Case Reports

Would you be able to recognize the signs and symptoms of this particular drug overdose?

J Fam Pract. 2019 June;68(5):290-292

References

1. Rudd RA, Aleshire N, Zibbell JE, et al. Increases in drug and opioid overdose deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64:1378-1382.

2. Scholl L, Seth P, Kariisa M, et al. Drug and opioid-involved overdose deaths—United States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2019;67:1419-1427.

3. Hibbs J, Perper J, Winek CL. An outbreak of designer drug-related deaths in Pennsylvania. JAMA. 1991;265:1011-1013.

4. Increases in fentanyl drug confiscations and fentanyl-related overdose fatalities. Centers for Disease Control and Prevention Web site. https://emergency.cdc.gov/han/han00384.asp. Published October 26, 2015. Accessed May 3, 2019.

5. Fentanyl. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/drugoverdose/opioids/fentanyl.html. Updated December 19, 2018. Accessed May 3, 2019.

6. Peterson AB, Gladden RM, Delcher C, et al. Increases in fentanyl-related overdose deaths—Florida and Ohio, 2013–2015. MMWR Morb Mortal Wkly Rep. 2016;65:844-849.

7. Streisand JB, Varvel JR, Stanski DR, et al. Absorption and bioavailability of oral transmucosal fentanyl citrate. Anesthesiology. 1991;75:223-229.

8. Kharasch ED, Whittington D, Hoffer C. Influence of hepatic and intestinal cytochrome P4503A activity on the acute disposition and effects of oral transmucosal fentanyl citrate. Anesthesiology. 2004;101:729-737.

9. Woodall KL, Martin TL, McLellan BA. Oral abuse of fentanyl patches (Duragesic): seven case reports. J Forensic Sci. 2008;53:222-225.

10. Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83:66-76.

11. Appropriate Use of Drug Testing in Clinical Addiction Medicine. American Society of Addiction Medicine Web site. https://www.asam.org/docs/default-source/quality-science/appropriate_use_of_drug_testing_in_clinical-1-(7).pdf?sfvrsn=2. Published April 5, 2017. Accessed May 30, 2019.

12. Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367:146-155.

13. Drugs@FDA: FDA approved drug products. US Food and Drug Administration Web site. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm?event=overview.process&ApplNo=208411. Accessed May 22, 2019.

Survival of fentanyl overdose depends on naloxone availability

Naloxone is a safe and effective antidote to an opioid overdose. It comes in 3 preparations, including intramuscular and subcutaneous injections and an intranasal spray.¹² Concerns that naloxone will harm patients with opioid dependence are unfounded. Naloxone can induce symptoms of opioid withdrawal, such as yawning, lacrimation, piloerection, diaphoresis, myalgia, vomiting, and diarrhea. While these withdrawal symptoms are unpleasant, they are not life threatening.¹² Due to its high potency, large doses of naloxone (ie, 4–16 mg) are required to reverse the effects of a fentanyl overdose.¹³Intranasal naloxone hydrochloride 4 mg delivered in a single spray is preferred due to the ease of administration. Repeat doses may be necessary if respiratory depression continues or recurs prior to the arrival of emergency medical services. Increasing the availability of naloxone to first responders has the potential to save many lives.⁶

THE TAKEAWAY

Fentanyl is a major contributor to the growing drug overdose crisis in the United States. When laced with heroin or consumed orally in the form of transdermal patches, fentanyl becomes more potent and is increasingly fatal. It’s crucial that primary care physicians be able to identify and educate at-risk patients about the fatal consequences of fentanyl overdose and coordinate care to help get them into an appropriate rehabilitation program.

In order to quickly recognize the signs of fentanyl-related overdose, it’s important to be alert for this possibility. At the bedside, the most easily recognized abnormality associated with fentanyl or other opioid overdose is a decline in respiratory rate culminating in apnea.¹⁰ A respiratory rate of 12 breaths/min or less in a patient who is not in physiologic sleep strongly suggests acute opioid intoxication, particularly when accompanied by miosis or stupor. Other signs include bradycardia, hypotension, and seizures from anoxia.¹⁰

Naloxone is a safe and effective antidote that is critical to the prevention of fatal opioid overdoses.

Apart from the severity of symptoms, it is hard to clinically distinguish fentanyl overdose from other opiate overdose incidents. Given the degree to which illegal opiates are contaminated with fentanyl in the United States,³ it is appropriate to screen for fentanyl with extended panel urine toxicology testing in patients with suspected opioid overdose.

CORRESPONDENCE
Jaividhya Dasarathy, MD, 2500 MetroHealth Medical Center, Cleveland, OH 44109; Jdasarathy@metrohealth.org

Would you be able to recognize the signs and symptoms of this particular drug overdose?

References

Survival of fentanyl overdose depends on naloxone availability

THE TAKEAWAY

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