UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Opioid intoxication in children and adolescents

Author
Shan Yin, MD, MPH
Section Editor
Michele M Burns, MD, MPH
Deputy Editor
James F Wiley, II, MD, MPH

INTRODUCTION

The epidemiology, pharmacology, clinical manifestations, and management of opioid toxicity in children and adolescents are reviewed here.

Opioid withdrawal in the pediatric patient and opioid use disorder, intoxication, withdrawal, and treatment in adults are discussed separately. (See "Neonatal abstinence syndrome" and "Opioid withdrawal in adolescents" and "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis" and "Pharmacotherapy for opioid use disorder" and "Acute opioid intoxication in adults".)

DEFINITIONS

Several terms are used to describe opioid substances:

Opioid refers to natural and synthetic substances with morphine-like activity.

Opiate describes a subclass of opioids consisting of alkaloid compounds extracted from opium, including morphine, heroin, codeine, and semisynthetic derivatives of the poppy plant.

                           

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Dec 05 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Hibbs J, Perper J, Winek CL. An outbreak of designer drug--related deaths in Pennsylvania. JAMA 1991; 265:1011.
  2. Recommendations for laboratory testing for acetyl fentanyl and patient evaluation and treatment for overdose with synthetic opioids. Health Alert Network Centers for Disease Control health advisory. June 20, 2013. Accessed at www.bt.cdc.gov/HAN/han00350.asp on July 16, 2013.
  3. Brittain JL. China white: the bogus drug. J Toxicol Clin Toxicol 1982; 19:1123.
  4. Ballard PA, Tetrud JW, Langston JW. Permanent human parkinsonism due to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP): seven cases. Neurology 1985; 35:949.
  5. Davis GC, Williams AC, Markey SP, et al. Chronic Parkinsonism secondary to intravenous injection of meperidine analogues. Psychiatry Res 1979; 1:249.
  6. Langston JW, Ballard P, Tetrud JW, Irwin I. Chronic Parkinsonism in humans due to a product of meperidine-analog synthesis. Science 1983; 219:979.
  7. DEA issues carfentanil warning to police and public. https://www.dea.gov/divisions/hq/2016/hq092216.shtml (Accessed on November 07, 2016).
  8. Opium/heroin. Drug statistics and trends. World Drug Report, 2009, United Nations Office on Drugs and Crimes. www.unodc.org/documents/wdr/WDR_2010/2.2_Opium-heroin.pdf (Accessed on June 01, 2011).
  9. Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med 2010; 363:1981.
  10. Gaither JR, Leventhal JM, Ryan SA, Camenga DR. National Trends in Hospitalizations for Opioid Poisonings Among Children and Adolescents, 1997 to 2012. JAMA Pediatr 2016.
  11. Centers for Disease Control and Prevention (CDC). Emergency department visits involving nonmedical use of selected prescription drugs - United States, 2004-2008. MMWR Morb Mortal Wkly Rep 2010; 59:705.
  12. Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Substance abuse treatment admissions involving abuse of pain relievers: 1998 and 2008. http://www.oas.samhsa.gov/2k10/230/230PainRelvr2k10.cfm.
  13. Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med 2006; 31:506.
  14. McCabe SE, West BT, Teter CJ, Boyd CJ. Medical and nonmedical use of prescription opioids among high school seniors in the United States. Arch Pediatr Adolesc Med 2012; 166:797.
  15. Yokell MA, Delgado MK, Zaller ND, et al. Presentation of prescription and nonprescription opioid overdoses to US emergency departments. JAMA Intern Med 2014; 174:2034.
  16. Effective medical treatment of opiate addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA 1998; 280:1936.
  17. Hayes BD, Klein-Schwartz W, Doyon S. Toxicity of buprenorphine overdoses in children. Pediatrics 2008; 121:e782.
  18. Sachdeva DK, Stadnyk JM. Are one or two dangerous? Opioid exposure in toddlers. J Emerg Med 2005; 29:77.
  19. Geib AJ, Babu K, Ewald MB, Boyer EW. Adverse effects in children after unintentional buprenorphine exposure. Pediatrics 2006; 118:1746.
  20. Martin TC, Rocque MA. Accidental and non-accidental ingestion of methadone and buprenorphine in childhood: a single center experience, 1999-2009. Curr Drug Saf 2011; 6:12.
