Toxic Alcohols and Opioids Jamil A. Alarafi, D.O. Jamil A. Alarafi, D.O. 02.01.2007 02.01.2007

Toxic Alcohols and OpioidsToxic Alcohols and Opioids

Jamil A. Alarafi, D.O.Jamil A. Alarafi, D.O. 02.01.200702.01.2007

Toxic AlcoholsToxic Alcohols

EthanolEthanol

Methyl AlcoholMethyl Alcohol

Ethylene GlycolEthylene Glycol

Isopropyl AlcoholIsopropyl Alcohol

EthanolEthanol

Everybody's favorite!Everybody's favorite!

Unique among abused drugsUnique among abused drugs

Most frequently used and abused in most societiesMost frequently used and abused in most societies

Estimated to contribute to 100,000 deaths/yrEstimated to contribute to 100,000 deaths/yr

40% of MVC’s are related to ETOH use40% of MVC’s are related to ETOH use

EthanolEthanol

PathophysiologyPathophysiology

CNS DepressantCNS Depressant

Absorption: mouth to small bowelAbsorption: mouth to small bowel

Elimination:Elimination:

2 – 10% from lungs, urine, and sweat2 – 10% from lungs, urine, and sweat

Primary metabolized in the liverPrimary metabolized in the liver

EthanolEthanol

Clinical FeaturesClinical Features

Slurred speech, nystagmus, disinhibited behavior, Slurred speech, nystagmus, disinhibited behavior, CNS depression ( a spectrum which my lead to CNS depression ( a spectrum which my lead to coma), and poor motor coordination and controlcoma), and poor motor coordination and control

HypotensionHypotension

ToleranceTolerance

EthanolEthanol

TreatmentTreatment

Mainstay of treatment is supportiveMainstay of treatment is supportive

Attention to ABC’s, associated injuries, or co-Attention to ABC’s, associated injuries, or co-morbid conditions. morbid conditions.

Bedside glucose checkBedside glucose check

Thiamine, Folate, Multivitamins, Magnesium, Thiamine, Folate, Multivitamins, Magnesium, Fluids (D5NS)Fluids (D5NS)

Ethanol Ethanol

TreatmentTreatment

Careful serial examines are crucialCareful serial examines are crucial

Respiratory depression may require intubationRespiratory depression may require intubation

Most eliminate ethanol at a rate of 0.20-0.25/hrMost eliminate ethanol at a rate of 0.20-0.25/hr

CocaethyleneCocaethyleneMetabolite formed by the combination of ETOH and CocaineMetabolite formed by the combination of ETOH and Cocaine

EthanolEthanol

DispositionDisposition

Most rarely require hospitalization and can be Most rarely require hospitalization and can be sent home as long as certain conditions are in sent home as long as certain conditions are in placeplace

State legal limits veryState legal limits veryOhio 0.08Ohio 0.08

MethanolMethanolOverviewOverview

Also called methyl alcohol or “wood alcohol”Also called methyl alcohol or “wood alcohol”

Colorless,volatile liquid, with a distinctive odorColorless,volatile liquid, with a distinctive odor

Common SourcesCommon Sources

Sterno, paint removers, varnishes, shellacs, windshield fluids, and Sterno, paint removers, varnishes, shellacs, windshield fluids, and antifreezeantifreeze

Toxic Metabolites Toxic Metabolites Formaldehyde & Formic acidFormaldehyde & Formic acid

MethanolMethanol

Pharmacology and MetabolismPharmacology and Metabolism

Rapidly absorbedRapidly absorbed

Transdermal and respiratory absorption has resulted Transdermal and respiratory absorption has resulted in toxicityin toxicity

As little as 1.5ml of 100% methanol can produce a toxic level As little as 1.5ml of 100% methanol can produce a toxic level in small childrenin small children

High risk for inhalation exposure: painting, glazing, High risk for inhalation exposure: painting, glazing, varnishing, lithography, and printingvarnishing, lithography, and printing

Methanol Methanol


Serum levels peak 30 to 60 minutesSerum levels peak 30 to 60 minutes

Half life is 24 to 30 hours Half life is 24 to 30 hours Prolonged by EthanolProlonged by Ethanol

Smallest lethal dose Smallest lethal dose 15 mL in adults and 1.5 mL in toddlers15 mL in adults and 1.5 mL in toddlers

MethanolMethanol


Methanol has little toxicity and produces less Methanol has little toxicity and produces less inebriation than ethanolinebriation than ethanol

