What provokes poisoning with opiates and narcotic analgesics. First aid for opiate poisoning

Opiates are opium, which is obtained from the milk of poppy capsules or substances synthesized from it - levamethadone, heroin, morphine. Aqueous solutions of these substances are used as medicinal material. These substances can be quite dangerous, since their uncontrolled use causes pronounced euphoria and pathological dependence. These drugs are among the most common drugs that lead to mental and physical dependence.

With the development of a pathological addiction to drugs of the opiate group, the dose of these substances is constantly increasing, which leads to their accumulation in the body. As a result, an overdose leads to poisoning, one of the main symptoms of which is respiratory paralysis.

Symptoms

Acute poisoning:

pallor, euphoria;

vomiting, nausea;

constriction of the pupils;

pupil dilation;

activity disruption circulatory system and hearts;

respiratory depression;

Chronic opiate poisoning:

disturbance of consciousness;

violation of urination;

When the body is intoxicated with opiates, severe nausea immediately occurs, with persistent vomiting, constriction of the pupils, the skin turns pale and then acquires a bluish tint. There is shallow breathing and a thready pulse. Further, respiratory depression develops, disruption of the circulatory system and heart, dilated pupils and coma occurs.

There is only one reason for the development of drug poisoning - an overdose. In this case, drugs act due to opioid receptors - specific nerve endings of brain neurons. When opioids bind to these receptors, all the functions of the nervous system are disrupted, which explains the analgesic effect of these substances.

First aid

With the development of a severe degree of intoxication with opium derivatives, the main task is to provide artificial ventilation of the patient's lungs in order to prevent disorders that can be triggered by respiratory paralysis. There is also an antidote for poisoning with these substances - "Naloxone", the action of which is aimed at displacing toxins from the receptors mentioned above. If drugs were taken orally, gastric lavage and bladder catheterization should be performed.

With an overdose of narcotic drugs, it is quite difficult to do something on your own, and it is often too late. When determining the first signs of poisoning, you should immediately call an ambulance.

In most cases, an overdose of narcotic drugs is the result of a pathological dependence on them. Therefore, when the first signs of addiction appear, you should immediately contact a narcologist. Poisoning with opiates in most cases indicates the presence of an addiction in a person.

After the doctor eliminates the life-threatening symptoms of poisoning, and the patient's condition improves, the patient is referred for treatment to a narcologist.

How to avoid opiate poisoning?

First of all, you need to get rid of drug addiction. In this case, the main thing is that a person should realize in time the full degree of danger that threatens him, and come to the doctor in time. Below are the main stages of drug addiction:

pathological attraction to the use of drugs and their acquisition at any cost;

the need for a constant increase in dose;

development of mental and physical dependence;

complete degradation of personality.

It can be administered intravenously, as well as ingested through smoking, sniffing, and through the skin. Along with heroin, other opiates are also used. Drugs such as dextrapropoxyphene and dehydrocodeine (may be part of a combination dosage form with paracetamol), often used with alcohol for suicidal purposes by people who do not suffer from drug addiction.

Opiate Poisoning: Symptoms

Typical symptoms of opiate intoxication are pinpoint pupils, cyanosis, and coma. CNS depression is more pronounced with the use of opiates along with alcohol. BP may decrease, but, oddly enough, is usually maintained at normal level. Although some opiates, such as dextrapropoxyphene and pethidine, increase muscle tone and cause convulsions in case of overdose, mainly muscle hypotonia is characteristic of opiate poisoning.

Opiate Poisoning: Predictions

• Non-cardiogenic pulmonary edema determines a poor prognosis.
• Patients with coronary heart disease are predisposed to the occurrence of hemodynamic disturbances after the appointment of naloxone.
• Impaired renal function reduces the elimination of opiates and increases the duration of their action.

Opiate Poisoning: Treatment

Control the frequency and depth of breathing, indicators of pulse oximetry. Spend the introduction of oxygen through the mask. Continuously monitor ECG to early detection arrhythmias.

Catheterize a vein; take blood for the study of urea, electrolytes and CPK. When taking opiates along with paracetamol, it is required to determine the level of paracetamol in the blood.