  21. Pedapati EV, Bateman ST. Toddlers requiring pediatric intensive care unit admission following at-home exposure to buprenorphine/naloxone. Pediatr Crit Care Med 2011; 12:e102.
  22. Glatstein M, Finkelstein Y, Scolnik D. Accidental methadone ingestion in an infant: case report and review of the literature. Pediatr Emerg Care 2009; 25:109.
  23. Kuehn BM. Fentanyl patch warning. JAMA 2012; 307:2139.
  24. Kim HK, Smiddy M, Hoffman RS, Nelson LS. Buprenorphine may not be as safe as you think: a pediatric fatality from unintentional exposure. Pediatrics 2012; 130:e1700.
  25. Shadnia S, Rahimi M, Hassanian-Moghaddam H, et al. Methadone toxicity: comparing tablet and syrup formulations during a decade in an academic poison center of Iran. Clin Toxicol (Phila) 2013; 51:777.
  26. Lavonas EJ, Banner W, Bradt P, et al. Root causes, clinical effects, and outcomes of unintentional exposures to buprenorphine by young children. J Pediatr 2013; 163:1377.
  27. Toce MS, Burns MM, O'Donnell KA. Clinical effects of unintentional pediatric buprenorphine exposures: experience at a single tertiary care center. Clin Toxicol (Phila) 2016; :1.
  28. Lovegrove MC, Mathew J, Hampp C, et al. Emergency hospitalizations for unsupervised prescription medication ingestions by young children. Pediatrics 2014; 134:e1009.
  29. Budnitz DS, Lovegrove MC, Sapiano MR, et al. Notes from the Field: Pediatric Emergency Department Visits for Buprenorphine/Naloxone Ingestion - United States, 2008-2015. MMWR Morb Mortal Wkly Rep 2016; 65:1148.
  30. Nielssen OB, Large MM, Westmore BD, Lackersteen SM. Child homicide in New South Wales from 1991 to 2005. Med J Aust 2009; 190:7.
  31. Perez A, Scribano PV, Perry H. An intentional opiate intoxication of an infant: when medical toxicology and child maltreatment services merge. Pediatr Emerg Care 2004; 20:769.
  32. Yaksh TL, Walla MA. Opioids, Analgesic, and Pain Management. In: Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12th, Brunton LL, Chabner BA, Knollman BC (Eds), McGraw-Hill, New York 2011. p.521.
  33. Dhawan BN, Cesselin F, Raghubir R, et al. International Union of Pharmacology. XII. Classification of opioid receptors. Pharmacol Rev 1996; 48:567.
  34. Brian M. Cox, Anna Borsodi, Girolamo Caló, et al. Opioid receptors, introduction. Last modified on 10/13/2009. IUPHAR database (IUPHAR-DB), http://www.iuphar-db.org/DATABASE/FamilyIntroductionForward?familyId=50 (Accessed on February 12, 2014).
  35. Glare PA, Walsh TD. Clinical pharmacokinetics of morphine. Ther Drug Monit 1991; 13:1.
  36. Clark RF, Wei EM, Anderson PO. Meperidine: therapeutic use and toxicity. J Emerg Med 1995; 13:797.
  37. Gasche Y, Daali Y, Fathi M, et al. Codeine intoxication associated with ultrarapid CYP2D6 metabolism. N Engl J Med 2004; 351:2827.
  38. Maurer PM, Bartkowski RR. Drug interactions of clinical significance with opioid analgesics. Drug Saf 1993; 8:30.
  39. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112.
  40. Schwartz RH. Adolescent heroin use: a review. Pediatrics 1998; 102:1461.
  41. Long H, Deore K, Hoffman RS, Nelson LS. A fatal case of spongiform leukoencephalopathy linked to "chasing the dragon". J Toxicol Clin Toxicol 2003; 41:887.
  42. Jenkins AJ, Keenan RM, Henningfield JE, Cone EJ. Pharmacokinetics and pharmacodynamics of smoked heroin. J Anal Toxicol 1994; 18:317.
  43. Tarabar AF, Nelson LS. The resurgence and abuse of heroin by children in the United States. Curr Opin Pediatr 2003; 15:210.
  44. Beno S, Calello D, Baluffi A, Henretig FM. Pediatric body packing: drug smuggling reaches a new low. Pediatr Emerg Care 2005; 21:744.
  45. Traub SJ, Kohn GL, Hoffman RS, Nelson LS. Pediatric "body packing". Arch Pediatr Adolesc Med 2003; 157:174.
  46. Thomas TJ, Pauze D, Love JN. Are one or two dangerous? Diphenoxylate-atropine exposure in toddlers. J Emerg Med 2008; 34:71.
  47. LoVecchio F, Pizon A, Matesick L, O'Patry S. Accidental dextromethorphan ingestions in children less than 5 years old. J Med Toxicol 2008; 4:251.
  48. Shelly MP, Park GR. Morphine toxicity with dilated pupils. Br Med J (Clin Res Ed) 1984; 289:1071.
  49. Nordt SP. "DXM": a new drug of abuse? Ann Emerg Med 1998; 31:794.
  50. Sporer KA. Acute heroin overdose. Ann Intern Med 1999; 130:584.
  51. Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema : a case series. Chest 2001; 120:1628.
