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Questions and Answers
Death in an addict is almost always due to cardiovascular failure rather than respiratory failure.
Death in an addict is almost always due to cardiovascular failure rather than respiratory failure.
False
Alpha-methyl fentanyl is 200 times as potent as morphine and has a minimum lethal dose of about 125 μg.
Alpha-methyl fentanyl is 200 times as potent as morphine and has a minimum lethal dose of about 125 μg.
True
The first step in managing an opioid overdose is to provide adequate cardiovascular support.
The first step in managing an opioid overdose is to provide adequate cardiovascular support.
False
3-Methyl-fentanyl is 5000 times as potent as morphine, with a reported minimum lethal dose of 10 μg.
3-Methyl-fentanyl is 5000 times as potent as morphine, with a reported minimum lethal dose of 10 μg.
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Naloxone is considered the drug of choice for treating opioid intoxications.
Naloxone is considered the drug of choice for treating opioid intoxications.
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The primary acute toxic effect of fentanyl derivatives is respiratory stimulation.
The primary acute toxic effect of fentanyl derivatives is respiratory stimulation.
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Death from high doses of cocaine typically results from medullary stimulation producing respiratory failure.
Death from high doses of cocaine typically results from medullary stimulation producing respiratory failure.
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Respiratory depression from opioids lasts much longer than the effect of naloxone.
Respiratory depression from opioids lasts much longer than the effect of naloxone.
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Meperidine is a pure opioid antagonist commonly used for analgesia.
Meperidine is a pure opioid antagonist commonly used for analgesia.
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Marijuana's tetra-hydro-cannabinol (THC) effects are felt within seconds to minutes after inhalation.
Marijuana's tetra-hydro-cannabinol (THC) effects are felt within seconds to minutes after inhalation.
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Pentazocine can cause increased blood pressure and heart rate at high doses, differing from other opioids.
Pentazocine can cause increased blood pressure and heart rate at high doses, differing from other opioids.
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Acute toxicity due to codeine is commonly encountered and leads to severe symptoms.
Acute toxicity due to codeine is commonly encountered and leads to severe symptoms.
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Propranolol is effective in treating hypertension and tachycardia caused by cocaine use.
Propranolol is effective in treating hypertension and tachycardia caused by cocaine use.
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Propoxyphene poses little toxicity when used for minor pain without medical advice.
Propoxyphene poses little toxicity when used for minor pain without medical advice.
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Diphenoxylate is a safe medication with a broad therapeutic window.
Diphenoxylate is a safe medication with a broad therapeutic window.
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With low doses of cocaine, motor coordination is usually significantly impaired.
With low doses of cocaine, motor coordination is usually significantly impaired.
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Cocaine's primary method of administration is intravenous injection, which also accounts for most fatalities.
Cocaine's primary method of administration is intravenous injection, which also accounts for most fatalities.
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Comatose patients should be awakened quickly in opioid overdose situations.
Comatose patients should be awakened quickly in opioid overdose situations.
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Hyperpyrexia is rarely a contributing factor in cocaine-related deaths.
Hyperpyrexia is rarely a contributing factor in cocaine-related deaths.
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Chronic use of naloxone leads to permanent respiratory failure.
Chronic use of naloxone leads to permanent respiratory failure.
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Cocaine interferes with the reuptake of norepinephrine at adrenergic nerve endings.
Cocaine interferes with the reuptake of norepinephrine at adrenergic nerve endings.
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The use of diuretics is a standard treatment for pulmonary edema in opioid overdose cases.
The use of diuretics is a standard treatment for pulmonary edema in opioid overdose cases.
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Classic signs of opioid poisoning do not occur with propoxyphene overdose.
Classic signs of opioid poisoning do not occur with propoxyphene overdose.
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5-10% of an oral dose of THC is absorbed after consumption.
5-10% of an oral dose of THC is absorbed after consumption.
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Cocaine use by body packing can lead to fatalities.
Cocaine use by body packing can lead to fatalities.
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Phenobarbital may be substituted for diazepam if seizure control from cocaine overdose is inadequate.
Phenobarbital may be substituted for diazepam if seizure control from cocaine overdose is inadequate.
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Anticholinergic effects are characteristic of acute diphenoxylate intoxications.
Anticholinergic effects are characteristic of acute diphenoxylate intoxications.
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Low doses of THC can produce a sense of relaxation and mild euphoria.
Low doses of THC can produce a sense of relaxation and mild euphoria.
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Cocaine-induced psychosis typically does not require treatment.
Cocaine-induced psychosis typically does not require treatment.
