Opium poisoning

DR ZAKIR HOSSAIN
MBBS,DFM(BSMMU)
DEPARTMENT OF FORENSIC MEDICINE & TOXICOLOGY
 Some terminology
Narcotics: It means the agent used for inducing sleep.
Analgesics: It means the agent used for relief pain.
Somniferous agent: the agent that is used to produce analgesia &
sleep. e.g morphine.
Alkaloid: alkaloids are complex substance having nitrogenous base
found in plants and acts on CNS. e.g atropine, morphine etc.
Opiate : it refers to natural alkaloids derived directly from poppy plant.
e.g morphine.
Opioids : The agent that can produce opium like effect but source is not
from natural poppy plant. e.g heroine.
 Opium
Also known as-
Neurotics poison (poisons affecting the brain)/somniferous poison/opium
(afim)
Opium at a glance:
Botanical: opium
Source plant (s): papaver somniferum
Part (s) of plant: latex
Geographic origin: Indochina region
Active ingredient: morphine, codeine
Main procedures: Afghanistan (primary), Pakistan, Northern India, Thailand,
Laos, Myanmar, Mexico, Colombia, Hungary
Main consumers: worldwide (# 1. US)
Wholesale price: $ 3000 per kilogram
Retail price: $16000 per kilogram
 Contd
In Asia, there are two main illicit opium producing areas:
➢Golden triangle
➢Golden crescent
Golden triangle:
The golden triangle is one of Asia’s two main illicit opium producing
areas. It is an area of around 350000 square kilometers that overlaps
the mountains of three countries of mainland Southeast Asia: Burma
(Myanmar), Laos and Thailand.
Golden crescent:
Afghanistan together with Iran and Pakistan, it has been one of the
most important opium producing area of Asia and of the world since
1950s.
 Contd
Neurotics poison or somniferous poisons are used to lessen pain and
induced sleep (somniferous or nacrotic effect)
The important poison in this group is opium
➢Opium is bitter in taste and has a characteristic smell
➢Papaver somniferum plant grows up to one meter in height. Each plant
bears 5 to 8 capsules
➢Opium is obtained from unriped capsules
➢Ripe and dried poppy capsules contain a trace of opium and are used for
their sedative and narcotic action
➢Poppy seeds (also known as postodona/khas khas), creamish or whitish in
color, are harmless as they do not contain opium. They are used as food.
They yield a bland oil which is used for cooking and lighting purposes
 Contd

➢The principal alkaloids of opium used in medicine are morphine and

codeine. These acts as narcotics or sedatives

➢Apomorphine, prepared from morphine, is chiefly used as an emetic

➢Opium for illegal use is often converted into heroin (brown sugar) which is
less bulky, making it easier to struggle and which multiplies its potency to
approximately twice that of morphine, heroin can be taken by intravenous
injection, intranasally or smoked (vaporized) and inhaled
 Opium (afim)
Definition:

Opium is the juice containing about 25 alkaloids combined with meconic, lactic and
sulphuric acids obtained by multiple longitudinal incision from the unripe poppy
capsules and inspissated by spontaneous evaporation

Uses of opium:

Medical use: commonly used as an analgesic

Domestic use: used in breads, cakes and rich foods for their attractive flavor, and
the source of poppy seed oil.

Illegal use: it is a choice of drug for abuse (heroine, morphine, pethidine etc.)
 Contd
How opium is collected?

Multiple longitudinal incision are given on unripe white poppy capsule → the
white milky juice is collected overnight and allowed to evaporate (air dried)
to obtain dark brown opium

Elimination of opium:

Opium is eliminated chiefly as morphine in the urine and faeces. In non-fatal

cases urine should be preserved for chemical analysis, when stomach has
been washed out with potassium permanganate. It is also detected in saliva,
bile and mothers milk
 Classification of opium

Natural Semi-synthetic Synthetic

Phenanthrine Morphine Benzyl-morphine Pethidine
group Codeine Oxy-morphine Methadon
Thebain Hydro-morphine Isomethadon
Diacetyl Hydroxyl
morphine(Heroin) Methadon
Isoquinolone Narcotine Nalorphine Nomethadon
group Narcine Hydrocodone Alpha-methadone
Papaverine Dehydrocodone Beta-methadon
Fatal dose:
✓Opium 2 gm.
✓Morphine 0.2 gm.
✓Codeine 0.5 gm.
✓Fentanyl is 50 to 100 times more potent than
morphine