Methanol Methanol Formaldehyde Formaldehyde Formic Acid Formic Acid CO2 CO2 and Waterand Water

Formic Acid responsible for much of Anion Gap and Formic Acid responsible for much of Anion Gap and Ocular toxicityOcular toxicity

Methanol Methanol

Pathophysiology/Clinical FeaturesPathophysiology/Clinical Features

Optic NeuropathyOptic Neuropathy““Snow blindness”: diplopia, photophobia, and blindnessSnow blindness”: diplopia, photophobia, and blindness

Putaminal InjuryPutaminal InjuryParkinsonian type motor dysfunction, hypokinesis, and rigidityParkinsonian type motor dysfunction, hypokinesis, and rigidity

MechanismMechanismFormic Acid has a high affinity for iron and inhibits mitochondrial Formic Acid has a high affinity for iron and inhibits mitochondrial cytochrome oxidase, halting cellular respirationcytochrome oxidase, halting cellular respiration

Metabolism in the cytosol and mitochondria account for a second Metabolism in the cytosol and mitochondria account for a second mechanism of ATP depletionmechanism of ATP depletion

MethanolMethanol


Symptoms may not appear until 12 to 18 hours after the Symptoms may not appear until 12 to 18 hours after the ingestioningestion

““Cardinal” signs of toxicity:Cardinal” signs of toxicity:

CNS effects similar to ETOH intoxication with N/V, abdominal pain, CNS effects similar to ETOH intoxication with N/V, abdominal pain, visual disturbances, and a wide anion gap metabolic acidosisvisual disturbances, and a wide anion gap metabolic acidosis

Coma and seizures can develop in severe casesComa and seizures can develop in severe cases

Hypotension and bradycardia are late findings and suggests a poor Hypotension and bradycardia are late findings and suggests a poor outcomeoutcome

Methanol Methanol

PrognosisPrognosis

Correlates with the degree of acidosis, not with the serum Correlates with the degree of acidosis, not with the serum methanol level. methanol level.

Treatment initiation within 8 hours of exposureTreatment initiation within 8 hours of exposure

Poor prognosis associated with coma, hypotension, bradycardia, Poor prognosis associated with coma, hypotension, bradycardia, seizures, or arterial pH less than 7.0seizures, or arterial pH less than 7.0

Patients who survive may have permanent blindness or severe Patients who survive may have permanent blindness or severe neurologic deficitsneurologic deficits

Methanol Methanol Laboratory FeaturesLaboratory Features

Anion GapAnion Gapmay be delayed 12 to 24 hoursmay be delayed 12 to 24 hoursAbsence with concomitant ethanol, lithium, or bromide Absence with concomitant ethanol, lithium, or bromide ingestioningestion

Elevated “Osmolar Gap”Elevated “Osmolar Gap”OG = Meas. Serum Osm. - Cal. OsmolalityOG = Meas. Serum Osm. - Cal. Osmolality

Normal gap is (-14 to +10)Normal gap is (-14 to +10)

Calculated osmolality= 2Na + BUN/2.8 + Calculated osmolality= 2Na + BUN/2.8 + glucose/18 + ethanol/4.6glucose/18 + ethanol/4.6


OverviewOverview

Viscous, colorless, slightly sweet-tastingViscous, colorless, slightly sweet-tasting

Primarily used in antifreeze and coolantsPrimarily used in antifreeze and coolants

Also in airplane deicing solutions, hydraulic brake Also in airplane deicing solutions, hydraulic brake fluids, industrial solvents, paints, lacquers, and fluids, industrial solvents, paints, lacquers, and cosmeticscosmetics

Most poisonings involve AntifreezeMost poisonings involve Antifreeze


Epidemiology Epidemiology

In 2001, there were 4938 exposures with 16 fatalitiesIn 2001, there were 4938 exposures with 16 fatalities 90% unintentional90% unintentional Most were children or suicide attemptsMost were children or suicide attempts 12% moderate to severe effects12% moderate to severe effects

Rapid treatment is imperative!Rapid treatment is imperative!