  52. Helpern M, Rho YM. Deaths from narcotism in New York City. Incidence, circumstances, and postmortem findings. N Y State J Med 1966; 66:2391.
  53. Ghuran A, Nolan J. Recreational drug misuse: issues for the cardiologist. Heart 2000; 83:627.
  54. Lipski J, Stimmel B, Donoso E. The effect of heroin and multiple drug abuse on the electrocardiogram. Am Heart J 1973; 86:663.
  55. Martell BA, Arnsten JH, Krantz MJ, Gourevitch MN. Impact of methadone treatment on cardiac repolarization and conduction in opioid users. Am J Cardiol 2005; 95:915.
  56. Wingert WE, Mundy LA, Nelson L, et al. Detection of clenbuterol in heroin users in twelve postmortem cases at the Philadelphia medical examiner's office. J Anal Toxicol 2008; 32:522.
  57. Koren G, Butt W, Pape K, Chinyanga H. Morphine-induced seizures in newborn infants. Vet Hum Toxicol 1985; 27:519.
  58. Centers for Disease Control (CDC). Street-drug contaminant causing parkinsonism. MMWR Morb Mortal Wkly Rep 1984; 33:351.
  59. Glick C, Evans OB, Parks BR. Muscle rigidity due to fentanyl infusion in the pediatric patient. South Med J 1996; 89:1119.
  60. Abs R, Verhelst J, Maeyaert J, et al. Endocrine consequences of long-term intrathecal administration of opioids. J Clin Endocrinol Metab 2000; 85:2215.
  61. Chapple D, Johnson D, Connors R. Baclofen overdose in two siblings. Pediatr Emerg Care 2001; 17:110.
  62. Perry HE, Wright RO, Shannon MW, Woolf AD. Baclofen overdose: drug experimentation in a group of adolescents. Pediatrics 1998; 101:1045.
  63. Baden LR, Horowitz G, Jacoby H, Eliopoulos GM. Quinolones and false-positive urine screening for opiates by immunoassay technology. JAMA 2001; 286:3115.
  64. Zacher JL, Givone DM. False-positive urine opiate screening associated with fluoroquinolone use. Ann Pharmacother 2004; 38:1525.
  65. Jaffee WB, Trucco E, Levy S, Weiss RD. Is this urine really negative? A systematic review of tampering methods in urine drug screening and testing. J Subst Abuse Treat 2007; 33:33.
  66. Levy S, Sherritt L, Vaughan BL, et al. Results of random drug testing in an adolescent substance abuse program. Pediatrics 2007; 119:e843.
  67. Levy S, Knight JR, Moore T, et al. Acceptability of drug testing in an outpatient substance abuse program for adolescents. J Adolesc Health 2011; 48:229.
  68. Osterwalder JJ. Naloxone--for intoxications with intravenous heroin and heroin mixtures--harmless or hazardous? A prospective clinical study. J Toxicol Clin Toxicol 1996; 34:409.
  69. Chamberlain JM, Klein BL. A comprehensive review of naloxone for the emergency physician. Am J Emerg Med 1994; 12:650.
  70. American Academy of Pediatrics Committee on Drugs: Naloxone dosage and route of administration for infants and children: addendum to emergency drug doses for infants and children. Pediatrics 1990; 86:484.
  71. Kerr D, Kelly AM, Dietze P, et al. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction 2009; 104:2067.
  72. Lewis JM, Klein-Schwartz W, Benson BE, et al. Continuous naloxone infusion in pediatric narcotic overdose. Am J Dis Child 1984; 138:944.
  73. Leblanc A, Benbrick N, Moreau MH. [Methadone poisoning in a 1-year-old child treated by continuous infusion of naloxone]. Arch Pediatr 2002; 9:694.
  74. Goldfrank L, Weisman RS, Errick JK, Lo MW. A dosing nomogram for continuous infusion intravenous naloxone. Ann Emerg Med 1986; 15:566.
  75. Gaddis GM, Watson WA. Naloxone-associated patient violence: an overlooked toxicity? Ann Pharmacother 1992; 26:196.
  76. Cuss FM, Colaço CB, Baron JH. Cardiac arrest after reversal of effects of opiates with naloxone. Br Med J (Clin Res Ed) 1984; 288:363.
  77. Schwartz JA, Koenigsberg MD. Naloxone-induced pulmonary edema. Ann Emerg Med 1987; 16:1294.
  78. Kaplan JL, Marx JA, Calabro JJ, et al. Double-blind, randomized study of nalmefene and naloxone in emergency department patients with suspected narcotic overdose. Ann Emerg Med 1999; 34:42.
  79. Chumpa A, Kaplan RL, Burns MM, Shannon MW. Nalmefene for elective reversal of procedural sedation in children. Am J Emerg Med 2001; 19:545.
  80. Gonzalez JP, Brogden RN. Naltrexone. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in the management of opioid dependence. Drugs 1988; 35:192.
  81. Loiselle JM, Baker MD, Templeton JM Jr, et al. Substance abuse in adolescent trauma. Ann Emerg Med 1993; 22:1530.