If the patient has a coma or respiratory symptoms, an x-ray of the lungs is required (identification of signs of infection, septic emboli, interstitial shadows).

The specific antidote for opiates is naloxone (a pure opioid receptor antagonist), which is given as an intravenous bolus until the patient awakens and spontaneous breathing is restored. Administration of up to 2 mg (or more) of naloxone may be required, but if no effect is observed, the diagnosis of opiate intoxication should be reconsidered.

The duration of action of naloxone is shorter than that of many opioids, therefore, to prevent recurrent CNS depression, intravenous continuous administration of naloxone should be started immediately after the administration of the bolus dose of naloxone (start with 2/3 of the dose that was required to wake the patient, injecting it over an hour, and further select the dose according to the effect). In case of poisoning with long-acting opiates, such as methadone®, naloxone infusion may be required.

In patients with drug dependence, when prescribing naloxone, the complete elimination of the effect of opiates is avoided, as this can provoke the development of a withdrawal syndrome. When it occurs and a significant increase in blood pressure, diazepam is administered and, if arterial hypertension persists, nitroglycerin infusion is started under the control of blood pressure. Note! Severe hypertension, acute pulmonary edema and VT or fibrillation may occur in non-addicted patients when naloxone is administered to reverse the effects of high doses of narcotic analgesics prescribed for pain relief.

Opiate-induced seizures (usually pethidine or dextrapropoxyphene) may resolve with intravenous naloxone. Sometimes additional administration of anticonvulsants is required.

For the treatment of pulmonary edema, oxygen therapy, the method of SDPPD and mechanical ventilation are used. Naloxone is not effective in treating pulmonary edema.

Treatment of rhabdomyolysis and acute renal failure.

Opiate poisoning: complications

• All opioids can cause non-cardiogenic pulmonary edema, although it is most commonly seen with intravenous administration heroin.
• Rhabdomyolysis is often seen in patients with opiate coma and should be suspected in all cases.
• Substances used to dissolve illegal opiates may also cause toxic reactions (to talc or quinine).
• Intravenous drug users often have right heart endocarditis and septic pulmonary embolism.
• When taking combined preparations containing paracetamol (for example, codydramol), renal and hepatic insufficiency may occur.

Opiate poisoning: important points

Dextrapropoxyphene in combination with alcohol causes severe CNS depression. Respiratory arrest can occur in less than 30 minutes after their use. The introduction of naloxone is indicated even with mild drowsiness of the patient. Dextrapropoxyphene also has an acute toxic effect on the heart, which is manifested by arrhythmias resulting from its membrane-stabilizing action (naloxone is not effective for its elimination).

Respiratory depression caused by buprenorphine is not completely eliminated by naloxone. In mild cases of buprenorphine intoxication, doxapram is used as a respiratory stimulant; (1-4 mg / min), in severe cases, mechanical ventilation is preferable.

The group of medicines made from the opium poppy includes opium, omnopon, morphine, codeine, ethylmorphine (dionine), fenadone, methadone, heroin (diacetylmorphine), pantopon, promedol, propoxyphene, etc., as well as handicraft preparations. Morphine-like substances are used not only as analgesics and antitussives, but also as agents used for diarrhea; an overdose of the latter in children can lead to severe poisoning and even death. These drugs include lomotil (containing 2.5 mg of diphenoxylate hydrochloride and 0.025 mg of atropine sulfate in 1 tablet) and loperamide (imodium), which resembles fentanyl and pyritramide in structure.

Opiates have a psychotropic (narcotic) and neurotoxic effect on the central nervous system, depressing the pain centers of the cerebral cortex and the region of the thalamus. However, their paralyzing effect on the vasomotor and respiratory centers is most dangerous. The speed of onset of symptoms of opium poisoning directly depends on the routes and methods of administration of opiates. The most dangerous in / in the introduction - by inhalation through the nose, s / c, / m intake or ingestion clinical manifestations intoxications are delayed in time and less pronounced. Cases of fatal poisoning during the illegal transportation of the drug in the stomach and (or) intestines have become more frequent due to the violation of the integrity of the swallowed containers. In these cases, the picture of poisoning develops slowly, repeating the clinic of acute intoxication (intoxication) with opiates.