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Intravenous fluids and vasopressors are recommended when addressing hypotension from cocaine poisoning.
Intravenous fluids and vasopressors are recommended when addressing hypotension from cocaine poisoning.
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Victims of opioid overdose only come from low socioeconomic backgrounds.
Victims of opioid overdose only come from low socioeconomic backgrounds.
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Respiratory depression in acute opioid overdose can lead to rates as low as 4 breaths per minute.
Respiratory depression in acute opioid overdose can lead to rates as low as 4 breaths per minute.
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The μ-receptors are primarily responsible for the respiratory depression caused by opioids.
The μ-receptors are primarily responsible for the respiratory depression caused by opioids.
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Cyanosis and foamy pulmonary edema are signs of mild opioid poisoning.
Cyanosis and foamy pulmonary edema are signs of mild opioid poisoning.
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Psychogenic effects from opioids mainly occur through action at the μ-receptors.
Psychogenic effects from opioids mainly occur through action at the μ-receptors.
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Hypotension is usually one of the first symptoms observed in opioid overdose.
Hypotension is usually one of the first symptoms observed in opioid overdose.
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A decrease in body temperature and cold, clammy skin are signs of opioid poisoning.
A decrease in body temperature and cold, clammy skin are signs of opioid poisoning.
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The release of antidiuretic hormone (ADH) is unrelated to opioid overdose symptoms.
The release of antidiuretic hormone (ADH) is unrelated to opioid overdose symptoms.
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Severe constipation can result from opioid overdose due to decreased gastric motility.
Severe constipation can result from opioid overdose due to decreased gastric motility.
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Bradycardia is rarely observed in acute opioid overdose.
Bradycardia is rarely observed in acute opioid overdose.
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Study Notes
Clinical Toxicology - Opioids
- Opioids (narcotics), heroin (diacetylmorphine) are commonly abused drugs.
- The association between opioid overdose and low socioeconomic status is inaccurate as victims span all age groups and socioeconomic backgrounds.
- Opioids can be obtained illegally or legally via prescription.
Mechanisms of Opioid Toxicity
- Opioid derivatives cause toxicity dependent on the dose and administration route.
- Analgesia, euphoria, respiratory depression, and miosis are linked to µ-receptor occupation.
- Different types of analgesia result from K-receptor involvement.
- Dysphoria, delusions, and hallucinations are associated with δ-receptor activation.
- Acute overdose can suppress respiration to extremely low rates (2-4 breaths per minute).
- Cyanosis and foamy pulmonary edema often accompany severe overdose.
- Death from acute opioid overdose is primarily due to respiratory arrest.
- Bradycardia and hypotension can further complicate respiratory depression.
- Hypotension usually occurs in later stages and results from hypoxia.
Signs of Narcotic Poisoning
- Pinpoint pupils (miosis) are a classic symptom of opioid poisoning.
- Body temperature decreases, and skin feels cold and clammy due to impaired hypothalamic heat regulation.
- Skeletal muscles become flaccid, and the jaw may relax.
- Tongue paralysis can cause airway obstruction.
- Urinary output decreases due to antidiuretic hormone (ADH) release.
- Gastric motility and tone in both intestines decrease, causing constipation.
- Even in addicts, death is usually a result of respiratory failure often complicated by conditions like pneumonia, shock, and pulmonary edema.
Management of Opioid Toxicity
- The primary treatment objective maintains vital functions due to depressed respiration in overdose victims.
- Initial steps include providing adequate respiratory and cardiovascular support.
- Opioid overdose is treated with direct antagonists (e.g., naloxone).
- Naloxone rapidly reverses CNS depression, analgesia, convulsions, psychotic effects, and dysphoria.
- Naloxone is the drug of choice for opioid intoxications bringing about rapid respiration improvement.
- Coma patients should be awakened quickly to limit potential for hypoxia.
- Patients with pulmonary edema should be carefully monitored and may require diuretics, digitalis, steroids, and antihistamines, though effectiveness is often uncertain.
Naturally Occurring Opioids - Codeine
- Codeine (or methylmorphine) possesses analgesic and antitussive properties.
- Codeine is less potent than morphine.
- Codeine overdose alone infrequently results in toxicity or death.
- Acute codeine ingestion produces typical morphine symptoms such as coma, miosis, and respiratory depression.
Synthetic Opioids
Diphenoxylate
- Diphenoxylate is a meperidine congener combined with atropine in an antidiarrheal preparation.
- It has a narrow therapeutic dosage range, differing from therapeutic to toxic concentrations.