Fatal period: 6-12 hours

 Signs and symptoms
✓The contact of morphine with the skin of sensitive person may cause
erythema, urticarial and itching dermatitis
✓When opium is taken by mouth, symptoms begin within half an hour
✓When opium injected, its action is noted within 3 to 4 minutes
✓Opium first stimulate, then depresses and finally paralysis the nerve
centers
Manifestation of signs and symptoms occurs in three stages:
1) Stage of excitement
2) Stage of stupor
3) Stage of narcosis
 Contd
Stage of excitement:
✓Increased sense of well-being
✓Increased mental activity
✓Freedom from anxiety
✓Loquaciousness
✓Restlessness or even hallucination
✓Flushing of the face
✓Increased action of the heart
✓Convulsion of the children
✓This stage is of short duration, may be absent if a large dose is
taken
 Contd
Stage of stupor:
✓The nerve centers are depressed during this stage, which sometimes
comes on quite suddenly
✓Headache and giddiness
✓Lethargic condition
✓Drowsiness
✓Nausea and vomiting
✓An uncontrollable desire to sleep from which the patient may be
roused by external stimuli
✓Pupils are contracted
✓Face and lips are cyanosed
✓Itching sensation is felt all over the skin
✓Pulse and respirations are still normal
 Contd
Stage of narcosis:

✓Patient now passes into deep coma from which he/she cannot be roused

✓Muscles are relaxed, the reflexes are lost

✓All the secretions are completely suspended except that of the skin which
is cold and clammy

✓Face pale, lips livid and the lower jaw drops

✓Pupils are contracted to pin point and are insensible to light, terminally
pupils may dilate (pre-mortal dilatation), when asphyxia intervenes
 Contd
✓Conjunctiva are congested
✓Blood pressure begins to fall
✓Pulse is slow, small and compressible
✓Respirations are slow, labored and stertorous and the rate may be 2 to 4
minute. If recovery don’t take place at this stage under prompt and proper
treatment ---- respiration will be more slower, more feeble and assume the
character of cheyne-stokes, heart may continue to beat for a short time
after respiratation has stopped
✓Odour of opium may be present in the breath (sweetish)
Cardinal feature of opium poisoning
✓Pupil are contracted & pin point
✓All secretion are suspended except sweat gland
✓Skin is cold with perspiration
✓Temperature is subnormal
✓Cheyne stroke breathing
✓Blood pressure is low, pulse slow & full.
✓Smell of opium from mouth.
 D/D of opium poisoning
AEIOUDAM
✓Apoplexy
✓Epileptic coma
✓Injury to head (head injury)
✓Opium poisoning
✓Uremic coma/uremia
✓Diabetic coma/diabetic ketoacidosis
✓Acute alcoholic poisoning
✓Meningitis
 Treatment of opium poisoning
1) Gastric lavage: washout the stomach at first with warm water and preserve the
washing for chemical analysis in a glass jar properly packed. Stomach wash
should also be done even when poisoning has occurred from injection of
morphine.
2) Catheterize the bladder
3) Give magnesium sulphate half an ounce to clear the bowels
4) Oxygen inhalation at high tension for cyanosis
5) Artificial respiration, if respirations are markedly depressed
6) To maintain respiration, analeptic drugs e.g. caffeine, amphetamine etc.
Maintain body heat by hot water bottles and warm blankets
 Contd
7) Give hot tea or coffee by mouth or by rectum

8) If coma has supervened, inject 5 mg of Nalorphine hydrobromide

(lethidrone) intravenously. Within a couple of minutes, the respiratory
rate usually increases and the pupils dilate. If no response is found, 5 to
15 mg may be given, I/V or I/M at 15 to 30 minutes intervals until the
patient is aroused

9) For shock give 100 ml of 5% glucose saline I/V by drip.