Symptoms, course acute poisoning opiates depend on its severity. Lung and medium degree severity of poisoning does not pose a threat to life and are considered as preceding serious conditions.

mild poisoning occurs 10-30 seconds after the intravenous administration of opiates. There is a feeling of warmth in the lumbar region or abdomen, rising up, accompanied by a feeling of light stroking on the skin; the face turns red, the pupils narrow, dry mouth appears. There is a focus on bodily sensations - an extraordinary lightness in the head, a feeling of "special joy" concentrating in the chest, which is characteristic only for occasional users or emerging drug addicts.

Further, with moderate poisoning, this state is replaced by complacent languor, lazy pleasure, quiet peace. Characterized by lethargy, inactivity, a feeling of heaviness and warmth in the arms and legs. Stunning of consciousness develops. Against its background, dream-like fantasies appear, replacing one another, visualization of representations is possible (the emergence of visions and representations on a certain topic - at will or “order”). External stimuli are perceived distortedly. A superficial sleep gradually develops, lasting 2-3 hours. Awakening is usually accompanied by bad feeling with headache, dizziness, nausea, causeless restlessness, sometimes with anxiety and even melancholy, tongue trainer, eyelids, outstretched fingers, urinary and stool retention.

Severe opiate poisoning characterized by lethargy with depression of consciousness (deep stupor, stupor, coma). The leading symptom is respiratory failure. The number of respiratory movements and their depth decrease, which leads to hypoxemia, hypoxia and even anoxia. Superficial rare breathing of the Cheyne-Stokes type in some cases can be born up to 2-3 breaths per 1 minute or to a complete stop. The pupils are sharply narrowed (pinpoint), their reaction to changes in illumination is absent. face and skin pale, dry (in rare cases, cold sweat), bluish lips. The body temperature is low, the extremities are cold to the touch. The pulse is slow, irregular, weak.

Arterial pressure is reduced, development of a collapse is possible. Reflexes disappear, complete anesthesia occurs. There may be an increase in muscle tone, clonic and tonic convulsions, sometimes opisthotonus (more often with heroin poisoning). The depth of the coma and the severity of hypoxia of the brain are evidenced by a sharp cyanosis of the skin and mucous membranes and a pronounced dilation of the pupils. With prolonged hypoxia, pulmonary and cerebral edema develops. AT late dates intoxication, signs of encephalopathy and paralysis appear. With a favorable outcome, the coma passes into deep sleep, lasting from 24 to 36 hours.

When taking codeine, a state of motor and mental excitement arises: such a patient is funny, animated, cannot sit still, gesticulates, speaks loudly, the pace of speech is accelerated. In case of severe codeine poisoning (more than 5 tablets), the described disorders (including convulsions and mydriasis) may develop against the background of the patient's preserved consciousness.

fatal opiate poisoning occurs as a result of paralysis of the respiratory, vasomotor centers. The lethal dose of morphine for an adult is 0.2-0.5 g when administered intravenously or 0.5-1 g when taken orally. For long-term opium addicts, the lethal dosage is usually 10 to 50 times or more higher. In adults in the absence of increased tolerance to drugs lethal dose heroin is 20 mg, fenadone - 75 mg. Most common cause The death of drug addicts is a drug overdose - the introduction of too high a dose of opiates, often without regard to the decrease in reactivity after treatment.

Diagnosis. To suspect drug intoxication and to start detoxification therapy, narrowing of the pupils, a dreamily absent look, slight staggering in the absence of the smell of alcohol from the mouth allow. The classic triad of significant opiate overdose includes coma, pinpoint pupils, and respiratory failure. The correct diagnosis is helped by traces of injections along the veins (“addict's path”) and anamnestic indications of taking drugs from the opium group. A quick laboratory express method is the determination of morphine and its metabolites in the urine by immunochromatography.

