Opiate overdose may present with a number of symptoms and signs, however, the classic triad is miosis, respiratory depression, and a decreased level of consciousness. Despite the above being hallmark features, patients may not experience all three. Opiate overdose manifestations typically occur as a result of an overdose in the medical or illicit use of opiates or opioids such as heroin, morphine, fentanyl, oxycodone, and hydrocodone [1] [2] [3]. It is possible, however, for individuals who are not chronic or regular users of opioids to experience overdose symptoms while using the recommended dose ranges. The presence of one of the above-mentioned manifestations is not sufficient to diagnose opiate overdose. Of note is that individuals who use multiple substances concomitantly may not present with expected symptoms [4].

Opiates have an excitatory effect on opioid receptors in the central nervous system. The activation of opioid receptors within the dopaminergic reward pathway of the brain results in euphoria [5]. Opiate overdose is responsible for features of intoxication which include nausea, vomiting, slowed gastric emptying, constipation, as well as the typical triad.

Respiratory depression may be presented as bradypnea and progress to apnea. Due to this reason, patients may become hypoxic and suffer from hypoxic injury of the brain and other tissues [5]. An impact on the respiratory system could also manifest in the development of acute respiratory distress syndrome (ARDS) and pulmonary edema with a potentially fatal outcome.

Opiate overdose may induce seizures. In addition, there is a possibility of renal injury, liver failure, and injuries stemming from a loss of consciousness such as compartment syndrome [5]. Simultaneous use of other CNS depressants such as alcohol has an exacerbating effect.

• Hypothermia

  […] include: Trouble breathing or slow irregular breathing; breathing may even stop, which can cause death Drowsiness, difficulty arousing, coma Small, pinpoint pupils Cyanosis, when lips and nails appear blue (not enough oxygen in the blood) Slow heart rate Hypothermia [fairview.org]

  Patients with hypothermia may require immediate rewarming. [ncbi.nlm.nih.gov]

  Hypothermia. Meningitis. Stroke. Subdural haematoma. Syncope. Investigations It is possible to obtain a urine screen for drugs of abuse and there are even some sticks available that will give a quick result. [patient.info]

  Ice down the pants or cold showers can slow down the respiratory system and can send someone into shock or hypothermia. A safer, quicker, more likely to work action is: Call 911, do rescue breathing and give naloxone. [harmreduction.org]

• Gastric Lavage

  lavage, or stomach pumping may be performed in addition to charcoal administration Treatment for cardiac arrest, if heart problems occur Venous line access for administration of intravenous fluids to stabilize hydration and to correct any electrolyte [americanaddictioncenters.org]

  As a nonspecific antidote, activated charcoal is frequently recommended if available within one hour of the ingestion and the ingestion is significant.[16] Gastric lavage, syrup of ipecac, and whole bowel irrigation are rarely used.[16] Epidemiology and [en.wikipedia.org]

• Anorexia

  […] symptoms such as lacrimation, rhinorrhea, sneezing, yawning, excessive perspiration, goose-flesh, fever, chilling, irritability, weakness, anxiety, depression, dilated pupils, tremors, tachycardia, abdominal cramps, body aches, involuntary twitching, anorexia [drugs.com]

  Anorexia can lead to body weight loss. There is delayed gastric emptying and intestinal transit. The syndrome is often confused with bowel obstruction. [ncbi.nlm.nih.gov]

• Sepsis

  […] need to consider redosing, starting an IV and g iving IV naloxone (only required 5-10% of the time) and seriously consider w hether there is another cause for the obtundation (mixed overdose, different clinical cause such as intracranial pathology, sepsis [intranasal.net]

• Yawning

  Opioid withdrawal symptoms may include body aches, diarrhea, increased heart rate, fever, runny nose, sneezing, goose bumps, sweating, yawning, nausea or vomiting, nervousness, restlessness or irritability, shivering or trembling, stomach cramping, weakness [narcan.com]

  These may consist of: Body aches Diarrhea Abdominal cramps Nausea Vomiting Runny nose Sneezing Sweating Yawning Restlessness Irritability Trembling These symptoms will go away as the naloxone wears off. [fairview.org]

  In someone who has been using opioids regularly, opioid withdrawal symptoms can happen suddenly after receiving EVZIO and may include: body aches, fever, sweating, runny nose, sneezing, goose bumps, yawning, weakness, shivering or trembling, nervousness [evzio.com]