If treated early and aggressively, death is unlikely, but If treated early and aggressively, death is unlikely, but delay will result in multiorgan failure in 24 to 36 hoursdelay will result in multiorgan failure in 24 to 36 hours


Pharmacology/MetabolismPharmacology/Metabolism

Rapid absorption after ingestionRapid absorption after ingestion

Distributes evenly in the tissues, with peaked levels at Distributes evenly in the tissues, with peaked levels at 1-4 hours1-4 hours

Nonvolatile and inhalation absorption is unlikelyNonvolatile and inhalation absorption is unlikely

Half life of 3 to 8.6 hoursHalf life of 3 to 8.6 hours

Toxic doses of 0.2 ml/kg - 1.4 ml/kgToxic doses of 0.2 ml/kg - 1.4 ml/kg


PathophysiologyPathophysiology

Metabolized in the liver (70%) and kidneys (30%) to toxic Metabolized in the liver (70%) and kidneys (30%) to toxic metabolites- aldehydes, glycolate, oxalate, and lactatemetabolites- aldehydes, glycolate, oxalate, and lactate

2.3% converted to Oxalic acid, of which a small portion 2.3% converted to Oxalic acid, of which a small portion complexes with calcium to form calcium oxalate crystalscomplexes with calcium to form calcium oxalate crystals

These precipitate in kidney, brain, and peripheral tissuesThese precipitate in kidney, brain, and peripheral tissues these are harmful but the generation of toxic metabolites appear to these are harmful but the generation of toxic metabolites appear to be most responsible for the lethal effects to target tissuesbe most responsible for the lethal effects to target tissues



Four Stages of Ethylene Glycol toxicityFour Stages of Ethylene Glycol toxicity

Acute NeurologicAcute Neurologic

Cardiopulmonary Cardiopulmonary

Renal Renal

Delayed Neurologic InjuryDelayed Neurologic Injury

Ethylene Glycol Ethylene Glycol

DiagnosisDiagnosis

Crystalluria is the hallmarks of EG ingestion, however Crystalluria is the hallmarks of EG ingestion, however its absence does not exclude the diagnosisits absence does not exclude the diagnosis

Useful test include:Useful test include:Electrolytes, calcium, BUN, Creatinine, glucose, serum Electrolytes, calcium, BUN, Creatinine, glucose, serum osmolality, ethanol level, ABG, ethylene glycol level, EKG, osmolality, ethanol level, ABG, ethylene glycol level, EKG, UAUA

Wood’s lamp fluorescence on a freshly voided urine Wood’s lamp fluorescence on a freshly voided urine specimen may be helpful if EG is suspectedspecimen may be helpful if EG is suspected


Diagnostic TestDiagnostic Test

Leukocytosis is nonspecific and non-sensitiveLeukocytosis is nonspecific and non-sensitive

QT prolongation with hypocalcemia secondary to QT prolongation with hypocalcemia secondary to crystal formation crystal formation

CPK may be elevated CPK may be elevated

Anion gap acidosis seen secondary to metabolites Anion gap acidosis seen secondary to metabolites glycolic acid and glyoxylic acidglycolic acid and glyoxylic acid

Methanol and Ethylene GlycolMethanol and Ethylene Glycol

ManagementManagement

Treatment essentially the same Treatment essentially the same

As in the OD setting, resuscitation and stabilization are As in the OD setting, resuscitation and stabilization are paramountparamount

Gastric emptying is not effective due to rapid absorption Gastric emptying is not effective due to rapid absorption

Only if ingestion in last 30 to 60 minutesOnly if ingestion in last 30 to 60 minutes

Activated charcoal not effectiveActivated charcoal not effective



Severely obtunded patients should receive attention Severely obtunded patients should receive attention to ABC’s and “DON’T” therapy to ABC’s and “DON’T” therapy (dextrose,oxygen,naloxone, and thiamine)(dextrose,oxygen,naloxone, and thiamine)

Forced diuresis is of no value and may cause Forced diuresis is of no value and may cause pulmonary edema or ARDSpulmonary edema or ARDS

Early intubation may be indicatedEarly intubation may be indicated



Treatment goalsTreatment goals

Correction of Metabolic AcidosisCorrection of Metabolic Acidosis

ADH Blockade thereby inhibiting the generation of ADH Blockade thereby inhibiting the generation of toxic metabolitestoxic metabolites

Hemodialysis to remove alcoholHemodialysis to remove alcohol



Metabolic AcidosisMetabolic Acidosis

Large doses of bicarbonate may be required to correct the Large doses of bicarbonate may be required to correct the acidosisacidosis

Early correction is imperative to reduce the chance of Early correction is imperative to reduce the chance of methanol induced visual lossmethanol induced visual loss

