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11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023
| Contributor Information
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
This photograph shows the left groin of an intravenous (IV) drug user with septicemic anthrax.
As the opioid epidemic expands in the United States, more patients battle addiction and the rate of opioid-related overdose deaths continues to climb—rising from 21,089 in 2010 to 80,411 in 2021.[1,2,3] Because opioid abuse can result in a myriad of neurologic, cardiovascular, musculoskeletal, and pulmonary complications,[4] healthcare providers must be prepared to diagnose and treat the potentially fatal conditions that can be precipitated by opioids, especially as they occur through IV drug abuse (IVDA)/injection drug use (IDU).
Image depicting heroin-related noncardiogenic pulmonary edema courtesy of Medscape.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
Respiratory Failure
The toxidrome that develops following the intake of opioids includes analgesia, sedation, slowing of the gastrointestinal tract and, most dangerously, respiratory depression. Stimulation of the mu receptors in the brain reduces the body's response to hypercarbia and hypoxia, resulting in a decreased incentive to breathe and a progression to apnea.[5] Thus, the most common cause of death following an opioid overdose is respiratory depression. Patients with a history of lung disease have an even higher mortality risk. Co-intake of opioids with other respiratory depressants, such as gabapentin, further raises the risk of death.[5]
Image from Wikimedia Commons / Evilleavenger.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
Use of naloxone
The treatment for an opioid overdose is naloxone, whose main purpose is to reverse respiratory depression. It is a competitive opioid antagonist with a high affinity for the mu receptor that can be administered intravenously, intranasally, subcutaneously, intramuscularly, or through an intraosseous line.[6]
After patients receive and respond to naloxone, they should be observed in the emergency department (ED).[6] Prior to discharge, it is recommended that the patient have a Glasgow Coma Scale of 15, no need for repeat dosing of naloxone, and a return to normal vital signs. Ideally, a ride would be procured to take the patient home, with monitoring for 12-24 hours.[6]
Image courtesy of Nicole Cimino-Fiallos, MD, FACEP, FAAEM.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
A 35-year-old male injection heroin user required resuscitation with both intranasal (IN) and intramuscular (IM) naloxone. He subsequently developed noncardiogenic pulmonary edema (shown) and was intubated due to hypoxia.
Pulmonary Edema
Although naloxone can be lifesaving and there are no absolute contraindications to its use (except for documented anaphylaxis), complications can develop from its administration.[6] In addition to the risks of acute withdrawal syndrome precipitated by too much naloxone, the drug can also cause noncardiogenic pulmonary edema. This condition, which develops in up to 4% of patients receiving the medication, is likely caused by the adrenergic response (the release of catecholamines) to naloxone-associated opioid withdrawal.[6] The sudden increase in plasma concentrations of catecholamines is thought to cause a shift in blood volume to the pulmonary vasculature, which triggers pulmonary vasoconstriction and resultant pulmonary hypertension.[7]
Images from Heinz UE, Rollnik JD. BMC Res Notes. 2015 Jun 17;8:243. [Open access.] PMID: 26081628; PMCID: PMC4469251.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
The above computed tomography (CT) scans of patients who suffered hypoxic brain damage show brain atrophy and hydrocephalus (left) and hypodense white matter changes (right).
Anoxic Brain Injury
Central nervous system (CNS) depression is a common result of opioid intake. It can range from mild somnolence to coma. Some opioids (eg, tramadol, tapentadol, propoxyphene) not only cause CNS depression but also, after prolonged oxygen deprivation, lead to seizures, which occur secondary to brain injury and subsequent electrical instability. Thus, the respiratory depression classically caused by opioid toxicity can end in anoxic brain injury if not reversed quickly.
Image of Staphylococcus aureus endocarditis with perforation of, and vegetation on, the aortic valve courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Administration Medical Center.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
Endocarditis
Many of the complications of IVDA/IDU result from the use of nonsterile needles.[5] The presence of S aureus on the skin, concomitant infection with human immunodeficiency virus (HIV), application of saliva to lubricate needles, and use of nonsterile ingredients in drug formulations all compound the risk for infections, including endocarditis, in the drug-abusing population.[8]
A difference between other causes of endocarditis and that associated with IVDA/IDU is that IVDA/IDU-related endocarditis typically results in infections on the right side of the heart.[5] The most commonly affected valve is the tricuspid valve. Patients may complain of malaise and fever. Clinicians may detect a new murmur on cardiac auscultation.[5]
Image courtesy of Nicole Cimino-Fiallos, MD, FACEP, FAAEM.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
The hand of a patient who uses IV drugs is shown. She was diagnosed with endocarditis and septic emboli, in which an arterial embolus resulted in ischemic disease of her left fifth digit.