  During the induction phase as patients are being withdrawn from illicit opioids, monitor of opioid withdrawal symptoms such as lacrimation, rhinorrhea, sneezing, yawning, excessive perspiration, goose-flesh, fever, chilling, irritability, weakness, anxiety [drugs.com]

  Concerns that naloxone will harm patients with opioid dependence are unfounded; all signs of opioid abstinence (e.g., yawning, lacrimation, piloerection, diaphoresis, myalgias, vomiting, and diarrhea) are unpleasant but not life-threatening. 25 In addition [ncbi.nlm.nih.gov]

• Bradypnea

  Respiratory depression may be presented as bradypnea and progress to apnea. Due to this reason, patients may become hypoxic and suffer from hypoxic injury of the brain and other tissues. [symptoma.com]

  One may observe shallow breathing, hypopnea, and bradypnea. The respiration rate may be 4 to 6 breaths per minute and shallow. Since opiates can also cause bronchoconstriction, some individuals may present with dyspnea, wheezing and frothy sputum. [ncbi.nlm.nih.gov]

• Dyspnea

  Clinically, heroin-induced lung injury will present with sudden onset of dyspnea, frothy sputum, cyanosis, tachypnea, and rales- features consistent with pulmonary edema. [ncbi.nlm.nih.gov]

• Vomiting

  These may consist of: Body aches Diarrhea Abdominal cramps Nausea Vomiting Runny nose Sneezing Sweating Yawning Restlessness Irritability Trembling These symptoms will go away as the naloxone wears off. [fairview.org]

  Opiate overdose is responsible for features of intoxication which include nausea, vomiting, slowed gastric emptying, constipation, as well as the typical triad. Respiratory depression may be presented as bradypnea and progress to apnea. [symptoma.com]

  While waiting for emergency medical help to arrive, roll the person suffering from the opioid overdose on their side to protect them from choking in the event that they vomit while unconscious. [americanaddictioncenters.org]

  Choking sounds, or a snore-like gurgling noise (sometimes called the “death rattle”) Vomiting Body is very limp Face is very pale or clammy Fingernails and lips turn blue or purplish black Pulse (heartbeat) is slow, erratic, or not there at all If someone [harmreduction.org]

• Nausea

  These may consist of: Body aches Diarrhea Abdominal cramps Nausea Vomiting Runny nose Sneezing Sweating Yawning Restlessness Irritability Trembling These symptoms will go away as the naloxone wears off. [fairview.org]

  Opiate overdose is responsible for features of intoxication which include nausea, vomiting, slowed gastric emptying, constipation, as well as the typical triad. Respiratory depression may be presented as bradypnea and progress to apnea. [symptoma.com]

  Effects include: euphoria, drowsiness/respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness, coma, tolerance and addiction. [columbus.gov]

  Opioid withdrawal symptoms may include body aches, diarrhea, increased heart rate, fever, runny nose, sneezing, goose bumps, sweating, yawning, nausea or vomiting, nervousness, restlessness or irritability, shivering or trembling, stomach cramping, weakness [narcan.com]

  […] on opiate drugs include: Slow respiration rate, usually 12 or fewer breaths per minute Small, pinpointed pupils Acting confused and disoriented Trouble staying awake Fighting people trying to keep them awake Sudden and severe mood swings Depression Nausea [projectknow.com]

• Constipation

  If no laxative was given, you may become constipated. If this happens, you may take an over-the-counter laxative or suppository. [fairview.org]

  Opiate overdose is responsible for features of intoxication which include nausea, vomiting, slowed gastric emptying, constipation, as well as the typical triad. Respiratory depression may be presented as bradypnea and progress to apnea. [symptoma.com]

  Effects include: euphoria, drowsiness/respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness, coma, tolerance and addiction. [columbus.gov]

  […] respiration rate, usually 12 or fewer breaths per minute Small, pinpointed pupils Acting confused and disoriented Trouble staying awake Fighting people trying to keep them awake Sudden and severe mood swings Depression Nausea Uncontrollable vomiting and constipation [projectknow.com]

  Your friend or loved one experiencing overdose may complain of a dry mouth, constipation, stomach, or abdominal spasms. However, one of the most visible signs of overdose is a bluish nails or lips. [ashleytreatment.org]

• Choking

  Choking sounds, or a snore-like gurgling noise (sometimes called the “death rattle”) Vomiting Body is very limp Face is very pale or clammy Fingernails and lips turn blue or purplish black Pulse (heartbeat) is slow, erratic, or not there at all If someone [harmreduction.org]

