Most emergency physicians have treated a few patients who have overdosed on heroin, and it's a relatively straightforward diagnosis and treatment protocol. The usual suspect is a 20- to 40-year-old man who arrives obtunded or unconscious with respiratory depression, hypoxia, hypotension, bradycardia, and the quintessential pinpoint pupils. Addicts must use heroin two or three times a day to stave off withdrawal, so stigmata of chronic IV drug abuse are often seen.
Some individuals use the leg, groin, or neck veins as opposed to the antecubital fossa. Other addicts skin pop, forming specific skin lesions on the legs or arms. Those who arrive alive usually survive after being resuscitated with IV naloxone. It doesn't take much IV naloxone to bring the patient back to his normal pre-overdose state if the overdose is pure heroin; that usually occurs within 30 to 60 seconds. Heroin also has a relatively short half-life of about one hour, so usually only one dose of naloxone is required.
Heroin is a favorite illegal drug, and is specific to various parts of the country. Heroin use in the United States has skyrocketed, more than doubling over the past five years. More than a quarter million people a year end up in the ED for heroin overdose. Heroin use is not, however, only an inner-city indigent problem. It's now an issue seen across the nation among all ages and populations, including teenagers and the rich and famous.
Major fuel for increased heroin use is its low cost when compared with the massive abuse of prescription opioids. One tablet of oxycodone can cost $20-$30, but users can get three or four glassine containers of heroin for the same price. Physicians are now more reluctant to prescribe large amounts of oral opioids because of the national spotlight on this problem. Heroin use in my area has increased, and prehospital deaths still occur. Reminiscent of prior epidemics is the recent but recurrent addition of fentanyl to street heroin. All emergency physicians know that small microgram doses of fentanyl are very powerful, and it's truly a deadly combination when added to heroin.
Overdoses from Tainted Opioids/Recommendations for Management
Philadelphia Department of Health
Jan. 28, 2014; http://1.usa.gov/1fk3TIg
This recent advisory alerted Pennsylvania physicians about numerous incidents of tainted heroin in the western and northwestern areas of the state, and it was even reported in the lay press. Heroin is cut with fentanyl and sold in brand-name packages such as “Theraflu,” “Bud Light,” “Bud Ice,” “Diesel,” and “Coors Light.” Branding a product is common practice among street heroin dealers. The health advisory emphasizes that fentanyl causes more severe opioid-induced intoxication and greatly increases the risk of death. Fentanyl will respond to naloxone administration, but greater doses of naloxone may be required for fentanyl-associated intoxication. One to two mg of naloxone should be plenty for a patient still alive, but it may require three to five times that for near-death from heroin if fentanyl is the culprit. Most abusers who happen to encounter fentanyl-contaminated heroin, however, die before they ever make it to medical care.
Comment: Fentanyl-heroin combinations are not new; they have been around since the early 1970s. The recent report of 22 deaths in Western Pennsylvania from heroin laced with fentanyl signifies that this practice has now been revived, at least regionally. The recent death of the actor Philip Seymour Hoffman brought heroin use to the forefront, and it is speculated (not yet confirmed) that his death was caused by the fentanyl-heroin combination. He was found with a needle still in his arm, not an uncommon scenario from pure heroin-related deaths but much more likely from an overdose of fentanyl.
A similar outbreak occurred in 2005 and 2006 when hundreds of addicts died from fentanyl-contaminated heroin. This epidemic was nationwide, but most recent fentanyl deaths are localized to a few specific regions. The prior nationwide outbreak was traced to a fentanyl production plant in Mexico, and closing this facility markedly reduced the problem in the United States. It is unclear whether these fentanyl-related deaths can be traced to a single source or whether multiple production sites exist. The current wave of fentanyl-contaminated heroin reports as much as 50 percent fentanyl in heroin samples. That concentration is likely going to be rapidly fatal for all but the most hardened and tolerant user.
Many cases of fentanyl-heroin overdose result in death outside the hospital. Death is caused by very rapid respiratory depression followed by cardiac arrest, and that usually occurs too rapidly for transfer to the hospital. Some countries have opted for giving a ready supply of naloxone and needles to heroin addicts, usually dispensed by their fellow addicts who witness problems. But it's unclear whether that would be of any value if high-dose fentanyl is the culprit.
I assume that most who arrive at the hospital with some vital signs have injected heroin with minimal fentanyl contamination. Heroin is rapidly metabolized to morphine, which shows as a positive opioid in the urine drug screen. Fentanyl by itself will not be detected by the traditional ED immunoassay screen, and requires GC/MS evaluation at a sophisticated laboratory. The clinician will not be able to differentiate the actual overdose mixture purely on clinical grounds. In fact, a pure fentanyl overdose will resemble a heroin or morphine overdose. The concentration of heroin alone on the street has markedly increased in this country.
