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Three Part Question

[In adults with acute opiate overdose] is [concomitant use of alcohol] associated with a [poorer prognosis in terms of death aspiration, admission to ITU]

Clinical Scenario

A 40 year old man is brought into the emergency department unconscious and smelling of alcohol. On examination he has pinpoint pupils, bradypnoea and needle track marks consistent with heroin injection. His friend claims they drank a bottle of whiskey together prior to him injecting. You wonder if the alcohol will potentiate his repiratory depression and result in a poorer prognosis.

Search Strategy

Medline 1966 to june week 2 2005 using the ovid interface.
Embase 1980 to 2005 week 26.
CINHAL 1982 to june week 3 2005.
[{ exp NARCOTICS AND exp OVERDOSE AND exp ALCOHOLS}]

Search Outcome

Medline:32 papers found, 3 were relevent to the question.
Embase:5 papers found. None were relevent.
Cinhal:7 papers were found. None were relevent.
The cochrane ibrary: No papers were found.
1 paper found from references of relevent paper.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Levine B et al. USA	119 cases investigated by the office of the chief medical examiner where where death was attributed to narcotic or alcohol and narcotic intoxication.	Retrospective analysis.	Frequency and contribution of concomitant ethanol concentrations in heroin related deaths.	Greater percentage of narcotic deaths where ethanol is present.At ethanol concentrations of 0.2-0.29g/dL increased blood morphine concentrations.In ethanol concentrations over 0.3g/dL morphine is less of a factor than ethanol in death.	Abstract only. Full paper not available.
Odegard E, Rossow I. 1998-2000 Norway	3838 cases of non fatal overdose reporded by ambulance staff given report sheets.	Retrospective study..	Was the overdose more severe if alcohol had been ingested.	A higher percentage of patients were unconscious and had insufficient respiration who had taken alcohol with opiates.However there is no statistically significant difference.	The number of non-fatal overdoses declined over time, which may have been due to a change in accuracy of completing the sheets. Ambulance data sheets may not be reliable. Data regarding alcohol intake relied on honestly and accuracy of subjects. No fatal overdoses were included in the data. No gold standard was given for diagnosis of opiate overdose.
Juan Gutitkrez- Cebollada et al. 1992 Spain	76 heroin addicts admitted to the emergency department; 54 because of overdose and 22 seeking urgent medical care for unrelated causes.	Survey and retrospective review.	Influence of plasma levels of alcohol on GCS.	Plasma concentrations of over 800mg/ml did not contribute significantly to heroin overdose.	Relatively small sample size. Large difference between sample size of overdose group and non-overdose group. Survey of events surrounding overdose relied on self-report. Concomitant use of alcohol may have affected factors other than the GCS, such as respiratory rate, andd this could have been studies.
Deborah Zador et al. 1992 Australia	Coronial files of 152 heroin related deaths.	Retrospective eview	Influence of blood alcohol levels on morphine levels	High levels of blood alcohol mean less heroin is required to exert a fatal effect.	The low levels of blood alcohol may have been due to alcohol induced liver enzymes increasing heroin metabolism. Heroin relalted deaths may not have been attributed to overdose but other causes. Subjects were designated into groups according to frequency of use based on accuracy of witnesses.

Comment(s)

The general consensus having read this bet appears to be that higher levels of blood alcohol result in a smaller amount of heroin to be taken to result in overdose. However, one study contradicts this viewpoint. There is also the pathophysiological arguement that lower morphine levels in overdose may result from increased breakdown from liver enzymes. Also, the results of Odegard et al were not statistically significant. Studies comparing alcohol intake in fatal and non-fatal overdose would be beneficial in answering this question.

Clinical Bottom Line

The evidence weakly suggests that high blood alcohol levels in heroin overdose result in a poorer outcome interms of lower GCS and respiratory rate and higher death rates.

References

1. Journal of Forensic Sciences The Role of Ethanol in Heroin Deaths. Journal of Forensic sciences 40(5):808-10
2. Odegard E, Rossow I. Alcohol and non-fatal Drug Overdoses European Addiction Research 10(4):pp168-172
3. Juan Gutitkrez- Cebollada et al. Psychotropic drug consumption and other factors associated with heroin overdose. Drug and alcohol Dependence 35 (1994) 169-174
4. Deborah Zador et al. Heroin-related deaths in New South Wales,1992:toxicological findings and circumstances. Medical Journal of Australia 1996, p 164-204