  If sedated or groggy, a person might be more likely to aspirate vomit and choke, particularly when alcohol and other sedatives are used. Cause a slight drop in blood pressure or trigger an abnormal heart rhythm. [sciencenews.org]

  While waiting for emergency medical help to arrive, roll the person suffering from the opioid overdose on their side to protect them from choking in the event that they vomit while unconscious. [americanaddictioncenters.org]

• Hypotension

  Hypotension. Hypothyroidism. Asthma (avoid during an attack) and decreased respiratory reserve. Prostatic hypertrophy. Opiates should still be used in terminal care, even in these groups. [patient.info]

  Because endogenous opioids and mu-receptors mediate vascular tone, naloxone can cause hypotensive patients who haven't taken any opioids to have a rise in blood pressure and arousal. [pulmccm.org]

  Cardiovascular Most opiates are known to cause peripheral vasodilatation, which can result in moderate to severe hypotension. However, this hypotension is easily reversed with changes in body position or fluid administration. [ncbi.nlm.nih.gov]

  Findings: Symptoms and Signs Altered Level of Consciousness (CNS depression or sedation) Coma Lethargy Stupor Hypotension Miosis (except Demerol which causes Mydriasis ) Pulmonary edema Respiratory depression Seizure s VII. [fpnotebook.com]

  Patients who overdose on opioids may also be bradycardic and hypotensive, and detection of a pulse can be difficult. Waveform capnography can help determine when patients have spontaneous circulation and when chest compressions are needed. [ems1.com]

• Palpitations

  Advise patients to seek medical attention immediately if they experience palpitations, near syncope, syncope, or other cardiac symptoms while taking this drug. [drugs.com]

• Cold, Clammy Skin

  clammy skin, or bluish skin around the lips or under the fingernails Depressed breathing is the most dangerous side effect of opioid overdose. [americanaddictioncenters.org]

• Piloerection

  Concerns that naloxone will harm patients with opioid dependence are unfounded; all signs of opioid abstinence (e.g., yawning, lacrimation, piloerection, diaphoresis, myalgias, vomiting, and diarrhea) are unpleasant but not life-threatening. 25 In addition [ncbi.nlm.nih.gov]

• Miosis

  Opiate overdose is characterized by respiratory depression, reduced consciousness, and miosis. The manifestations are a result of opiate activity on the central nervous system. [symptoma.com]

  Constricted pupils (miosis) or poor arousability in a slow-breathing patient further suggest opioid toxicity. [pulmccm.org]

  […] by, last update April 2, 2019 CLINICAL FEATURES miosis CNS depression respiratory depression complications of hypoxia: seizures, dysrrhythmia, brain injury MANAGEMENT Resuscitation appropriate use of naloxone can prevent intubation Electrolytes and Acid-base [lifeinthefastlane.com]

  A respiratory rate of 12 breaths per minute or less in a patient who is not in physiologic sleep strongly suggests acute opioid intoxication, particularly when accompanied by miosis or stupor. 34 Miosis alone is insufficient to infer the diagnosis of [ncbi.nlm.nih.gov]

  Findings: Symptoms and Signs Altered Level of Consciousness (CNS depression or sedation) Coma Lethargy Stupor Hypotension Miosis (except Demerol which causes Mydriasis ) Pulmonary edema Respiratory depression Seizure s VII. [fpnotebook.com]

• Euphoria

  They may be prescribed or used illegally to reduce pain, manage opioid dependence or produce a state of euphoria/relaxation. [towardtheheart.com]

  The activation of opioid receptors within the dopaminergic reward pathway of the brain results in euphoria. [symptoma.com]

  As some patients continue to take the medication and enjoy the euphoria that might come with it, it can mark the beginning stages of a deadly addiction. [edition.cnn.com]

  They also produce a feeling of euphoria and, thus, have the potential to be abused. [pedsinreview.aappublications.org]

• Hunger

  Titration and Maintenance of Opioid Dependence Detoxification: -Titrate to a dose that prevents opioid withdrawal, reduces drug hunger or cravings, and blocks or attenuates the euphoric effects of self-administered opioids while ensuring the patients [drugs.com]

• Confusion

  Effects include: euphoria, drowsiness/respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness, coma, tolerance and addiction. [columbus.gov]

  Confused thinking can lead to accidents and injury. Confused thinking can be caused by a medical condition, disease, side-effects from medications, and drug or alcohol use. Some of these factors can be controlled, and some cannot. [blog.reliasacademy.com]

