Transcript Opioid Overdose and Cardiac Arrest

Opioid Overdose and Cardiac Arrest
Joseph Yanta, MD
Clinical Assistant Professor, Division of Medical Toxicology, Department of Emergency Medicine, UPSOM
Assistant Medical Director, Pittsburgh Poison Center
Presenter Disclosure Information
Joseph H. Yanta, MD
Opioid Overdose and Cardiac Arrest
Financial Disclosure: No relevant financial
relationship exists
Session Objectives
• Understand the incidence and prevalence of
opioid-related death
• Understand how outcomes after opioidrelated out-of-hospital cardiac arrest (OOHCA)
differ from non-opioid-related OOHCA
• Understand other cardiac-related
consequences opioids and opioid abuse
Game Plan
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Epidemiology
Pathophysiology
Prognosis
Opioid-induced dysrhythmia
Drug adulterants and cardiovascular pathology
Challenges in drug testing
Definitions
• Opiate = alkaloid with opioid receptor binding derived from the
poppy plant
– Morphine
– Codeine
– Thebaine
• Opioid = an agonist of opioid receptors
– Semisynthetic: heroin, hydromorphone, oxycodone, etc.
– Synthetic: fentanyl, methadone, tramadol, etc.
• Opiate is to opioid as square as rectangle
• Narcotic includes opioids as well as all other illegal drugs
Opioid Death Epidemiology
• 19,000 deaths per year due to
prescription opioid overdose
Drug overdose death involving opioids, by type of
opioid, United States, 2000-2014
– 52 deaths deaths per day
• More than 10,500 deaths per year
due to heroin
– 29 deaths per day
• More people die from opioid
overdose than either car
accidents or gun violence
• Available data likely
underestimate true number of
deaths
www.cdc.gov/drugoverdose/data/analysis.html
Opioid Death Epidemiology
• Pennsylvania had the 8th-highest rate of drug
overdose deaths in 2014
– 21.9/100,000
– 2,732 deaths overall
• West Virginia had the highest
Opioid Death Epidemiology
• Allegheny County Data
– 2015: 424 opioid overdose deaths
• 70% men
• 86% white
• 28% between ages 25-34
– 37% increase compared to 2014
• 234 deaths so far in 2016 (as of July 31)
Opioid Death Pathophysiology
• Opioid agonism of m2-opioid receptors results
in respiratory depression
• Death due to asphyxiation and subsequent
cardiovascular collapse and arrest
• Complicated by: ischemic liver/kidney injury,
rhabdomyolysis, aspiration pneumonitis,
pulmonary edema
Opioid Overdose and OOHCA
• Scant data exist comparing opioid- and nonopioid-related OOHCA
• Elmer J, Lynch MJ et al. Recreational Drug
Overdose-related Cardiac Arrests: Break on
Through to the Other Side. Resuscitation.
2015; 89:177.
Opioid Overdose and OOHCA
• Patients suffering overdose-related OOHCA (compared to
non-overdose-related) are:
– Younger
– Healthier at baseline
• More likely to present with a non-shockable rhythm, i.e. PEA
or asystole
• More likely to have worse initial neurologic examination
• Survival, neurologic outcomes, length of stay do not differ
from non-overdose-related subjects
– Despite poorer initial neurologic examination
Post-Arrest Management
• Little data exist to differentiate post-arrest
management of the poisoned patient from the
non-poisoned patient
• Aggressive temperature control (euthermia) is
still (probably) beneficial
• Consideration for coronary disease in
appropriate patients
Post-Arrest Challenges
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Neuroprognostication
Hypothermia drug kinetics
Withdrawal syndromes
Management of multisystem organ injury
– Rhabdomyolysis
– Acute liver injury
– Acute kidney injury
Challenges in Drug Testing
• Urine drug immunoassays imply presence
of drug, not causation
• “Opiate” screen = morphine screen
– Heroin metabolized to morphine
• Positive screen does not prove causality
• Negative screen does not disprove
causality
• So, the basic urine drug immunoassay
screen is USELESS
Negative on “Opiate” Urine Drug
Immunoassay
Methadone
Fentanyl (and derivatives)
Buprenorphine
Oxycodone (often)
Hydrocodone (sometimes)
Oxymorphone
Tramadol
Opioid-Associated Dysrhythmia
• Propoxyphene – essentially unavailable in the
United States
– Sodium channel blockade
• Methadone
– Doses >100 mg/day associated with increased risk
of sudden death
– Inhibits Ikr resulting in QT prolongation
Drug Adulteration
• Adulterant = intentional inclusion of xenobiotic
in drug sample for dilution, synergistic, or
maleficent intent
• Contaminant = unintentional inclusion of a
xenobiotic, usually as result of poor laboratory
technique
– E.g. lead, other heavy metals, codeine, MPTP
CV-Active Drugs as Adulterants
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Quinine/quinidine
Diltiazem
Verapamil
Lidocaine
Caffeine
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Procaine
Atropine
Arsenic
Clenbuterol
UPMC Medical Toxicology Service
via MedCall: 412.647.7000
Thank you for your attention!
Questions?