The New Opioid Epidemic: Prescriptions, Synthetics, and Street Drugs

How can we detect novel opioid use?

As noted, there is no ability to specifically detect the use of novel potent opioids in the clinical setting (eg, hospital laboratory); therefore, clinicians must maintain a high level of suspicion and provide care empirically. The ability to make a specific diagnosis is further clouded because a patient who has used a synthetic opioid may have also used certain prescription opioids or heroin, which can be detected by standard testing.

Blood and urine samples obtained early in care and sent to specialized laboratories may provide specific identification. Such testing is typically only done by reference laboratories, health departments, or law enforcement agencies. The information obtained from these analyses may help to understand the epidemiology of novel opioid abuse, prevent others from succumbing to addiction, and determine the cause of related deaths.

Which patients can be safely discharged from the ED after an opioid overdose?

Patients who survive reversal of an opioid overdose, whether from a conventional or novel opioid, are at extremely high risk of subsequent death from continued use, as well as from the initial exposure to a long-acting opioid that outlasts the reversal effects of naloxone. Such patients should undergo a sufficient observation period after the last dose of naloxone has been administered to allow its effects to dissipate. This is likely at least 2 hours, but may be longer in certain individuals. Attempts at establishing a link for the patient to long-term treatment or (where available) providing a naloxone rescue kit and training to patients and their families are worthwhile. Although some data support releasing responsive patients after a short, but safe interval after naloxone administration, the changing landscape of opioid use should prompt reconsideration of such practices.¹²

To whom should suspected opioid overdose patients be reported?

While most EPs are familiar with the management of patients with opioid-induced respiratory depression, atypical cases (eg, patients less responsive to naloxone, those who suffer cardiac arrest) or clusters of suspected cases should always be reported to a regional poison control center (PCC) or health department. The PCC is typically engaged in surveillance and works cooperatively with area EDs and public health officials to track and notify physicians of emerging trends. The epidemiological data derived from reports from a variety of hospitals allow health officials to effectively engage resources for public warnings, facilitate forensic identification of circulating products, and determine any unique clinical information that can then be broadly disseminated.

Case Conclusion

The patient was supported with BVM ventilations. Despite additional titrated IV naloxone (up to a total of 4 mg) the patient was nonresponsive and unarousable. She was intubated, and awoke several hours later. She fully recovered and subsequently was referred to both a harm-reduction and an opioid detoxification program. Analysis of her blood and urine, available several weeks later, confirmed an exposure to U47700.