  Common Symptoms to Look For Signs of an overdose on opiate drugs include: Slow respiration rate, usually 12 or fewer breaths per minute Small, pinpointed pupils Acting confused and disoriented Trouble staying awake Fighting people trying to keep them [projectknow.com]

  If the person suffering the overdose is still awake, they may exhibit disorientation or confusion. If they do lose consciousness, they may slip into a coma. Emergency Care for Overdose For many people, an opiate overdose is fatal. [ashleytreatment.org]

  Symptoms of opioid intoxication can include: Altered mental status, such as confusion, delirium, or decreased awareness or responsiveness Breathing problems (breathing may slow and eventually stop) Extreme sleepiness or loss of alertness Nausea and vomiting [medlineplus.gov]

• Stupor

  Although the classic toxidrome of apnea, stupor, and miosis suggests the diagnosis of opioid toxicity, all of these findings are not consistently present. 32 The sine qua non of opioid intoxication is respiratory depression. [ncbi.nlm.nih.gov]

  Patients who are tolerant to opioids may not manifest the classic symptoms of stupor or miosis (for example, polysubstance ingestions, including drugs such as cocaine, can normalize or dilate pupils). [pulmccm.org]

  Findings: Symptoms and Signs Altered Level of Consciousness (CNS depression or sedation) Coma Lethargy Stupor Hypotension Miosis (except Demerol which causes Mydriasis ) Pulmonary edema Respiratory depression Seizure s VII. [fpnotebook.com]

  The term narcotic specifically refers to any substance that induces sleep, insensibility, or stupor, and it is used to refer to opioids or opioid derivatives. It is derived from the Greek "narke" that means "numbness or torpor." [emedicine.medscape.com]

• Lethargy

  Findings: Symptoms and Signs Altered Level of Consciousness (CNS depression or sedation) Coma Lethargy Stupor Hypotension Miosis (except Demerol which causes Mydriasis ) Pulmonary edema Respiratory depression Seizure s VII. [fpnotebook.com]

  In most emergency rooms, patients who present with an unknown cause of lethargy or loss of consciousness have their blood glucose levels drawn. Initial treatment of overdose begins with supportive care. [ncbi.nlm.nih.gov]

  They found both treatment regimens equivalent in reversing both respiratory depression and CNS depression. 100% of the IN group progressed to a state of either lethargy or full consciousness following naloxone delivery compared to only 60% of the IV group [intranasal.net]

• Altered Mental Status

  Symptoms of opioid intoxication can include: Altered mental status, such as confusion, delirium, or decreased awareness or responsiveness Breathing problems (breathing may slow and eventually stop) Extreme sleepiness or loss of alertness Nausea and vomiting [medlineplus.gov]

  The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991; 20 :246–52. [ PubMed ] 35. Clark RF, Wei EM, Anderson PO. Meperidine: therapeutic use and toxicity. [ncbi.nlm.nih.gov]

Although history, physical examination, and various investigations are important, in cases of severe respiratory compromise, resuscitation should be prioritized. Clinical examination should encompass a recognition of typical features and serious complications such as compartment syndrome.

Laboratory studies include the screening of urine for opiates or opioids and various drugs [6]. Opiate overdose may lead to an excretion of opiates in urine up to 2 days after administration. Routine investigations that are conducted include a complete blood count, urea, electrolytes, liver function tests, and arterial blood gas analysis [7]. Additional investigations may be ordered, taking into account the possibility of concomitant ingestion of other substances.

As pulmonary edema and ARDS may be expected, chest X-ray may be required [7]. An abdominal X-ray in conjunction with computerized tomography (CT) is useful in the detection of swallowed packages [8]. Electrocardiography may be utilized to monitor cardiac function [9].

FINDINGS: History of personal overdose was found with 38% of the community sample and 55% of the treatment sample--mainly involving opiates and in the company of friends. [ncbi.nlm.nih.gov]

These treatment centers are so essential for getting Opioids addiction help as they provide around the clock medical care and treatment. [addictionresource.com]

The development of noncardiogenic pulmonary oedema (also known as acute lung injury) carries a poor prognosis (it is not naloxone-reversible). [patient.info]

Prognosis If the patient does arrest in the setting of a pure opiate overdose, the cause in most cases is severe hypotension, hypoxia and poor perfusion of the brain. The outcome for these patients is poor. [ncbi.nlm.nih.gov]