One clinical aspect of this quandary should be emphasized: 1 mg of naloxone is usually more than enough to reverse a heroin-intoxicated patient who is still alive. Administer much larger doses if any significant fentanyl component is present. The last round of overdoses from Philadelphia usually required 4-5 mg and up to 8-10 mg of naloxone in some cases for complete reversal of fentanyl overdoses in the field. The classic narcotic overdose should be aggressively treated with naloxone; Philadelphia EMS was criticized for stopping at 1-2 mg when that was ineffective. Just exactly how much naloxone to administer is impossible to decipher, but you probably have the wrong diagnosis if the opioid-appearing overdose is not responding at least somewhat to 5-6 mg of naloxone. I would continue giving naloxone without increasing it if the patient has a partial response. Most patients with a large fentanyl component will die prehospital.
It is unclear how long a patient who overdosed on heroin should be observed in the ED. Many patients are in withdrawal shortly after they awaken, and want to leave AMA. That's always a difficult choice, but patients who are awake, alert, and oriented can make decisions about their own health. They may want more heroin to stave off withdrawal, but it may be blunted by the naloxone in their blood when injected shortly after leaving. This results in an even greater propensity for death once the naloxone wears off completely. You can't keep some patients from eloping, but my advice is to try to keep those who respond to naloxone in the ED for at least four or five hours because the naloxone will wear off and any residual opioid will cause recurrent symptoms. You can also treat withdrawal with 0.1-0.2 mg of clonidine every half hour or a little benzodiazepine in those who are markedly withdrawing.
Pay strict attention to charting details if a patient does leave against your wishes, and be sure to emphasize how fanatical you were in telling the patient that he shouldn't leave and how absolutely clinically pristine he was. Stress that you told the patient that he was better only because you recently saved his life, and additional heroin or a resurfacing of the circulating heroin could be fatal. It's not a bad idea to write that on the chart and have the patient sign it, signifying your concern and efforts to keep him. Other physicians will simply restrain patients for the requisite time, sedate them, offer them food, or otherwise attempt to cajole the recently resuscitated individual to remain in the ED for further observation.
Some patients who have overdosed on heroin tend to aspirate, and they get ARDS (rarely), so any hypoxia or tachypnea following reversal suggests a pulmonary problem that requires further treatment and usually admission to the hospital. Patients who overdose on heroin who are fully resuscitated with a small initial dose of naloxone and remain normal for four to six hours are generally stable for discharge. At least a 12-hour stay is more reasonable if you used 10 mg of naloxone.
Obviously, the FDA does not monitor the purity of street heroin, and many additives have been identified over the years. Quinine used to be omnipresent, giving a distinct taste to low-grade heroin to simulate a purer drug. This process has been depicted in movies, where bitterness is tasted when heroin is rubbed on the gums by a prospective buyer.
Clenbuterol, an animal sedative with beta-adrenergic properties, was reported in 12 postmortem cases where death was attributed to illicit drug use. (J Anal Toxicol 2008;32:522.) Again, finding this contaminant requires GC-MS analysis. Heroin causes a bradycardia, so the presence of tachycardia or other beta-adrenergic findings suggest clenbuterol contamination. Another veterinary sedative, xylazine, was reported in heroin-related deaths in Philadelphia in 2006. (J Forensic Sci 2008;53:495.)
Denton et al reported 350 fentanyl deaths certified by Chicago's Cook County medical examiner from 2005 to 2006. (J Forensic Sci 2008;53:452.) Illicit fentanyl fatalities represented an amazing seven percent of all medical examiner cases in 2006. Clinically rapid collapse and death followed injection of supposed heroin. About half of the deaths were caused by fentanyl itself, with no heroin or morphine found. The source of the clandestinely produced fentanyl was Mexico. Some of these more fortunate patients were seen and reported by Schumann et al at Cook County Hospital. (Clin Toxicol 2008;46:501.) These patients survived, so the fentanyl concentration was most likely minimal, but the authors noted that up to 12 mgs of naloxone were administered for reversal. Most of these patients (80%) were subsequently discharged from the ED after reversal.
Friends of those who overdose are often reluctant to bring their associates to medical attention, and many U.S. clinicians agree with supplementing heroin addicts with naloxone to use on the street. This is currently legal practice. This is a similar to the concept of supplying clean needles to prevent HIV and hepatitis from needle-sharing. Maxwell et al described the distribution of naloxone in 10 ml vials (0.4 mg/ml) more than 3500 times at the height of the Chicago epidemic, and noted that it was used 319 times in the field with miniscule problems. (J Addict Dis 2006;25:89.)
It's always best to give naloxone IV, but it will work via ET tube, sublingually, or IM injection, albeit more slowly. IV naloxone has usually worked its magic by the time you assemble the ET tube for intubation. Don't forget that the neck, foot, and groin veins work just fine, too.
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