Target pH is 7.45 to 7.50Target pH is 7.45 to 7.50

Bicarbonate may worsen hypocalcemia with Ethylene GlycolBicarbonate may worsen hypocalcemia with Ethylene Glycol



Blocking ADHBlocking ADH

Either Ethanol or Fomepizole may be usedEither Ethanol or Fomepizole may be used ETOHETOH

Target level of ethanol is 100 to 150 mg/dLTarget level of ethanol is 100 to 150 mg/dLETOH increases the half-life to 30 hours Methanol and 17 ETOH increases the half-life to 30 hours Methanol and 17 hours Ethylene Glycolhours Ethylene Glycol

Fomepizole Fomepizole blocks ADH and has more predictable pharmacokinetics blocks ADH and has more predictable pharmacokinetics and improved safety profileand improved safety profilemore expensive more expensive



HemodialysisHemodialysis

Indications: triad of hx, clinical, and lab results confirm Indications: triad of hx, clinical, and lab results confirm toxic ingestion, EG > 20, ARF, metabolic acidosistoxic ingestion, EG > 20, ARF, metabolic acidosis

Removes preformed metabolitesRemoves preformed metabolites

Peritoneal dialysis is less effectivePeritoneal dialysis is less effective

Endpoint is undetectable serum ethylene glycol or Endpoint is undetectable serum ethylene glycol or methanol concentrationmethanol concentration


OverviewOverview

Clear, colorless, slightly bitter Clear, colorless, slightly bitter

Second most commonly ingested alcoholSecond most commonly ingested alcohol

Found in nail polish removers, household disinfectants, Found in nail polish removers, household disinfectants, and window cleaners, and common rubbing alcoholand window cleaners, and common rubbing alcohol

Less toxic than methanol or ethylene glycolLess toxic than methanol or ethylene glycol


EpidemiologyEpidemiology

In 2002In 2002

31,187 exposures31,187 exposures91% unintentional91% unintentional3% moderate to major effects3% moderate to major effects4 fatalities4 fatalities

Fatalities are usually associated with chronic Fatalities are usually associated with chronic alcoholics with mixed ingestionsalcoholics with mixed ingestions


Phamacology/MetabolismPhamacology/Metabolism

Absorption is rapid and complete, with peak serum Absorption is rapid and complete, with peak serum levels in 30 min, with a half-life of 3-7 hourslevels in 30 min, with a half-life of 3-7 hours

Potentially lethal dose is 150 to 240 mL (2 to 4 Potentially lethal dose is 150 to 240 mL (2 to 4 mL/Kg) but adults have survived up to 1 LitermL/Kg) but adults have survived up to 1 Liter

80% undergoes hepatic metabolism to acetone80% undergoes hepatic metabolism to acetone

Remaining 20% undergoes renal elimination Remaining 20% undergoes renal elimination unchanged unchanged


Clinical FeaturesClinical Features CNSCNS

Inebriation with acetone odorInebriation with acetone odor

Headache, dizzinessHeadache, dizziness

Neuromuscular dysfunction, confusion, nystagmusNeuromuscular dysfunction, confusion, nystagmus

Coma in severe ingestionsComa in severe ingestions

Respiratory depression or failure may occurRespiratory depression or failure may occur


Clinical FeaturesClinical Features GIGI

Gastritis may occurGastritis may occur

Hematemesis associated with gastritis but not Hematemesis associated with gastritis but not commoncommon

Abdominal pain, nausea, vomiting commonAbdominal pain, nausea, vomiting common



Hypotension Hypotension Rare but associated with severe ingestions, mortality rate is 45%Rare but associated with severe ingestions, mortality rate is 45%

Caused by peripheral vasodilatation and direct myocardial Caused by peripheral vasodilatation and direct myocardial depressiondepression

Sinus tachycardia Sinus tachycardia common but other dysrythmias if found are usually associated with common but other dysrythmias if found are usually associated with hypoxia, acidosis, or shockhypoxia, acidosis, or shock

Myoglobinuria, ATN, or hemolytic anemias may be presentMyoglobinuria, ATN, or hemolytic anemias may be present


Diagnostic Test:Diagnostic Test:

Isopropanol levelIsopropanol level

electrolytes, osmolality, serum and urine ketoneselectrolytes, osmolality, serum and urine ketones

KetosisKetosismost common lab abnormality (from acetone)most common lab abnormality (from acetone)

