Heroin Intoxication

Heroin Intoxication: Excerpt from The 5-Minute Pediatric Consult

Cynthia J. Mollen, MD, MSCEThomas J. Mollen, MD

Heroin Intoxication - BASICS

Heroin Intoxication - description

Heroin is a semisynthetic derivative of opium. The opioid family includes the following:

• Drugs that occur naturally in opium (from the poppy plant)
• Codeine
• Morphine
• Semisynthetic derivatives (e.g., hydromorphone, oxycodone)
• Synthetic compounds (e.g., meperidine, methadone)

Heroin Intoxication - epidemiology

• Neonatal:
  • Fetal exposure commonly involves polysubstance abuse.
  • 60–80% of heroin-exposed infants develop withdrawal—dependent on maternal dosing and length of use.
• Adolescents:
  • Use peaked among US adolescents in the 1970s and then declined.
  • Use is increasing again because a more pure product allows for smoking or snorting as well as injecting.
  • Most use experimentally or intermittently; few become addicted and use daily.
  • Use of opioid analgesics has increased dramatically over the last 10 years, and has become more common than heroin use.
• Overdose:
  • Up to 1/3 of heroin users experience nonfatal overdose.
  • Most occur in the home and with other people present.
  • Risk factors include length of injecting history and concurrent use of CNS depressants.
• Deaths:
  • Most heroin deaths occur when drug administered IV.
  • Most deaths in patients in their late 20s or 30s, with significant drug dependence
  • Multiple drug use common in heroin-related death
  • Many deaths occur in people with a history of a nonfatal overdose.

Heroin Intoxication - incidence

• Statistically significant increase in new heroin use since 1992
• 141,000 new users in 1995
• Mean age of 1st use in 1995 = 19.3

Heroin Intoxication - prevalence

• Precise estimates of prevalence of use difficult
• ~2.9 million people used at least once
• ~633,000 used in last year
• Prevalence of fetal exposure <1–3.7%

Heroin Intoxication - pathophysiology

• Well-absorbed from gastrointestinal (GI) tract, nasal mucosa, pulmonary capillaries, and SC and IM injection sites
• Oral dose less potent than parenteral because of 1st-pass hepatic metabolism
• IV heroin peaks in <1 minute; intranasal and IM heroin peak in 3–5 minutes.
• Very lipid soluble; crosses blood–brain barrier within 15–20 seconds
• Extensive distribution into skeletal muscle, kidneys, liver, intestine, lungs, spleen, brain, and placenta
• Rapidly crosses the placenta, entering fetal tissues within 1 hour
• Crosses into breast milk in quantities sufficient to cause addiction
• Excreted in urine as morphine
• Receptor types:
  • Mu (or OPLocated in CNS, GI tract, and sensory nerve endings
  • Effect: Analgesia, euphoria, respiratory depression, physical dependence, GI dysmotility, miosis, pruritus, bradycardia
• Kappa (or OPLocated in CNS
• Effect: Analgesia, miosis, diuresis, dysphoria

Heroin Intoxication - DIAGNOSIS

Heroin Intoxication - signs & symptoms

Heroin Intoxication - history

• Neonate:
  • Maternal history of heroin or other drug use
  • Extent of prenatal care
  • Time from most recent use to delivery
  • Breast-feeding
• Older child/Adolescent:
  • History of heroin use
  • Observed overdose
  • Found in setting consistent with possible drug use

Heroin Intoxication - physical exam

• Neonate with in utero exposure:
  • Prematurity
  • Low birth weight
  • Perinatal depression with 5-minute Apgar <5
  • Hypotonia
• Intoxication/Overdose:
  • Classic toxidrome: Depressed level of consciousness, very decreased respiratory effort, miotic pupils, with or without diminished bowel sounds
  • More severe overdose: Bradycardia, hypotension
• Withdrawal:
  • Early signs (8–24 hours): Anxiety, restlessness, insomnia, yawning, rhinorrhea, lacrimation, diaphoresis, stomach cramps, mydriasis
  • Late signs (up to 3 days): Tremor, muscle spasms, vomiting, diarrhea, hypertension, tachycardia, fever, chills, piloerection, seizures
• Additional neonatal withdrawal signs and symptoms:
  • Hyperirritability
  • Hypertonicity
  • Posturing
  • Exaggerated startle
  • Tachypnea
  • Hyperpyrexia
  • Poor suck/swallow coordination
  • High-pitched cry
  • Poor weight gain