Detection of morphine in wash water and vomit is carried out using a color reaction with ferric chloride (causing them to turn blue). An important differential diagnostic value is response to naloxone administration- improvement or restoration of spontaneous breathing and an increase in the level of consciousness are in favor of opiate poisoning. At the same time, a certain effectiveness of naloxone in overdose of barbiturates, benzodiazepine receptor agonists, as well as in acute alcohol intoxication can cause a false positive reaction, which to some extent reduces the diagnostic value of the naloxone test.

In the absence of the “awakening effect” of naloxone, the patient should be assumed to have a concomitant pathology - a traumatic brain injury, an overdose of “street” narcotic analgesics (fentanyl and its derivatives), poisoning with drug mixtures (heroin with cocaine - “speed-ball”, etc.), hypoxic encephalopathy, hypoglycemic state, state after convulsions (if there are indications of a convulsive syndrome in history), etc.

Treatment. The main task of emergency therapy for prehospital stage is the normalization of respiration and cardiovascular activity. If breathing is disturbed, clean Airways and start artificial respiration. An opioid receptor antagonist, naloxone, is administered intravenously. By displacing opiates from specific receptors, it quickly restores depressed breathing and consciousness, and therefore it is especially indicated at the prehospital stage, even when tracheal intubation and mechanical ventilation are impossible. The initial dose of naloxone is started with 0.4 mg (1 ml of a 0.04% solution) in / in a slow stream in isotonic sodium chloride solution or endotracheally.

If necessary, after 3-5 minutes, the introduction of naloxone (1.6-2 mg, 4-5 ml of a 0.04% solution) is repeated until the level of consciousness rises, spontaneous breathing is restored and mydriasis appears. When administered intravenously, the effect of the drug begins after 2 minutes and lasts 20-45 minutes. In parallel, to eliminate hypersalivation, bronchorrhea and bradycardia, 1-2 ml of a 0.1% solution of atropine is injected s / c. If the condition worsens again, the administration of naloxone is repeated after 20-30 minutes. Combined intravenous and s / c administration of naloxone is possible. Upon reaching therapeutic effect the introduction is stopped. It is advisable to fix the result in / m or / in the drip of an additional dose of naloxone - 0.4 mg. The drug is used for opiate intoxication of any severity.

With prolonged severe hypoxia, especially with possible aspiration (vomiting), the introduction of naloxone should be preceded by tracheal intubation (after premedication, intravenous atropine is indicated) and mechanical ventilation. With the introduction of naloxone to patients with aspiration syndrome during prolonged hypoxia, after 30-60 minutes, an undesirable effect can be obtained in the form of pronounced psychomotor agitation and pulmonary edema.

For short-term activation of breathing, you can use the / in the introduction of etimizole. Other analeptics (bemegride, corazol) are contraindicated, as they can provoke convulsions or increase the tone of skeletal muscles, increasing oxygen consumption by skeletal muscles, and thereby aggravate brain hypoxia. In the absence of naloxone, 2 ml of a 10% caffeine solution with 2 ml of cordiamine is administered s.c. or i.v. In severe cases, in the absence of the effect of the introduction of antagonists or the inability to prescribe other medicines it is necessary to carry out IVL in the mode of hyperventilation. Oxygen should be given to the patient to inhale constantly until the respiratory disorders are eliminated.

The stomach is washed repeatedly, since opiates cause spasm of the pyloric sphincter of the stomach and linger in it, and are also partially released into the intestinal lumen, from which they are reabsorbed. Repeated gastric lavages are carried out with the introduction activated carbon or an opiate-oxidizing solution of potassium permanganate (1:5000). They give a saline laxative (sodium sulfate or magnesium sulfate 25-30 g per reception) and put a cleansing enema. The gastric lavage procedure is performed carefully due to the risk of convulsions. The probe, previously lubricated with oil or water, is inserted slowly, carefully, since the tone of the esophagus is increased and there is a danger of its rupture.