Increased osmolar gapIncreased osmolar gap


Diagnostic StrategiesDiagnostic Strategies

““Pseudo-renal failure”Pseudo-renal failure”

Early diagnostic clue with elevated creatinine and normal Early diagnostic clue with elevated creatinine and normal BUNBUN

100mg/dL of Isopropanol falsely elevates the creatinine 100mg/dL of Isopropanol falsely elevates the creatinine 1mg/dL1mg/dL

CPK should be obtainedCPK should be obtained



ABC’s, glucose check, thiamine, narcanABC’s, glucose check, thiamine, narcan

Gastric emptying or charcoal is not useful unless Gastric emptying or charcoal is not useful unless ingestion was large and recentingestion was large and recent

ADH blockade not indicatedADH blockade not indicated

Manage hypotension with fluids/vasopressorsManage hypotension with fluids/vasopressors



Dialysis is indicated for refractory hypotension or Dialysis is indicated for refractory hypotension or patients vital signs deterioratepatients vital signs deteriorate

Coma not an indication for dialysisComa not an indication for dialysis

Hemodynamic stability without coma in first 6 hours Hemodynamic stability without coma in first 6 hours rarely develops significant sequelaerarely develops significant sequelae

Care can generally be supportive in this case Care can generally be supportive in this case

Toxic AlcoholsToxic Alcohols

Key ConceptsKey Concepts

Small doses can killSmall doses can kill Latent periods can fool you (EG & Methanol)Latent periods can fool you (EG & Methanol) Double gap acidosis, think: ethylene glycol or Double gap acidosis, think: ethylene glycol or

methanol ingestionsmethanol ingestions Early treatment improves outcomes, you must act Early treatment improves outcomes, you must act

quicklyquickly Toxicity can not be excluded based on “normal” Toxicity can not be excluded based on “normal”

osmolar gaposmolar gap

OpioidsOpioids

IIII

OpioidsOpioids

Historical perspectiveHistorical perspective

In use for over 5000 yearsIn use for over 5000 years

Term for Term for opium opium is derived from the Greek word for is derived from the Greek word for poppy juicepoppy juice

Receptors and endogenous opioids have been Receptors and endogenous opioids have been recognized and characterized only in the last 25 yearsrecognized and characterized only in the last 25 years

OpioidsOpioidsTerms/Definitions:Terms/Definitions:

OpioidsOpioids natural, synthetic, and semi synthetic agent with morphine like natural, synthetic, and semi synthetic agent with morphine like

propertiesproperties In the US, heroin and opioid derivatives are abused most often and In the US, heroin and opioid derivatives are abused most often and

the cause of most deathsthe cause of most deaths

OpiateOpiate only natural agentonly natural agent

NarcoticsNarcotics any agent that induces sleep and is nonspecificany agent that induces sleep and is nonspecific

EndorphinsEndorphins Any peptide in the three opioid family: enkephalins, B-endorphins, Any peptide in the three opioid family: enkephalins, B-endorphins,

and dynorphinsand dynorphins

OpioidsOpioids

Mechanism of Action:Mechanism of Action: Modulate nociception in the terminals of afferent Modulate nociception in the terminals of afferent

nerves in the CNS and PNSnerves in the CNS and PNS

Three endogenous receptorsThree endogenous receptors OPOP11 (delta) (delta)

OPOP22 (kappa) (kappa)

OPOP33 (mu) (mu)

Concentrated in pain pathways, periaqueductal grey matter, Concentrated in pain pathways, periaqueductal grey matter, locus ceruleus, limbic system, nucleus raphe locus ceruleus, limbic system, nucleus raphe

OpioidsOpioidsClinical FeaturesClinical Features Wide variety of signs and symptomsWide variety of signs and symptoms

Miosis is not universalMiosis is not universal

Respiratory effects are variableRespiratory effects are variableLook for shallow respirations, cyanosis, bradypnea, or Look for shallow respirations, cyanosis, bradypnea, or hypercarbiahypercarbia

Diagnostic triad:Diagnostic triad:CNS depression, miosis, and respiratory depressionCNS depression, miosis, and respiratory depression

strongly suggest opioid intoxicationstrongly suggest opioid intoxication

OpioidsOpioids

Differential DiagnosisDifferential Diagnosis

ClonidineClonidinePeriods of apnea that respond to tactile stimPeriods of apnea that respond to tactile stim

Organophosphates and CarbamatesOrganophosphates and CarbamatesMuscle fasciculations, profuse N/VMuscle fasciculations, profuse N/V