Heroin Intoxication - tests

• Therapy should not be withheld pending laboratory results.
• Urine toxicology screen (heroin easily detected)
• Serum toxicology screen for acetaminophen level, etc., if suspect polydrug use
• Serum tests to rule out other causes, if needed (e.g., glucose)
• Meconium testing in neonates

Heroin Intoxication - differencial diagnosis

• Neonatal exposure:
  • Sepsis
  • Hypoglycemia
  • CNS abnormality
  • Metabolic disorder
  • Withdrawal from other maternal drug use
• Intoxication/Overdose
• Other pharmacologic agents:
  • Clonidine, sedative hypnotics, barbiturates, antipsychotics, gamma hydroxy butyrate
• Hypoglycemia
• Hypothermia
• Hypoxia
• Heatstroke
• Pontine or subarachnoid hemorrhage

Heroin Intoxication - TREATMENT

Heroin Intoxication - general measures

• Intoxication/Overdose:
  • Start with the ABCs (airway, breathing, circulation).
  • Antidote is naloxone (Narcan).
  • Assessment of respiratory status/adequacy of ventilation
  • If adequate respiratory effort, observe until normal level of consciousness:
    • Consider naloxone as diagnostic challenge.
  • If inadequate respiratory effort:
    • Bag-valve-mask ventilation
    • IV naloxone (or SC, IM, endotracheal)
    • If <20 kg, 0.1 mg/kg; 2 mg if >20 kg. Can repeat to 10 mg total dose
  • If suspect dependence, start with lower dose (0.4 mg ampule)
  • If no response to large dose, question diagnosis of heroin toxicity—heroin exquisitely sensitive to naloxone
  • Naloxone loses efficacy in 20–40 minutes; may need repeat dosing
  • Can give as continuous infusion if necessary; dosing recommendations vary
  • One method: 2/3 of effective dose given over 1 hour with gradual wean
  • Endotracheal intubation if no response to naloxone in 5–10 minutes, or other reason for invasive airway management
  • Observe in emergency department for a minimum of 2–3 hours for respiratory status stabilization.
  • Consider chest radiograph.
• Withdrawal:
  • Standard treatment methadone maintenance (adolescents/adults):
    • Blocks euphoria and prevents withdrawal symptoms
    • Patients generally treated in established methadone maintenance programs
    • Stabilize with 20–40 mg/d; wean by 2–5 mg/wk over several months.
    • Adjust wean if signs of withdrawal appear.
    • Some programs utilize heroin maintenance when methadone fails; research ongoing
  • Clonidine (0.2 mg q4–6h for 7–10 days) can control acute withdrawal symptoms.
  • Diazepam (10–15 mg q4–6h for 3–4 days), an alternative to clonidine
  • Rapid and ultrarapid detoxification (using opioid antagonist with or without general anesthesia) a possibility in selected patients; recent review suggests high-rate adverse events:
    • Should be used only by experienced team with appropriate resources
  • In neonates:
    • Paregoric (0.4 mg/mL) not recommended owing to high alcohol content (45%) and toxic compounds such as camphor, anise oil, benzoic acid, and glycerin
    • Tincture of opium (10 mg/mL) best diluted 25-fold to a concentration equal to paregoric (0.4 mg/mL)
    • 0.1 mL/kg (2 drops/kg) q4h; increase 0.1 mL/kg q4h as needed to control symptoms. After 3–5 days, wean dose by 0.1 ml/kg/d. Observe infant for 3–5 days after stopping therapy.
    • May need IV morphine in severe cases
    • Methadone has been used occasionally.
    • Clonidine gaining favor for use in infants; pharmacokinetic data not available; although use is currently recommended only in the context of a randomized clinical trial
    • Phenobarbital not a 1st-choice agent owing to long half-life, CNS depression, induction of drug metabolism, and rapid tolerance to sedative effect, however, has been shown to be effective in conjunction with diluted tincture of opium.