400 ml of 0.06% sodium hypochlorite solution and 400 ml of 5-10% glucose solution or 400 ml of rheopolyglucin and 300 ml of 4% sodium bicarbonate solution are injected intravenously. The patient is warmed up. Antibiotics are used to prevent infectious complications. For the prevention and control of pulmonary edema, 40 mg of Lasix, glucocorticoids (hydrocortisone, prednisolone, etc.) are administered. To eliminate psychomotor agitation and convulsions, intramuscularly or intravenously, slowly, very carefully (if mechanical ventilation is possible in case of respiratory depression), 2-4 ml of a 0.5% solution of diazepam (seduxen, relanium), 200-300 mg sodium thiopental.

In the hospital, forced diuresis, plasma alkalinization by fractional administration of a freshly prepared 4% sodium bicarbonate solution, and peritoneal dialysis are carried out.

Forecast depends on the dose taken, individual tolerance, speed of provision and adequacy of emergency care. In the case of the development of encephalopathy with convulsions, swelling of the brain and lungs, the prognosis is often unfavorable.

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a) Toxicokinetics of opiates. The table below summarizes the toxicokinetic parameters and clinical data for some commonly used opioids.

b) Therapeutic dose. The table below lists doses of opioid analgesics for adults and children weighing at least 50 kg who have not previously received opioids.

in) Mechanism of action of opioids. Healthy men who run until they collapse without feeling uncomfortable have elevated levels of beta-endorphins (endogenous opioids). Such people can easily run to a state of confusion, dehydration, hyperthermia and hypophosphatemia. Signs of opiate addiction, opioid receptor interactions, and physiological effects of opioids are in the tables below.

G) Clinical picture opioid poisoning. The difference between the pseudo-adaptive behavior associated with regular opiate use and the direct effects on the central nervous system must be understood. The first is opioid dependence and abuse. The second includes opioid intoxication and withdrawal syndromes. Acute overdose is a condition requiring urgent medical care and is a complication of acute intoxication.

- Opioid addiction. The American Psychiatric Association has established diagnostic criteria for opioid dependence of varying severity, as well as for opioid abuse.

- Abuse of opioids. Opioid abuse is now considered a "residual" category of misadaptive opioid use that does not meet the criteria for opioid dependence. Its main feature is the regular use of drugs, despite persistent or recurrent problems of a social, professional, psychological or physical nature. The time factor is also important.

- Seizure induction. Anecdotal evidence suggests that morphine, meperidine, fentanyl, sufentanil and alfentanil induce seizures in non-epileptic individuals (morphine also in epileptics). Anticonvulsants (eg, phenytoin, phenobarbital, and phenothiazines) stimulate the conversion of meperidine to normeperidine, which has strong proconvulsant properties.

1. Central nervous system:
analgesia
Sedative action
Nausea and vomiting
miosis
Antitussive action
Seizures
Dysphoria

2. Respiratory depression:
Reaction to CO2
Minute ventilation, respiratory rate, tidal volume

3. Cardiovascular system:
Bradycardia (fentanyl, morphine)
Tachycardia (meperidine)
Release of histamine (morphine)

4. Digestive system:
Decreased motility and peristalsis
Increasing the tone of the sphincters (hepatic-pancreatic ampulla, ileocolic)

e) Diagnostic criteria opioid withdrawal guidelines suggested by the American Psychiatric Association are listed below.

Signs of opioid addiction:

1. Unusual behavioral changes: mood swings, periods of depression, anger and irritability alternating with periods of euphoria
2. Drug addiction is a state of loneliness and isolation from the world. Addicts quickly abandon family, friends and outdoor activities
3. Denial is the most characteristic symptom of drug addiction. If family members directly express their suspicions, the addict may become defensive and vehemently argue that the accusations are unfounded.
4. An increase in the frequency and intensity of family conflicts, quarrels and fights is possible

5. The addict needs to be near the source of the drug. If you suffer from drug addiction or other drug dependence medical worker, he will linger at the workplace for a long time, even on someone else's shift. Alcoholics often affect work sick; they can, without informing anyone, "disappear" in a bar or secluded place with a drink
6. Increasing expenses that others don't understand, illegal activities (such as driving while intoxicated), gambling, adultery, and problems at work
7. Possible significant decrease in libido
8. Drug addicts usually have pills, syringes, or liquor bottles in their home.

