Question regarding opioid overdose tx

[Pharmavixen]

Hi folks. I'm having a discussion/argument with a workmate, and I'm wondering if urine drug testing has a utility in the emergency tx of a suspected opioid OD. I know when we've sent suspected OD pts to hospital, a blood tox screen is standard, but I'm skeptical about the role of urine testing as part of pre-hospital standard of care.

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[xaelia]

Drug screening in the ER is typically of only minimal utility, probably only useful in the evaluation of altered mental status of uncertain etiology.

It would not have any role in directing treatment for an opiate overdose, which, if needed, would be treated based on clinical history and examination. In the setting of decreased responsiveness or respiratory depression where the diagnosis is unclear, it is also reasonable to give a trial of naloxone as a diagnostic and therapeutic option. Many EMS units carry this and have protocols for its use as well.

That being said, we frequently order drug screening on patients out of general academic interest and they are a huge waste of money.

 

[WilcoWorld]

Agree with the above.

The best way to test for opiate toxicity is to give a dose of naloxone.

 

[Apollyon]

Hi folks. I'm having a discussion/argument with a workmate, and I'm wondering if urine drug testing has a utility in the emergency tx of a suspected opioid OD. I know when we've sent suspected OD pts to hospital, a blood tox screen is standard, but I'm skeptical about the role of urine testing as part of pre-hospital standard of care.

Pre-hospital? Zero utility. From my years in EMS, such is the following:
1. For the crew, whiz when you can, 'cause there's a good chance you won't get the chance when you have to
2. For the patient, don't piss your pants on my stretcher.

 

[The White Coat Investor]

Narcan is better than a drug screen, because a drug screen can stay positive for several days, but if they wake up, start breathing, start puking, and start cussing after narcan, you've got your diagnosis.

 

[gutonc]

What they said...unless polypharmacy is a significant concern (e.g. opiate + BZD OD) in which case Narcan alone may not uncover the underlying pathology. But not really an issue in the pre-hospital setting at all.

 

[ALFI]

Narcan is better than a drug screen, because a drug screen can stay positive for several days, but if they wake up, start breathing, start puking, and start cussing after narcan, you've got your diagnosis.

theres no 'like' button here so to this.... 8 out of 10 times on a friday, saturday and sunday narcan is given and i'm just called the bitch that ruined their life and most awesome high....even though i did nothing because i'm pre-health. the other 2 times its DKA and i've usually picked it up before the EMD's can say anything...

 

[Nervous Ned]

Narcan is better than a drug screen, because a drug screen can stay positive for several days, but if they wake up, start breathing, start puking, and start cussing after narcan, you've got your diagnosis.

Exactly. As a medical student, I was working once with an attending who gave a full dose of Narcan to an unresponsive patient. Nothing happened for a minute or two, and then all of a sudden, it took five of us to hold the guy down, followed by a call to environmental services. The effect was impressive, to say the least.

 

[Farmer2DO]

Pre-hospital? Zero utility. From my years in EMS, such is the following:
1. For the crew, whiz when you can, 'cause there's a good chance you won't get the chance when you have to
2. For the patient, don't piss your pants on my stretcher.

 

[Pharmavixen]

How about dosing? Some folks want our naloxone protocol to state that we give 1 mg, but in references I've looked in, it's more like 0.1-0.4 mg, repeated 2-3 minutes prn. In my workplace, we're dealing with a high proportion of potentially violent individuals. My understanding is you want to reverse the resp dep, but you don't need to restore the person to full consciousness.

 

[EctopicFetus]

I dont ever give less than 0.2mg, my typical dose is 0.4mg.

Depending on the situation I would go as high as the 2mg noted.

 

[EM2BE]

From the tox rotation I did, we never gave more than 0.4mg for opioid overdose. We may give it q30min PRN for resp depression, but that was the only reason to give more. If there is no change with 0.4mg, you should be looking for other drugs. Drug screen is helpful when looking for other possible causes.

 

[WilcoWorld]

I start with 0.4mg in adults - from there it's a sliding scale.

If there is a lot of evidence pointing to OD (track marks, young raver kid, constricted pupils, concerned boyfriend with lots of piercings swearing "she didn't take anything!") then I'll go up to 2mg total before I usually quit. If the suspicion of OD is lower (old lady who smells like urine and is tachypneic) then I'm unlikely to try multiple doses if the initial 0.4 got no response.