 Post mortem findings
External findings:

✓The smell of opium is present

✓The face is deeply cyanosed, almost black

✓The finger nails are blue

✓The neck veins engorged and distended

✓The post mortem lividity is almost black and is better seen in a fair skinned body

✓There is froth at the nose and nose, but neither so fine nor so copious as in
drowning
 Contd
Internal findings:
✓The stomach may show the presence of small, soft and brownish
lumps of opium
✓The trachea, bronchi, lungs and brain exhibit a marked degree of
venous congestion
✓The trachea and bronchi are covered with froth and lungs are
oedematous
✓The blood is usually dark and fluid
✓The heart ---- right side full and left side empty
✓Brain and its membranes are congested
In cases of suspected opium poisoning--- blood, bile and brain should
be preserved in addition to routine viscera
 Medico legal aspects of opium
1) It is so easily obtained everywhere in Bangladesh and death from its use
is so painless that it is the poison of choice for suicidal purposes
2) On account of its black color, characteristics odour and bitter taste, it is
rarely used for homicidal purposes
3) It is sometimes used for infanticide. Death has resulted from the breast
feeding of an infant by a woman who had smeared her nipple with
tincture of opium with evil intention
4) Accidental poisoning may occur from drugging of infants and children to
keep them quite or from overdose of a medicinal preparation
5) It is sometimes used as an aphrodisiac agent
6) It is stated to build nerves before performing act of violence or crime like
homicide
Question: a patient brought to you and you found that it is a case of
morphine poisoning and several injections mark present in the body--
-- will you wash the stomach of that patient or not?
Answer: yes, I shall give stomach wash even when poisoning has
occurred from injection of morphine, as morphine after absorption into
the blood is excreted into the stomach where it is again liable to be
reabsorbed.

What is coma cocktail?

In comatose patient where the identity of poison is not known.100 ml.

50% glucose, 100 mg thiamine & 2mg. Naloxone should be given IV.
 Speed ball
Also known as power balling
Definition: it is a term commonly referring to the hazardous intravenous use
of heroin or morphine and cocaine together in the same syringe .
Cocaine acts as a stimulant, where heroin/morphine acts as a depressant
Co-administration provides an intense rush of euphoria with a high that
combines the effects of both drugs, while excluding the negative effects,
such as anxiety and sedation
The effects of cocaine wear off far more quickly than heroin or morphine.
Fatal respiratory depression can occur when the cocaine wears off and the
full effects of heroin or morphine are felt in isolation.
## Opioids are substances having action similar to opium but not derived
from it
 Heroine poisoning
Heroine (Diacetylmorphine) or brown sugar are three types white,
brown & black tar.

Street heroine is also known as smack, junk or dope.

It is 2-4 times more potent than morphine.

It can be smoked, injected or used as snuff.

Fatal dose is 50mg.

 Contd
After taking heroine it causes intense euphoria lasts for several minutes
followed by sedation about 1 hour & effects are completely lost for 3-6
hours.
Treatment :
i. Methadone 40mg
ii. Detoxification
iii. Narcotic antagonist like naloxone, clonidine etc.
 Cocaine poisoning

Cocaine, also known as coke, is a strong stimulant mostly used as

recreational drug. After cannabis, cocaine is the most frequently used
illegal drug globally. It is crystalline white powder made and purified
from coco plant leaves.
 Contd
Methods of use:

injection – IV or SC, snoring, Inhalation, Smoking, Oral, as chewing ball,

as tea, dust, as indigenous medication.

Fatal dose: one gram.

Fatal period : Few minutes-few hours.

 Sign symptoms

Stage of excitement : patient is- Stage of depression: -within hour

Euphoric Respiration become feeble
Talkative Profuse respiration
Excited Collapse
Restless Convulsion
Reflexes are exaggerated Death occurs due to respiratory
Tremor & convulsion failure & cardiac failure.
Hypertension
Hallucination etc.
 Treatment
1. Airway & circulatory stabilisation
2. Stomach wash with KMnO4, charcoal & tannic acid
3. Antidote – Amyl nitrate is given by inhalation.
4. Vit-K orally or IV
5. Thiamine 100mg I.V
6. Naloxone HCl 2mg i.v
7. If convulsion then correction it by barbiturates
8. Antibiotics
9. Symptomatic treatment.