Heroin Intoxication - FOLLOW UP

Developmental follow-up for exposed neonates

Heroin Intoxication - disposition

Most patients with overdose warrant hospitalization.

Heroin Intoxication - issues for referral

• Social services and referral to substance abuse program
• Consider referral for testing for HIV and hepatitis B and C.

Heroin Intoxication - prognosis

• Neonatal:
  • Long-term morbidity from neonatal heroin dependence unclear owing to confounding variables (e.g., developmental environment)
• Intoxication/Overdose:
  • With adequate early treatment, patients with uncomplicated overdoses do well—key is to prevent respiratory arrest.
• Addiction:
  • Dependent on involvement in other risky behaviors (polydrug use, high-risk sexual practices, school failure, delinquency, etc.)
  • Longer treatment likely produces a better outcome.
  • Most relapses require lifetime of therapy

Heroin Intoxication - complications

• Intoxication/Overdose:
  • Respiratory arrest
  • Noncardiogenic pulmonary edema
  • CNS depression/coma
  • Hypotension
  • Aspiration pneumonia
• Pregnancy:
  • No known teratogenic effects
  • Poor prenatal care
  • Preterm labor
  • Premature rupture of membranes
  • Breech presentation
  • Antepartum hemorrhage
  • Toxemia
  • Anemia
  • Uterine irritability
  • Infection (e.g., HIV, hepatitis B)
  • Infantile dependence
• Naloxone use:
  • May precipitate withdrawal syndrome in opioid-dependent patients
  • Symptoms: Agitation, hypertension, tachycardia, emesis
  • See dosing recommendations.
  • May cause acute severe withdrawal in infants born to addicted mothers

Heroin Intoxication - bibliography

1. Bishai R, Koren G. Maternal and obstetric effects of prenatal drug exposure. Clin Perinatol. 1999;26:75–86.
2. Chamberlain JM, Klein BL. A comprehensive review of naloxone for the emergency physician. Am J Emerg Med. 1994;12:650–660.
3. Coyle MG, Ferguson A, LaGrasse L, et al. Neurobehavioral effects of treatment for opiate withdrawal. Arch Dis Child Fetal Neonatal Ed. 2005;90:F73–F74.
Emerging Trends in Drug Abuse; Heroin abuse in the United States. From: Office of Applied Studies, U.S. Dept Health and Human Services. March 2006. http://www.oas.samhsa.gov/NHSDA/Treatan/treana 11.htm.
4. Ferri M, Davoli M, Perucci CA. Heroin maintenance for chronic heroin dependents. Cochrane Database of Systematic Reviews. 2005, Issue 2. Art. No. CD003410.
5. Gonzalez G, Oliveto A, Kosten TR. Treatment of heroin (diamorphine) addiction: Current approaches and future prospects. Drugs. 62:1331–1343, 2002.
6. Gowing L, Ali R, White J. Opioid antagonists under heavy sedation or anaesthesia for opioid withdrawal. Cochrane Database of Systematic Reviews. 2006, Issue 2. Art. No. CD002022.
7. Johnson K, Gerada C, Greenough A. Treatment of neonatal abstinence syndrome. Arch Dis Child. 2003;88:F2–F5.
8. Osborn DA, Jeffery HE, Cole M. Opiate treatment for opiate withdrawal in newborn infants. Cochrane Database of Systematic Reviews. 2005, Issue 3. Art. No.: CD002059.
9. Osborn DA, Jeffery HE, Cole M. Sedatives for opiate withdrawal in newborn infants. Cochrane Database of Systematic Reviews. 2005, Issue3. Art. No. CD002053.
10. Tarabar AF, Nelson LS. The resurgence and abuse of heroin by children in the United States. Curr Opin Pediatr. 2003;15:210–215.

Heroin Intoxication - CODES

Heroin Intoxication - icd9

304.0 Heroin addiction

Heroin Intoxication - FAQ

• Q: Is nalmefene an appropriate substitute for naloxone in a heroin overdose?
• A: Nalmefene, a long-acting specific narcotic antagonist, has not proved to be as effective as naloxone in a randomized, double-blind trial. It also may result in prolonged, dangerous withdrawal. It therefore has limited usefulness in this setting.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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