Acute opioid overdose Seyed Mostafa Mirakbari MD Assistant

Acute opioid overdose Seyed Mostafa Mirakbari MD Assistant Professor of clinical toxicology & Chair, QUMS

Opioid overdose syndrome sensitivity for diagnosing heroin overdose, 92%; specificity, 76% • Abnormal mental status • Decreased respiration • Miotic pupils The response of naloxone does not improve the sensitivity of this diagnosis.

The algorithm for the diagnosis of the drug intoxication and withdrawal current research grant stock; speaker Constricted

Symptoms of stimulant Withdrawal Each person quitting stimulants will have slightly different symptoms. They vary based on a number of factors, like the person’s tolerance and metabolism, as well as their history of use. Withdrawal from stimulants is characterized by a dysphoric mood and the presence of two or more of the following symptoms: *Jittery reactions/ Chills *Anxiety * Dehydration *Dulled senses *Slowed speech *Loss of interest *Slowed movement * Slow heart rate * Irritability *Fatigue *Hallucination/Paranoia *Weight loss or gaunt appearance * Insomnia or hypersomnia * Drug cravings *Unpleasant dreams *Body aches *Impaired memory *Increased appetite *Depression

The algorithm for the diagnosis of the drug intoxication and withdrawal Dilated

Sedation

Binding profile (affinity, n. M) µ-OR Morphine Buprenorphine Oxycodone Hydrocodone d-Propoxyphene Codeine Dextromethorphan Tramadol (+) enantiomer (–) enantiomer Imipramine 0. 3 NE IA 5 -HT IA 4 9 10 30 200 1, 300 2, 100 IA IA IA 20 800 IA IA IA 200 1, 000 1, 300 24, 800 3, 700 2, 500 430 20 500 2, 400 7 Source: Raffa et al. , J Pharmacol Exp Ther 260: 275 -85, 1992 Raffa et al. , J Pharmacol Exp Ther 267: 331 -40, 1993

Early discharge criteriae of patients with presumed opioid overdose M 1 • • tramadol is a racemate with only weak opioid binding the enantiomers have synergistic pharmacologies M 1 metabolite is opioid ( ) No other metabolites are active

Adverse events within 24 hours after the onehour assessment • more tramadol than mice M 1 enters the brainrats • the ratio increases with dose Source: Tao et al. , J Clin Pharm Ther 27: 99 -106, 2002

Remember: • 60% of patients will suffer adverse events if they do not meet discharge criteria. • It does not guarantee methadone patients.

The end

Lack of naloxone block: humans • • Randomized, placebo-controlled, crossover study Transcutaneous electrical stimulation of the sural nerve Analgesia assessment • Objective test (R-III Reflex) • Subjective test (Pain Visual Analog [PVA] scale) • Tramadol (100 mg, po) naloxone (0. 8 mg, iv) Mean maximal inhibition of tramadol analgesia by naloxone was 26% (R-III) and 31% (PVA) Reduced >50% by yohimbine Source: Desmeules et al. , Brit J Clin Pharmacol 41: 7 -12, 1996