Secretions and/or mucous in the airway A closed glottis Opioid-induced glottis laxity Finally, it is important to recognize that pulmonary edema can occur in patients with heroin overdose who did not receive naloxone, which again points to a multifactorial etiology [ebmconsult.com]

Pulmonary edema Typically follows Opioid reversal (unclear etiology) May require Endotracheal Intubation XII. [fpnotebook.com]

the methadone overdose death rate peaked during 2005–2007 and declined in subsequent years. [1, 19] The rate of overdose deaths involving methadone decreased from 1.4 per 100,000 in 2011 to 1.1 in 2016, with 3,493 deaths reported in 2016. [20] The etiology [emedicine.medscape.com]

Etiology Causes of opioid overdose can include: Complications of substance abuse Unintentional overdose Intentional overdose Therapeutic drug error Risk of opioid overdose increases in the following: Those that take escalating doses Return to use after [ncbi.nlm.nih.gov]

The purpose of this study is to examine the epidemiology of acute opiate overdose in a poisoning center in Tehran. [ncbi.nlm.nih.gov]

Epidemiology Opioid Overdose is the leading cause of death in U.S. for those under age 50 years old Opioid s have been implicated in 16,000 deaths per year in U.S. as of 2013 (2015) MMWR Morb Mortal Wkly Rep 64(1): 32 [PubMed] IV. [fpnotebook.com]

Ruttenber AJ, Luke JL: Heroin-related deaths: New epidemiological insights. Science 1984;226:14–20. Gutierrez J, De La Torre R, Ortuno J, Garces JM, Cami J: Psychotropic drug consumption and other factors associated with heroin overdose. [karger.com]

Epidemiology [ 1 ] It is difficult to get reliable incidence figures. The elderly are more liable to poisoning from opiates and more likely to be taking them, especially drugs like co-codamol for arthritis. [patient.info]

As a nonspecific antidote, activated charcoal is frequently recommended if available within one hour of the ingestion and the ingestion is significant.[16] Gastric lavage, syrup of ipecac, and whole bowel irrigation are rarely used.[16] Epidemiology and [en.wikipedia.org]

While increased availability certainly plays a role in opioid abuse, the link between legitimate use and abuse is not well proven. [11, 10] Pathophysiology Activation of opioid receptors results in inhibition of synaptic neurotransmission in the central [emedicine.medscape.com]

[…] with death from opioid overdose. 9 In addition, data indicate that the frequent prescription of opioid analgesics contributes to overdose-related mortality among children, who may find and ingest agents in the home that were intended for adults. 10, 11 Pathophysiology [ncbi.nlm.nih.gov]

We estimate that at least two-thirds of witnessed overdose fatalities could be prevented by administration of home-based supplies of naloxone. [ncbi.nlm.nih.gov]

CDC’s Work to Prevent Opioid Overdose Deaths CDC is committed to an approach that protects the public’s health and prevents opioid overdose deaths. [cdc.gov]

U.S. deaths MPR News graphic | Source: Centers for Disease Control and Prevention In Minnesota, the struggle with prescription painkillers and illegal drugs has left communities grieving for people whose deaths could have been prevented. [mprnews.org]

12-hours-opioids-forum-north-tonawanda-high-school F or more information regarding prevention, opioid abuse and addiction, visit https://www.hhs.gov/opioids/prevention/index.html [kaleidahealth.org]

1. Chou R, Clark E, Helfand M. Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review. J Pain Symptom Manage. 2003;26(5):1026–1048.
2. Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309(7):657–659.
3. Jones CM, Paulozzi LJ, Mack KA. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use United States, 2008-2011. JAMA Intern Med. 2014;174(5):802–803.
4. Zacny JP. Profiling the subjective, psychomotor, and physiological effects of tramadol in recreational drug users. Drug Alcohol Depend. 2005;80(2):273-278.
5. Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367(2):146-155.
6. Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing: current recommendations and best practices. Pain Physician. 2012;15(Suppl.3):ES119-33.
7. Ridgway ZA, Pountney AJ. Acute respiratory distress syndrome induced by oral methadone managed with non-invasive ventilation. Emerg Med J. 2007;24(9):681.
8. Pinto A, Reginelli A, Pinto F, et al. Radiological and practical aspects of body packing. Br J Radiol. 2014;87(1036):20130500.
9. Modesto-Lowe V, Brooks D, Petry N. Methadone deaths: risk factors in pain and addicted populations. J Gen Intern Med. 2010;25(4):305-309.