Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 38-48: Opiate & Opioid + Key Features Download Section PDF Listen +++ ++ Widely varying potencies and durations of action (eg, some illicit fentanyl derivatives are 2000 times more potent than morphine) In recent years, poisonings and fatalities have been reported due to the illicit use of fentanyl and the presence of fentanyl and its derivatives in counterfeit medications + Clinical Findings Download Section PDF Listen +++ ++ Heroin's duration of action is usually 3–5 h; methadone, 48–72 h Euphoria, drowsiness, and constricted pupils can occur with mild intoxication Severe intoxication may cause Hypotension Bradycardia Hypothermia Coma Pulmonary edema Respiratory arrest Death usually results from apnea or pulmonary aspiration Methadone may cause QT interval prolongation and torsades de pointes Tramadol, dextromethorphan, and meperidine also occasionally cause seizures Meperidine metabolite normeperidine can cause seizures, particularly with repeated use in patients with chronic kidney disease Skin-popping, especially with "black tar" heroin, associated with wound botulism and tetanus Buprenorphine Newer partial agonist opioid used in some outpatient drug treatment programs May precipitate acute withdrawal symptoms when added to an opioid regimen + Diagnosis Download Section PDF Listen +++ ++ Routine urine toxicology screening usually positive for patients with heroin, morphine, codeine overdose Toxicology screening may be falsely negative if opioid is methadone, fentanyl, oxycodone + Treatment Download Section PDF Listen +++ ++ Activated charcoal Administer 60–100 g orally or via gastric tube, mixed in aqueous slurry if ingestion within 1 h Do not give to comatose or convulsing patients unless airway protected by cuffed endotracheal tube Naloxone Administer 4 mg intranasally if no intravenous access is available Otherwise, administer 0.2–2 mg intravenously; repeat as needed to awaken the patient and maintain airway protective reflexes and spontaneous breathing Effect duration: ~2–3 h Repeated doses may be necessary for intoxication by methadone or other long-acting drugs Large doses (10–20 mg) may be needed for codeine, fentanyl derivatives Continuous observation for at least 3 h after the last naloxone dose is mandatory