- Acute ingestions, particularly in children, can cause anticholinergic symptoms like hyperpyrexia, skin flushing, lethargy, hallucinations, urinary retention, and tachycardia.
- These anticholinergic effects are followed by opioid activity – miosis, respiratory depression, and coma.
Fentanyl
- Alpha-methyl fentanyl is 200 times and 3-methyl-fentanyl is 7000 times more potent than morphine.
- The minimum lethal dose of α-methyl fentanyl is ~125 µg, and 3-methyl fentanyl is ~5µg.
- Fentanyl derivatives' primary toxic effect is dose-dependent respiratory depression, typically lasting up to 30 minutes.
- Other hemodynamic effects include bradycardia and hypotension.
Meperidine
- Meperidine hydrochloride is a pure opioid agonist and the most commonly used opioid analgesic in the medical field.
- Meperidine structure is different from morphine but similar to fentanyl.
- To achieve therapeutic efficacy, meperidine's dose may need to be escalated while posing a potential problem due to cumulative doses and pharmacokinetics.
Pentazocine
- Pentazocine primarily acts on CNS and smooth muscle.
- Common CNS effects include analgesia, sedation, respiratory depression, dysphoria, depression, confusion, and hallucinations.
- Cardiovascular effects differ from many other opioids; high doses can increase blood pressure and heart rate, cause flushing, chills, and sweating.
Propoxyphene
- Propoxyphene is a synthetic opioid analog that causes classic opioid-poisoning signs if administered in overdose.
- Propoxyphene's toxic potential is often underestimated.
- Ingestion of propoxyphene products is often mistaken for minor pain management. (e.g., when acetaminophen is also present in the product).
- Symptoms caused by propoxyphene overdose may mask symptoms from a toxic acetaminophen ingestion.
Cocaine
- Cocaine's primary pharmacological and toxic effects are centered around central stimulation.
- Common use patterns include intranasal insufflation, inhalation of freebase (crack) cocaine, smoking the freebase form, and intravenous use.
- Intranasal use is the most common cocaine administration method, and fatalities typically result from intravenous use.
- Body packing is another dangerous method associated cocaine fatalities.
###Mechanism of Cocaine Toxicity
- Cocaine inhibits norepinephrine reuptake at adrenergic nerve endings, leading to heightened norepinephrine levels.
- Cocaine also blocks dopamine and serotonin reuptake, further affecting neurotransmission.
Cocaine Poisoning Symptoms
- Euphoria or dysphoria may occur.
- Motor coordination is generally unaffected at lower doses but is impaired with higher doses, affecting lower motor centers and cord reflexes.
- Muscular twitching, possibly progressing to tonic-clonic seizures, are characteristic.
- Death due to medullary depression and respiratory failure is a severe risk associated with high doses of cocaine.
Cocaine Poisoning Management
- Diazepam is the primary seizure control medication, with phenobarbital possible as a backup.
- Cardiovascular effects require aggressive treatment with β-adrenergic blockers (like propranolol) to address hypertension and tachycardia.
- Immediate measures to raise blood pressure are crucial if the victim is in a depressed (hypotensive) state.
- Intravenous fluids and vasopressors (e.g., dopamine) may be necessary.
- Addressing hyperthermia is important.
Marijuana Toxicity
- Tetrahydrocannabinol (THC) rapidly enters the bloodstream after inhaled use.
- Subjective effects arise within seconds to minutes, lasting 2-3 hours after inhaled use and potentially longer after oral administration.
- Only approximately 5% to 10% of oral THC is absorbed.
- Low doses (2 mg) often result in mild euphoria, relaxation, increased sensory perception, and less common but observable periods of hilarity
- Moderate doses (5-7mg) often exhibit thought processes, time perception, and brief-term memory impairments, potential ataxia
- High doses (15 mg) may induce depersonalization, disorientation, paranoia, and marked sensory distortion.
- Cardiovascular effects are usually minor, although dose-related sinus tachycardia may manifest.
- However, long-term marijuana use can result in impaired pulmonary functioning, manifested as conditions like bronchitis, pharyngitis, coughing, and an asthma-like condition.
- Marijuana smoking may increase cancer risk due to high tar content.
- Management is primarily supportive and symptomatic.
- Removal of ingested material is possible using emesis, lavage, or activated charcoal.
- A disoriented patient, or patient experiencing hallucinations or panic episodes, require a prolonged talking down intervention.
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Description
This quiz covers essential information on opioids, their toxicity mechanisms, and common patterns in overdose cases. It discusses the effects of different receptors involved and highlights the dangers of opioid misuse. Test your knowledge on the implications of opioid-related clinical issues.