Septic emboli
Once bacterial vegetations grow on the cardiac valves, septic emboli can disperse to any organ system.[8] Occasionally, the presence of multiple infections or signs of embolic disease are the only clue pointing to a diagnosis of endocarditis. The valves themselves can become compromised and develop regurgitation or insufficiency, and complete valve destruction can occur. Mortality ranges from 25% to 50% at 1 year after diagnosis, worsened by a frequent lack of patient compliance with long-term antibiotic regimens.[4]
Adapted image from Chan JJ, Oh JJ. Int J Emerg Med. 2016;9(1):22. [Open access.] PMID: 27456667, PMCID: PMC4960080.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
The image reveals compression of the thecal sac and the cauda equina by an abscess in the posterior epidural space and a posterior disc bulge.
Spinal Epidural Abscess
Spinal epidural abscess is a feared IVDA/IDU complication.[9] Bacteria seeded into the epidural space forms an abscess, which causes a mass effect on the spinal cord, conus medullaris, or cauda equina (shown). Left untreated, the compression of blood flow to the spinal cord can result in muscle weakness, sensory loss, bowel and bladder dysfunction, sepsis, or mortality. Less than 20% of patients with spinal epidural abscess will develop the classic triad of fever, back pain, and neurologic deficit.[9]
Most infections are caused by S aureus, including methicillin-resistant S aureus (MRSA).[10]
Surgery is typically recommended; however, medical management may be pursued in patients with early disease, normal neurologic status, or poor surgical candidacy. Postoperative antibiotics are usually required for 4-6 weeks.
Adapted image from pxhere.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
Mediastinitis
Prolonged use of IV drugs causes sclerosis and scarring of the involved peripheral veins; thus, many people with substance use disorders will attempt to inject into the deep veins of the neck.[11] Known as a "pocket shot,"[12] injection into this region (supraclavicular fossa) (shown) is fraught with danger; patients can develop jugular venous thrombophlebitis, pseudoaneurysms of the carotid artery, Horner syndrome, septic arthritis of the sternoclavicular joint, and/or mediastinitis.[5]
Mediastinitis is known for its rapid progression and high mortality rate. The infection can result in the development of an abscess, the creation of an esophagopleural fistula, or involvement of the pericardium.[4] Initiate early administration of antibiotics, and, because debridement is often indicated, obtain surgical consultation.
Left image from the Centers for Disease Control and Prevention / Gregory Moran, MD. Right image courtesy of Medscape.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
Skin Infections
In addition to using the neck veins as alternative sites when peripheral veins are inaccessible due to sclerosis/scarring, individuals who inject drugs may advance to the use of a technique known as "skin popping," wherein drugs are injected into subcutaneous tissues.[12] Superficial infections such as cellulitis and abscess formation (left image) can occur. If users inject into deeper structures with dirty needles or without cleaning their skin, they can develop myositis, rhabdomyolysis, necrotizing fasciitis (right image), and/or compartment syndrome.[4]
Image courtesy of Nicole Cimino-Fiallos, MD, FACEP, FAAEM.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
The photograph shows a mycotic pseudoaneurysm that developed after the patient injected heroin into his left radial artery. Operative repair and a prolonged course of IV antibiotics were required.
Pseudoaneurysm
If IV drug users unintentionally inject into an arterial structure, they are at high risk for the formation of a pseudoaneurysm,[13,14] a collection of blood that forms between the two outer layers of an artery. Patients may describe the development of an expanding pulsatile mass. Pseudoaneurysms most commonly occur after injection into the groin,[13,14] but they have also been reported to develop after accidental injection in the carotid, radial, and other vessels.[13]
Excision and subsequent ligation of the pseudoaneurysm is often the treatment of choice.[14]Bedside drainage should not be attempted.[13]
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
The above image, showing the left groin of an IV drug user with septicemic anthrax, is from the same patient as in slide 1. This photo reveals the lesion after 4 weeks of negative pressure wound therapy.
Sepsis/Bacteremia
IV drug users are frequently bacteremic and can develop sepsis.[15] Most patients become infected because they use nonsterile needles and do not clean their skin prior to injection. Sharing needles with other drug users also raises the risk of infection. S aureus and Streptococcus pyogenes are the most common causes of bacteremia, but oral flora (from licking needles) can cause a similar presentation.
