com/watch?v=8a18abrzpEY

2017 opioids dos and donts

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