PhenothiazinesPhenothiazinesCNS depression and miosisCNS depression and miosis

Carbon Monoxide exposureCarbon Monoxide exposureProfound CNS depressionProfound CNS depression

OpioidsOpioidsManagementManagement::

ABC’s…Airway managementABC’s…Airway managementInterventions may include supplemental oxygen,BiPaP, or Interventions may include supplemental oxygen,BiPaP, or BVM leading to intubationBVM leading to intubation

GI DecontaminationGI Decontamination Usually not routine Usually not routine Consider whole bowel irrigation for “body packers”Consider whole bowel irrigation for “body packers”

Activated CharcoalActivated Charcoal 1 g/Kg1 g/Kg may be beneficial to promote motility with large may be beneficial to promote motility with large

ingestionsingestions

HypotensionHypotension Treat with IV fluids, pressor agents as neededTreat with IV fluids, pressor agents as needed

OpioidsOpioidsReversal AgentsReversal Agents

Narcan (Naloxone)Narcan (Naloxone) a pure opioid antagonist with rapid onset of actiona pure opioid antagonist with rapid onset of action IV, SC, down ETT, and IM…not effective PO!IV, SC, down ETT, and IM…not effective PO! Acts by competitive binding at the receptor siteActs by competitive binding at the receptor site

Revex (Nalmefene)Revex (Nalmefene) Opioid antagonist alternative with long half-life and Opioid antagonist alternative with long half-life and

rapid onsetrapid onset PO, IV, SC, IM routesPO, IV, SC, IM routes Initial IV dose is 0.5 to 1.5mgInitial IV dose is 0.5 to 1.5mg

OpioidsOpioids

WithdrawalWithdrawal Not life threateningNot life threatening

Heroin Half-life : 0.5 hoursHeroin Half-life : 0.5 hours

Signs and symptoms may include CNS excitation, tachypnea, Signs and symptoms may include CNS excitation, tachypnea, tachycardia, hypertension, and mydriasistachycardia, hypertension, and mydriasis

Care is supportive and focused at minimizing symtoms in Care is supportive and focused at minimizing symtoms in

tolerant individualstolerant individuals

Withdrawal can be managed in the outpatient settingWithdrawal can be managed in the outpatient setting

Patients who have refractory N/V, electrolyte abnormalities, or those Patients who have refractory N/V, electrolyte abnormalities, or those with an uncertain diagnosis should be admittedwith an uncertain diagnosis should be admitted

OpioidsOpioidsWithdrawal AgentsWithdrawal Agents

Methadone or l-a-acetylmethadol (LAAM)Methadone or l-a-acetylmethadol (LAAM)

Long and longer acting opioids Long and longer acting opioids Used to treat chronic herion addictionUsed to treat chronic herion addiction 20mg PO or 10mg IM20mg PO or 10mg IM Controls cravings with limited euphoric effectControls cravings with limited euphoric effect LAAM dose is 30mg POLAAM dose is 30mg PO

ClonidineClonidine

Central a2-agonistCentral a2-agonist Controls symptoms by suppressing sympathetic hyperactivityControls symptoms by suppressing sympathetic hyperactivity Dose is 0.1mg PO, patches are an optionDose is 0.1mg PO, patches are an option Hypotension may limit treatment but usually not common in withdraw Hypotension may limit treatment but usually not common in withdraw

treatmenttreatment

OpioidsOpioids

Key ConceptsKey Concepts Diagnosis is based on history& physical examDiagnosis is based on history& physical exam

Key triad: CNS depression, respiratory depression, and miosisKey triad: CNS depression, respiratory depression, and miosis

Supportive care is the mainstay, with attention to airwaySupportive care is the mainstay, with attention to airway

Duration of opioids is longer than narcanDuration of opioids is longer than narcanSo…don’t discharge your patient until your certain the opioid So…don’t discharge your patient until your certain the opioid properties are fully metabolizeproperties are fully metabolize

This depends on the agents involved!This depends on the agents involved!

Opioid withdrawal is supportive and focused at minimizng the Opioid withdrawal is supportive and focused at minimizng the symptoms of withdrawalsymptoms of withdrawal

THE END!!!THE END!!!

Questions?Questions?

Documents

Toxic Alcohols and Opioids Jamil A. Alarafi, D.O. Jamil A. Alarafi, D.O. 02.01.2007 02.01.2007