For those who do respond, but need repeat dosing I start a drip at 2/3 the reversal dose per hour and titrate as needed.

 

[BADMD]

How about dosing? Some folks want our naloxone protocol to state that we give 1 mg, but in references I've looked in, it's more like 0.1-0.4 mg, repeated 2-3 minutes prn. In my workplace, we're dealing with a high proportion of potentially violent individuals. My understanding is you want to reverse the resp dep, but you don't need to restore the person to full consciousness.

I give enough to have the patient breath adequately. That can be as little as 0.1 mg with a standard natural opiate or can require swinging for the fences with some of the synthetic opioids. 0.1-0.4 mg IV is a reasonable starting dosing for most opiate overdoses.

 

[Aesculapius]

Has anyone had any experience with the nebulized naloxone strategy that has been floating out in the literature? (http://www.ncbi.nlm.nih.gov/pubmed/12609650)

 

[Venko]

I agree mostly with what is listed above, but would also suggest that any response to narcan is not diagnostic of opioid intoxication, but rather a prominent and continued response is diagnostic. It may seem like splitting hairs, but if there are endogenous opioid release in a patient who has another primary condition (i.e. trauma, head injury, etc), you can have some response to narcan, but since it is no the primary issue in these patients the response is tempered in its effect and not as continually effective...

I'm not sure if others have the same experiences

TL

 

[Hamhock]

I agree mostly with what is listed above, but would also suggest that any response to narcan is not diagnostic of opioid intoxication, but rather a prominent and continued response is diagnostic. It may seem like splitting hairs, but if there are endogenous opioid release in a patient who has another primary condition (i.e. trauma, head injury, etc), you can have some response to narcan, but since it is no the primary issue in these patients the response is tempered in its effect and not as continually effective...

I'm not sure if others have the same experiences

TL

My thinking is similar, in that there are circumstances that push me beyond 2mg narcan.

I usually start low and titrate to results in opiod tox (drip previously, but would like to try the neb method), but in the polytox or unclear presentation, I often find some response to 0.4 narcan (usually transient, which makes me think it is not opioid tox).

I think many street drug toxicities respond to some degree to 0.4 narcan. In these cases, I'll push 2mg or more. It's risky, but diagnositic. If 2-4mg of narcan results in a crazed, pissed patient trying to harm all staff, I apologize and diagnose opioid tox. If only transient, I assume "other" tox or non-tox AMS.

Recently I had a patient who was later determined to be GHB tox, who would briefly respond to 0.4 then 2 then 4mg narcan, but within 30 seconds return to GCS 3...this was diagnostically significant for me and endotrach-eally significant for the patient.

HH

 

[pinipig523]

I use narcan as either a diagnostic method or a way to alleviate respiratory depression.

1. Narcan 0.4mg neb x1 as a diagnostic method
2. Narcan 2mg iv x1 as a reversal only if resp depressed to the point where they still don't really need intubation

The one thing about the 2mg dose is that you have to be very careful about severe withdrawal including acute plum edema... seen this once - not good.... which is why I like the neb. They (patient) can rip it off before too much gets in.

 

[njac]

Recently I had a patient who was later determined to be GHB tox, who would briefly respond to 0.4 then 2 then 4mg narcan, but within 30 seconds return to GCS 3...this was diagnostically significant for me and endotrach-eally significant for the patient.

HH

my understanding with GHB toxicity (and this is the hallmark example as to why GCS shouldn't be blindly applied to tox patients) is that even if they're totally unresponsive, they never lose their respiratory drive and can be left to sleep it off without a tube. Of course that gets thrown out the window when there are coingestants.

Where I went to school there was a large heroin problem and I was taught to start small and titrate to breathing with the Naloxone. Where I am now, there isn't quite as much heroin and they seem rather apt to slam everyone with 2mg, even once they're in the ED. And then insist on a naloxone gtt and run it at 3-4mg/hr, titrating to belligerence.

 

[shookwell]

Has anyone had any experience with the nebulized naloxone strategy that has been floating out in the literature? (http://www.ncbi.nlm.nih.gov/pubmed/12609650)

I've used it. It works remarkably well, but you have to keep on eye on them. When they start waking up they tend to pull the mask off, so you have to put it back on them every once in a while. I find that this tends to titrate the naloxone pretty well; if the patient is awake enough to pull the mask off they probably don't need more naloxone at the moment, and when they do you push the mask back onto their face.