Opioids are among the commonly misused substance by drug abusers around the world. Opioids come in various forms – Heroin , Morphine, Methadone, Coedine, Pethidine, Dihydrocoedeine.

Opioids are a class of drugs derived from the extracts of plant- opium poppy. Used as Analgesics but  most opiates give a feeling of euphoria and a degree of sedation. These side effects are the cause of Abuse of Opioids.

Opioid overdose can be lethal

Clinical Features Of Opiod Intake in body are-
Rapid, intensely presurable experience
Heightened sexual arousal
Increase dose required for same experience within weeks

Withdrawl Symptoms include-
Intense craving , Rhinorrhea, Lacrimation, Yawning, Perspiration, Shivering, Piloerection, Vomiting and diarrhea, abdominal cramps.
Tachycardia, hypertension, mydriasis ( dilation of Pupil ) and facial flushing.

Hallmark Of Opioid Poisoning are-
Respiratory depression – may lead to death
Pin-point Pupil
CNS depression- decresed level of consciousness.
Signs of IV drug misuse like needle tract marks, tattoo.

Severe –
Respiratory depression
Hypotension
Non-cardiogenic pulmonary edema
Hypothermia
Death due to Respiratory arrest and Gastric aspiration
Others- Ventricular Arrhythmia, Conduction defects and heart blocks

Lab Diagnosis Criteria ( CDC)

• Biologic: A case in which opioids are detected in urine, as determined by hospital or commercial laboratory tests. Fentanyl derivatives and certain other synthetic opioids (e.g., oxycodone) might not be detected by routine toxicologic screens.

- OR-

• Environmental: Detection of opioids in environmental samples, as determined by FDA

Management-
1. Clear Airway and provide Respiratory support
2. Supplement increase flow Oxygen administration
- Severe cases Endotrachel intubation may be required.
3. Antidote- Naloxone is the anti-dote for Opioids. Naloxone is given in dose of 0.8-2 mg bolus IV and repeated every 2 minutes until pupil dilates. Opioid overdose is a challenging condition that requires a difficult balancing act between over and under treatment with naloxone. Nalorphine is an alternative. Literature : Naloxone in Opioid Overdose
4. O2 saturation must be monitored .
5. Management of Hypotension.
6. CPAP/ PEEP for ventilator support.

SAY NO TO DRUGS- Medchrome Against Drug Abuse
Warning- Do not take drug without physician’s prescription.

-OP compounds are widely used as pesticides, for eradication of vectors.

Malathion,Fenthion,Methamidophos,Diazinon,Chlorpyrifos,Parathion are the common insecticides.

Organophosphorus Poisoning

CLINICAL PRESENTATION

• Acute cholinergic syndrome:- occur within minutes of exposure.
• Pungent garlic like odour in breath, vomit and clothing; Muscarinic effects -miosis , bronchorrhoea, bronchospasm, salivation , lacrimation , abdominal pain , bradycardia
• Nicotinic effects- Muscle fasciculation, hyper-reflexia, flaccid muscle weakness with reduced tendon reflexes
• CNS effects- headache, dizziness, confusion, drowsiness, coma , fits , central respiratory depression
• The Intermediate Syndrome- begins 48hrs after poisoning but may be delayed for 72-96 hrs. Follows resolution of the acute phase , in some instances occurs while symptoms of acute phase are still present.
• Muscle weakness causing respiratory distress and failure; progression of muscle weakness from ocular muscles to the neck and proximal limbs to the respiratory muscles.

Organophosphate induced delayed polyneuropathy:-

Occurs 1-3 weeks after acute exposure due to degeneration of long myelinated nerve fibres. Cramping muscle pains in the legs , numbnesss and paraesthesiae in the distal upper and lower limbs, shuffling gait , wrist drop.

Muscle wasting and deformity, symmetrical flaccid weakness of distal limbs, tendon reflexes reduced or lost, absent ankle reflexes.

MANAGEMENT

-Removal from site of exposure and of contaminated clothing and contact lenses.

-airway cleared and high flow oxygen administered.

-skin washed with soap and water and eyes irrigated.

-gastric lavage within an hour of ingestion by KMNO4 via nasogastric tube after establishing intravenous access and airway protection.

-Atropine : 1.8-3mg bolus immediately.

Atropine vial 1 ml conating 0.6 mg

Double the dose every 5mins until atropinised- dilated pupil, clear lungs, dry tongue, normal heart rate and BP.

Heart rate maintain 110-120/min not<90.

Once patient is atropinised give 20-30% dose required for atropinisation as infusion/hr.

Eg: 15ml for atropinisation ( 1ml=0.6mg) then maintain at 20% dose of atropinisation at 1 hr i.e 3ml

Total dose = 3ml x 24 hr= 72ml

72ml/5 pint?15ml

In 1 pint put 15ml of atropine and as muscarinic effect decreases decrease dose i.e 8ml-6ml-4ml-2ml

-Oximes : Pralidoxime 1g bolus in 30 mins then infusion 0.5g/hr

Or

Pralidoxime 1g in 100ml NS drip in 30 mins stat then TDS for 5 days.

Or , Obidoxime 0.25mg bolus then infusion 0.75g/24hrs.

Convulsions are controlled with I.V. Diazepam.

Monitoring of ECG, blood gases, temperature, urea and electrolytes , amylase and glucose is mandatory.

OP poisoning cases should be always kept under observation in Intensive Care Unit for 5-6 days.

– Dr. Mahesh Shrestha