9. Bloody swabs or pieces of cloth in the home may indicate the presence of an injecting drug user.
10. There may be a sudden onset of the habit of locking yourself in the bathroom or another room (to inject drugs)
11. An obvious sign of alcoholism is the smell of alcohol from the mouth.
12. Drug addicts often have pinpoint pupils.

13. Addicts have obvious signs of withdrawal, especially often - heavy sweating and tremors.
14. Pallor and weight loss are common.
15. Undiagnosed drug addicts are found in a coma
16. Untreated drug addicts are found dead.

* Relatives of a doctor or nurse addicts may notice some of the symptoms of addiction, both similar to those seen in the workplace, and additional.
Addiction to hard drugs progresses very quickly (in a matter of weeks - months), therefore, to identify subjective symptoms on early stage difficult. Signs of addiction can take years to appear.

Diagnostic criteria for opioid dependence and its severity (presence of at least three):
1. Opioids are used in larger quantities or for longer than the person intended.
2. The desire to take opioids persists, or the person repeatedly tries to stop or limit their use without success
3. A lot of time is spent getting opioids (including stealing them), using them, or bouncing back after taking them
4. The person is often intoxicated or suffers from withdrawal symptoms when they are required to perform important duties at work, school, or home (e.g., truancy, going to work or school "high", caring for children in the same state) or when opioid use poses a physical danger (eg, driving while high)
5. Social, occupational or recreational activity that was important in the past for a person ceases or decreases.
6. Severe tolerance: the need to significantly increase the dose (at least 50%) to achieve the desired effect, or a noticeable weakening of the effect at the same dose
7. Characteristic symptoms withdrawal symptoms
8. Opioids are often used to prevent or relieve withdrawal symptoms.
At least some of these signs persist for at least a month or recur repeatedly over a longer period

Severity of opioid dependence:
a) Weak. Other than those necessary for diagnosis, there are few or no symptoms; professional qualities suffer slightly, and general social activity and relationships with other people do not worsen
b) Moderate. A state intermediate between "weak" and "heavy" addiction
c) heavy. In addition to those needed for diagnosis, many symptoms are present; they greatly interfere with work or school, as well as general social activity and relationships with other people
d) Partial remission. In the past six months, the drug has been used occasionally and there are some symptoms of dependence
e) Complete. In the last six months, opioids were either not used or used without symptoms of dependence

Diagnostic criteria for opioid withdrawal according to the third, revised edition of the Diagnostic and Statistical Manual mental disorders"American Psychiatric Association (DSM-III-R):
BUT. Termination of prolonged(for at least several weeks) moderate or heavy opioid use or reduction (or use of an antagonist after short-term use) followed by at least three of the following symptoms:
1. Opioid cravings
2. Nausea or vomiting
3. Muscle pain
4. Lachrymation or rhinorrhea
5. Pupil dilation, piloerection or sweating
6. Diarrhea
7. Yawning
8. Fever
9. Insomnia
B. These symptoms not caused by a physical or other (except drug addiction) mental disorder

Typical screening flowchart published by Braithwaite et al.:

e) Treatment of withdrawal syndrome:

- Clonidine (Catapres) for opioid withdrawal. A preliminary study of clonidine hydrochloride and naltrexone used in combination with each other showed that with the help of this drug 12 out of 14 heroin addicts successfully overcame the opioid withdrawal syndrome ("withdrawal").
Clonidine relieves its symptoms mediated by noradrenergic mechanisms, including lacrimation, rhinorrhea, sweating, diarrhea, chills, and piloerection ("goosebumps"). Neither clonidine nor its structural analogue lofexidine (licensed in the UK) alleviates muscle and bone pain, insomnia and cravings for opioid-induced euphoria.

- Nitrous oxide for opioid withdrawal. Promising results have been obtained in experiments with the treatment of alcohol and opioid withdrawal with inhaled nitrous oxide. In one of the cases, this gas was used according to the following scheme: 20 min - oxygen, 20 min - precisely dosed nitrous oxide, 20 min - cleaning respiratory system oxygen.
The patient remained conscious throughout the procedure. Before this method becomes routine, it needs to be further researched and risk assessed. So far, it has only been used to treat adults.