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For further information, see CMDT Part 38-48: Opiate & Opioid

Key Features

  • 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

  • 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


  • 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


  • 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

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