A review of the acute treatment of illicit and prescription drug poisonings

Drug poisonings, both intentional and unintentional, represent a growing challenge to healthcare systems worldwide. As acute poisonings can lead to rapid clinical deterioration, physicians must be well versed in providing efficient, evidence-based management, including supportive care, decontamination procedures, and antidotes. This review provides up-to-date advice pertaining to the management of several of the most common drug poisonings. Opioids are considered to be the most lethal drugs in the United States. Priorities in management include airway, breathing, and circulation, followed by administration of the safe and reliable antidote, naloxone. Several alternatives to naloxone have been proposed, including buprenorphine, CX717, and doxapram, but evidence is limited. Poisoning by benzodiazepines is usually treated with supportive care alone. A classic antidote is flumazenil; however, this benzodiazepine antagonist may induce life-threatening withdrawal, causing arrhythmias and seizures that are difficult to treat. Physicians should be well acquainted with flumazenil’s contraindications and use this drug with caution. Beta blocker and calcium channel blocker poisonings are treated in a similar fashion. Following airway, breathing, and circulatory support, gastrointestinal decontamination may be considered. Single-dose activated charcoal is preferred. Pharmacologic treatment may include some combination of high-dose insulin euglycaemic therapy, epinephrine, atropine, calcium, and glucagon. Finally, in the case of acetaminophen (APAP) poisoning, physicians should consider single-dose activated charcoal, as well as the safe and effective antidote, N-acetylcysteine (NAC). Dosing of NAC is based on serum concentration of APAP following a single acute ingestion. This review aims to educate clinicians as to the appropriate management of the aforementioned poisonings, preparing them for encounters in which time is limited and the proper treatment could be lifesaving.