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Acute opioid intoxication in adults

Authors
Andrew Stolbach, MD
Robert S Hoffman, MD
Section Editor
Stephen J Traub, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM

INTRODUCTION

Opiates extracted from the poppy plant (Papaver somniferum) have been used recreationally and medicinally for millennia. Opiates belong to the larger class of drugs, the opioids, which include synthetic and semi-synthetic drugs, as well. Opioid abuse is a worldwide problem and deaths from opioid overdose are numerous and increasing [1-5].

This topic review will discuss the mechanisms, clinical manifestations, and management of acute opioid intoxication. A summary table to facilitate emergent management is provided (table 1). Issues related to opioid withdrawal, chronic opioid abuse, and general management of the poisoned patient are found elsewhere. (See "Opioid withdrawal in the emergency setting" and "Pharmacotherapy for opioid use disorder" and "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis" and "General approach to drug poisoning in adults".)

PHARMACOLOGY AND CELLULAR TOXICOLOGY

The opioid pharmaceuticals are analogous to the three families of endogenous opioid peptides: enkephalins, endorphins, and dynorphin. The most recent classification scheme identifies three major classes of opioid receptor, with several minor classes [6]. Within each receptor class there are distinct subtypes. Each subtype produces a variety of distinct clinical effects, although there is some overlap (table 2). For most clinicians, the nomenclature derived from the Greek alphabet is more familiar, although the International Union of Pharmacology (IUPHAR) Committee on Receptor Nomenclature has recommended a change from the original Greek system to make opioid receptor names more consistent with other neurotransmitter systems [6].

The opioid receptors are distinct in their locations and clinical effects, but they are structurally similar (table 2). Each consists of seven transmembrane segments, with amino acid and carboxy termini. Although the opioid receptors are all coupled to G proteins, they use a variety of signal transduction mechanisms [6]. These include reducing the capacity of adenylate cyclase to produce cAMP, closing calcium channels that reduce the signal to release neurotransmitters, or opening potassium channels to hyperpolarize the cell [6].

The end result of these mechanisms is to modulate the release of neurotransmitters. Opioid receptors exist throughout the central and peripheral nervous system and are linked to a variety of neurotransmitters, which explains the diversity of their clinical effects. The analgesic effects of opioids result from inhibition of nociceptive information at multiple points of its transmission from the peripheral nerve to the spinal cord to the brain. Euphoria results from increased dopamine released in the mesolimbic system [7]. Anxiolysis results from effects on noradrenergic neurons in the locus ceruleus [8].

                         

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Literature review current through: Nov 2016. | This topic last updated: Mon Jan 25 00:00:00 GMT+00:00 2016.
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