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Opioid toxicity case study

  1. OPIOID TOXICITY Neeraj Ojha Yuvraj Kalathoki Om Acharya
  2. INTRODUCTION Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia.[ Other medical uses include suppression of diarrhea, replacement therapy for opioid use disorder, reversing opioid overdose, suppressing cough, as well as for executions in the United States.
  3. Contd. Opioid are potent respiratory depressants.Opium is latex obtained from Papaver somniferum.It is an alkaloid . An opioid overdose is toxicity due to excessive opioids. Examples of opioids include morphine, heroin, fentanyl, tramadol, and methadone. Symptoms include insufficient breathing, small pupils, and unconsciousness. Onset of symptoms depends in part on the route by which the opioids are taken.
  4. Mechanism of action of opioids Opioids produce their actions at a cellular level by activating opioid receptors. These receptors are distributed throughout the central nervous system (CNS) with high concentrations in the nuclei of tractus solitarius, peri-aqueductal grey area (PAG); High densities of opioid receptors known as mu ,delta and kappa are found in the dorsal horn horn of spinal cord and higher CNS centres.
  5. Contd. Most currently used opioid receptors act mainly at mu -opioid receptors.Morphine acts at kappa receptors of the substancia granulosa of spinal cord and decrease the release of substance p which modulates pain perception in the spinal cord .
  6. MOA of toxicity User ingests opioids that attaches to receptors in the brain responsible for breathing and suppress respiratory drive. User’s breathing slows and the user becomes unresponsive with respiratory depression and hypoxia; Lack of oxygen (oxygen starvation) affects vital organs, including the heart and brain, leading to organ damage, coma, and death • Within 3-5 minutes without oxygen, brain damage starts to occur.
  7. Clinical features /symptoms 1. Respiratory depression 2. Stupor 3. Miosis 4. Hypothermia 5. Drowsiness 6. Euphoria 7. Rhabdomyolysis 8. Myoglobinuric renal failure
  8. Treatment and management Patients with apnea need a pharmacologic or mechanical stimulus in order to breathe; In patients lacking spontaneous respirations, orotracheal intubation is preferred. If advanced life support (ALS) is available, intravenous naloxone (Narcan) may be given to reduce respiratory depression. Alternate routes of naloxone administration include intraosseusly, intramuscularly, intranasally, or via endotracheal tube
  9. ANTIDOTE Naloxone ,the antidote for opioid overdose, is a competitive mu opioid -receptor antagonist that reverses all signs of opioid intoxication; The onset of action less than 2 minutes when naloxone is administered intravenously ,and its apparent duration of action is 20-90 minutes; It is active when the parenteral ,intranasal or pulmonary
  10. Contd. route of administration is used but has negligible bioavailability when administered orally because of extensive first pass metabolism .
  11. CASE STUDY A 28-year-old male was admitted to an inpatient medically supervised withdrawal facility in Vancouver, Canada, for management of comorbid opioid and stimulant use disorders. Hewas not in contact with his family and had a history of homelessness. Before admission, the patient was living in a shelter and supported by income assistance. His past medical history was significant for schizoaffectivedisorder,whichwas treated by a psychiatrist with medications including olanzapine, quetiapine, lorazepam, and trazodone. The patient was both HIV and hepatitis C negative. He had a history of attending inpatient medically supervised withdrawal on numerous previous occasions. He had a brief 2-week period of methadone maintenance therapy 2 months before, up to a maximum daily dose of 50mg, which he had abruptly discontinued for unclear reasons. The patient had never previously been prescribed buprenorphine/naloxone treatment.
  12. Contd. ● Subjective details: Male 28 yrs old Country:Canada
  13. Objective details: ● Signs of opioid withdrawal, including frequent yawning, piloerection, and dilated pupils at 6 mm diameter; ● Pulse=0 ● Needle was found in the right antecubital fossa when the person was found; ● His urine drug screen on arrival at the hospital was positive for opiates and amphetamines; ● Brain magnetic resonance imaging was consistent with severe anoxic brain injury;
  14. Assessment/Diagnosis: ● So, the patient was diagnosed on the day after admission of various symptoms related to opioid toxicity; ● Patient had a return of spontaneous respiration after the administration of naloxone IM; ● The patient failed to regain consciousness after several days in the ICU.
  15. Planning:  A plan for buprenorphine/naloxone taper was initiated to manage the acute symptoms of opioid withdrawal;  An initial dose of buprenorphine/naloxone 8 mg/ 2 mg was to be tapered by 2/0.5 mg daily to discontinuation over 4 days;  The patient was also prescribed trazodone, clonidine, quetiapine, and dimenhydrinate as needed to treat any residual opioid withdrawal symptoms;  The patient was discharged from the facility back to a shelter after completion of the 4-day buprenorphine/naloxone taper;  After discussion with the family, a decision was made to transfer the patient to a palliative care unit, and the patient died 20 days in unit.
  16. Discussion: ● Risk factors for fatal overdose like this one include co- ingestion of CNS depressants such as BZDs, and alcohol, use of illicit opioids, particularly by injection, past nonfatal overdose, and recent periods of abstinence from opioids.