Patients with a history of IVDA/IDU who present to the ED with fever and tachycardia should have blood cultures drawn, and clinicians should be aware of the possibility that bacteremia and sepsis exist.[15]
Image from Wikimedia Commons / James Heilman, MD.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
The above radiograph shows a retained needle fragment in the arm following IV drug use.
Needle Fragment Foreign Body
Another complication that can result from the reuse of needles for IDU occurs when the needle breaks during injection.[12,16] The distal fragment from the broken needle can remain in the subcutaneous/soft tissues around the injection site (shown), or it can become an embolus.[16] Patients often develop local infection and inflammation around the retained fragment.
Ideally, once identified, the needle fragment is removed to prevent further problems.
Image from Wikimedia Commons / Jer5150.
11 Opioid-Related Emergencies: When Highs May Become Fatal
Nicole Cimino-Fiallos, MD, FACEP, FAAEM | June 30, 2023 | Contributor Information
Loperamide Overdose
Many patients addicted to opioids sometimes use inexpensive and readily available substitutes, such as loperamide (Imodium). This over-the-counter medication works by acting on the opioid receptors in the large intestine.[17]
Using this drug at high dosages can result in opioid intoxication.[17] Unfortunately, at the larger dosages required to "get high," patients are at risk for QT prolongation, QRS widening, ventricular arrhythmias, and torsades de pointes (shown), because of loperamide's physiologic activity. These cardiac effects can result in syncope and death.[17]
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Contributor Information
Nicole Cimino-Fiallos, MD, FACEP, FAAEM
Emergency Medicine Specialist
US Acute Care Solutions;
Assistant Medical Director
Emergency Department
Meritus Medical Center
Hagerstown, MD
Disclosure: Nicole Cimino-Fiallos, MD, FACEP, FAAEM, has disclosed no relevant financial relationships.
Editor
Olivia Wong, DO
Senior Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
Mehta AB, Weinstein Z, Walkey AJ. The untold toll of the opioid crisis on intensive care units in the United States. Ann Am Thorac Soc. 2017 Dec;14(12):1763-5. PMID: 29192818
Centers for Disease Control and Prevention (CDC). Opioids. Reviewed: November 3, 2022. Available at: https://www.cdc.gov/opioids/index.html. Accessed June 21, 2023.
Hossain R, Almeida RR, Natcheva H, et al. Complications of intravenous substance use disorders (SUDs): a multimodality pictorial essay for cardiothoracic radiologists. J Thorac Imaging. 2018 Mar;33(2):W1-12. PMID: 29257030
Jordan MR, Morrisonponce D. Naloxone. StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. 2023 Apr 29. PMID: 28722939 [Full text].
Jiwa N, Sheth H, Silverman R. Naloxone-induced non-cardiogenic pulmonary edema: a case report. Drug Saf Case Rep. 2018 May 10;5(1):20. PMID: 29749582
Koshkelashvili N, Shah M, Codolosa JN, Climaco A. Polymicrobial infective endocarditis caused by Neisseria sicca and Haemophilus parainfluenzae. IDCases. 2015 Nov 26;4:3-5. PMID: 27051571 [Full text].
DiGiorgio AM, Stein R, Morrow KD, Robichaux JM, Crutcher CL, Tender GC. The increasing frequency of intravenous drug abuse-associated spinal epidural abscesses: a case series. Neurosurg Focus. 2019 Jan 1;46(1):E4. PMID: 30611170
Rammell J, Kansal N, Bhattacharya V. Management options in the treatment of femoral pseudoaneurysms secondary to intravenous drug abuse: a case series. Int J Surg Case Rep. 2017;36:30-3. PMID: 28528282
Wurcel AG, Merchant EA, Clark RP, Stone DR. Emerging and underrecognized complications of illicit drug use. Clin Infect Dis. 2015 Dec 15;61(12):1840-9. PMID: 26270683
Fu X, Chen K, Liao X, Shen K. Case report: surgical removal of a migrated needle in right ventricle of an intravenous drug user. Subst Abuse Treat Prev Policy. 2017 Dec 8;12(1):51. PMID: 29216882
Katselou M, Papoutsis I, Nikolaou P, et al. "Poor man's methadone" can kill the poor man. Extra-medical uses of loperamide: a review. Forensic Toxicol. 2017 July;35(2):217-31.
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