Poisoning                       Narcotics
                                =========
þ Heroin
 - may contain (be cut with) lead <P-Lead.TXT -heroin>

þ Propoxyphene (e.g., Darvon):
 - will not be detected by many hospital's urine opiate drug screens.
 - naloxone will not revers propoxyphene's seizures or cardiopulmonary
   sequelae.
   [Roberts J. In Focus: Drug-induced seizures. Emerg Med News April
   1997:9-10.]

þ Meperidine (e.g., Demerol):
 - naloxone ineffective against neurotoxicity, but phenobarb or benzos may
   help.
   [Roberts J. In Focus: Drug-induced seizures. Emerg Med News April
   1997:9-10.]

þ Complications of Naloxone:
 - <<The only study that I have seen is by Osterwalder, J Tox Clin Tox
43:409-416, 1996 where they prospectively studied 453 patients given
naloxone. They report a complication rate of 6.6 %. Although they conclude
that recommended doses 0.4 - 2 mg is too high they don't present data to
support this. Additionally some of their complications do not appear to
relate well to naloxone, and some patients were also given flumazinal !!!>>

We reviewed this at a recent journal club. From what I recall, the doses of
naloxone used in this study were homeopathic (0.04 mg?!) and some of the
complications (such as asystole) could well have been a result of the toxic
substance injected prior to naloxone. We wrote the study off as completely
flawed.

The nalfamene rep has been by recently, and has been pushing their drug
(called Revex) in lieu of Narcan, with the line "just tell your heroin
addicts they *can't* get high for 12 hours before you discharge them." We've
had it in the box for a good month now, and so far no one's tried it. At
Charity, it seems a waste of money, when we could just intubate the patient
and let the heroin wear off. Several of us, from emed-l influences, are
convinced that intubation and observation is the way to go with heroin, just
because there's no way the patient can sign AMA until s/he gets weaned from
the ventilator, and once weaned, there's no heroin rebound from the shorter
acting naloxone.

James Li, MD
Resident, Emergency Medicine
Charity Hospital, New Orleans