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CE ARTICLE obtained for free from friends or relatives. Fewer persons actually buy (11.4%) or steal (4.8%) prescription painkillers from friends or relatives or get them from drug dealers or strangers (4.4%). The CDC has identified groups susceptible to death from unintentional overdose of prescription painkillers:4 • Men are twice as likely to die of prescription painkiller overdoses as women. • Middle-aged adults have the highest overdose rates. • Persons living in rural counties are nearly twice as likely to overdose as those living in urban areas. • Whites, Native Americans and Alaska natives are more likely to overdose. • About 1 in 10 Native American or Alaska natives 12 or older used prescription painkillers for nonmedical reasons in the past year, compared to 1 in 20 whites and 1 in 30 African-Americans. Clinical Presentation The diagnosis of opioid intoxication and overdose can be reached based on a history and physical examination. It is a clinical diagnosis, and toxicology screens are not always necessary. EMS providers should concentrate on obtaining clear histories and identifying specific components of opioid toxidromes. A toxidrome is a group of signs and symptoms characteristic of an exposure to a specifc substance or class of substances. The classic toxidrome associated opioid toxicity is CNS depression, respiratory depression and miosis (constricted pupils). Additional signs and symptoms include GI symptoms like nausea and vomiting, decreased motility, ileus; cardiac symptoms including bradycardia and hypotension; and respiratory symptoms including acute lung injury and pulmonary edema, plus respiratory arrest. The respiratory depression associated with opioid intoxication is characterized by breathing that is both slow (bradypnea) and shallow (hypopnea). Opioids decrease respiratory drive by suppressing the sensitivity of the respiratory centers in the medulla oblongata. This depression occurs in a dose-dependent manner, with more severe depression occurring with higher doses of opioids. Inadequate ventilation can lead to development of hypoxia (and cyanosis) and hypercarbia, and profound hypoxia can lead to seizures. Acute lung injury and pulmonary edema can occur with therapeutic opioid use but are more common after overdose.5 The exact mechanisms are unclear, but theories include capillary leakage secondary to hypoxia6 or excessive negative pressure created when a comatose patient with an obstructed airway from a closed or collapsed glottis attempts to breathe.7 While miosis is considered a classic finding associated with opioid overdose, there are factors that can prevent it from occurring. Not all opioids will produce miosis, and it is not typically seen with meperidine (Demerol), pentazocine (Talwin) or propoxyphene (Darvon, new for 2013! Co-Located With 25th Thrive in the new age of mobile healthcare. At EMS World Expo's Mobile Integrated Healthcare Summit, EMS executives and medical directors who are already making the transition to a mobile healthcare delivery model come together to help agencies navigate this radical new environment. Attend this exclusive event to fnd out why mobile healthcare is more than just community paramedicine and will redefne your operations. September 11, 2013 Las Vegas Convention Center For event details and to register, visit EMSWorldExpo.com. Sign up by August 12 & save up to $70! EMSWORLD.com | JUNE 2013 59