Poisoning Emergencies

Opioid Poisonings

Opioids are a class of drug that affects specific receptors in the brain which produces feelings of euphoria (intoxication, happiness and bliss). Opioids are frequently prescribed by medical practitioners to help with the management of severe pain. These medications can also be prescribed for other reasons such as managing coughs or suppressing diarrhea. Due to their side effects, mainly the feelings of euphoria, opioids are often misused for non-medical purposes.

Some commonly prescribed opioids are morphine, hydrocodone, oxycodone, codeine and fentanyl. These medications are also commonly known for their brand names such as Vicodin®, OxyContin® and Percocet®.

Side effects, which are magnified when too much of the drug is taken, include:

Nausea
Constipation
Respiratory depression
Lowered level consciousness or sedation

Anyone who takes an opioid, whether by prescription or recreationally, is at risk of poisoning. Canada is currently facing a growing opioid crisis. Refer to the Health Canada website for the latest statistics on opioid-related deaths across Canada(1).

With prescription opioid use, poisoning can happen due to a person taking more of an opioid than is prescribed. This can be either by mistake (they forgot if they took it or not) or due to a tolerance build up where the original prescription no longer provides the same relief. This often affects those who have had a recent surgery or suffer from chronic pain.

A casualty who is also using another substance (alcohol, other drugs) can also be at increased risk of poisoning due to the interactions between opioids and the other substances.

In some cases, the casualty may not even know they took an opioid (it was in another substance they took, or they took the opioid while under the influence of another substance).

In emergency medicine, fentanyl is commonly used for rapid and effective pain control. Recreational fentanyl use has emerged as a public health crisis in many jurisdictions. It is 100 times more potent than morphine and has a very rapid onset, which has made it a leading cause of fatal poisoning among drug users.

In Canada, fentanyl is being mixed (“cut”) into many drugs to increase their potency, most commonly heroin and cocaine. Another problem facing Canada is the proliferation of counterfeit pills on the black market that have been mixed with fentanyl, the most common being OxyContin®.

Even small amounts of fentanyl can lead to severe reactions when misused. It is a tasteless drug and has no smell, meaning it cannot be detected when it is mixed with other drugs.

Fentanyl and opioid prescriptions should be filled only at a pharmacy to ensure safety.

Carfentanil is an even more potent and deadly opioid, and has been found in Canada’s recreational drug supply. Carfentanil is 100 times more powerful than fentanyl and is used in veterinary medicine primarily as a sedative. A single grain of Carfentanil, the size of a grain of salt, can cause a fatal poisoning.

Note: There have not been any documented cases of skin exposure to these substances leading to a poisoning.

An opioid poisoning will display some or all of the following signs and symptoms:

A scene survey or history of the incident indicating potential drug use
Excessive drowsiness or loss of consciousness
Slow or absent breathing
Gurgling or snoring sounds
Cool, sweaty skin that is lacking colour
Cyanosis, a condition which occurs if someone cannot breathe or is not breathing enough. This results in a decrease in oxygen levels in the blood. For casualties with darker skin tones, their lips and fingernails turn greyish purple. For casualties with lighter skin tones, their fingernails and lips will turn blue or purple and their skin will also exhibit an unhealthy pallor, and may also take on a purple or blue hue.
Constricted pupils (“pinpoint pupils”)

Naloxone

Naloxone (or Narcan®) can help slow the effect of an opioid poisoning; it is an opioid inhibitor. Naloxone can force opioids away from receptors in the brain and coats the receptors preventing opioids from binding again. This temporary barrier then allows important brain functions, such as breathing, to happen normally. Naloxone is available as a nasal spray or as an injection.

In most parts of Canada, a naloxone kit can be obtained from a pharmacy free of charge. When the kit is dispensed, you will receive instructions on how to use the kit. Everyone is encouraged to get a naloxone kit and ensure it is properly maintained, especially if you are likely to be in contact with an individual who is experiencing an opioid poisoning.

First Aid for an Opioid Poisoning

First aid for an opioid poisoning is a combination of rescue breathing, administration of naloxone (if trained and available), and CPR.

Rescue breathing is the same as the breaths delivered during CPR, except without chest compressions. Deliver one breath every 5 seconds, ensuring the chest rises. Perform this step even if they are breathing, as it may be an indication that they are likely not breathing fast enough.

If possible, have someone else perform the first aid steps while you prepare the naloxone for delivery. If you are alone, deliver the naloxone as soon as possible and continue rescue breathing or CPR.

Note: There are two types of naloxone: nasal and intramuscular (IM). IM is the most common form of naloxone in Canada, with the exception of Ontario, where nasal naloxone is used.

First Aid Steps for an Opioid Poisoning
Without Naloxone	With Naloxone
Perform a scene survey.	Perform a scene survey.
Call 9-1-1.	Call 9-1-1.
Perform a primary survey.	Perform a primary survey.
Provide 5 rescue breaths: one breath every 5 seconds, ensuring the chest rises.	Deliver 5 rescue breaths.
If the casualty is not breathing normally, begin CPR.	Deliver one dose of naloxone (see below for instructions).
Reassess regularly to see if the rescue breaths and CPR are helping.	If the casualty is not breathing normally, provide CPR.
	Reassess after 2-3 minutes to see if the naloxone is helping. If there is no improvement, deliver another dose of naloxone and continue CPR.
If at any point the casualty stops breathing entirely, begin CPR.

Administering nasal naloxone

To administer nasal naloxone, perform the following steps:

Open the naloxone packaging.
Hold the dispenser with your thumb on the plunger.
Insert the long end into the casualty’s nostril (it does not matter which side).
Depress the plunger fully to deliver the dose.

If there is no improvement after 2 to 3 minutes, administer a second dose of naloxone. The dosage for a child is the same as for an adult.

Naloxone reverses the effects of an opioid poisoning, which may cause the casualty to vomit, to have a fast heart and breath rate, or to have a seizure. They may experience symptoms of withdrawal, which can be extremely painful for them. They may become anxious, agitated, or distressed. In rare cases, they may become aggressive. Be ready to assist with these conditions if they happen and ensure your own safety.

Naloxone has a 20 to 30-minute window of effectiveness. If they wake up before EMS arrives, monitor the casualty and be alert for the signs and symptoms to reappear.

SAVE ME Steps

Remember the steps to respond to a suspected opioid poisoning with the SAVE ME mnemonic.
S – Stimulate. Shout and/or tap the casualty’s foot. Call 9-1-1.
A – Airway. Open the airway. Is the casualty breathing?
V – Ventilate. Deliver one breath every 5 seconds, ensuring the casualty’s chest rises, for 5 breaths.
E – Evaluate. Are these steps helping?
M – Medication. Prepare and deliver one dose of naloxone.
E – Evaluate again. Did the naloxone help? Keep giving rescue breaths. It can take 2 to 3 minutes for naloxone to become effective. If the casualty is not breathing, continue to provide CPR.

1 Opioid- and Stimulant-related Harms in Canada. (September 2021). Retrieved October 1, 2021, from https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/.