Opium and its derivatives

Introduction

Opium is coagulated juice of opium poppy - Papaver somniferum; Lacrimal

papaveris.

Powdered opium is opium dried at 70 degree Celsius

 History
Fossilised opium poppy seeds 30000yrs ago.

Homer 9th century BC in his epic Iliad and odyssey - Nepenthe

Telemachus hero of trojan war 1150 BC

Sicyon town - the town of poppies

Meconium

First known cultivation of poppies was in Mesopotamia - 3400BC

 History
Arabian traders introduced drug to the east

Famous people Samuel Coleridge and Thomas de Quincey were confirmed opium
addicts

German chemist in 1804 Friedrich Serturner isolated morphine

Invention of hypodermic needle

American civil war (1861 - 1865)

Opium dens

1914- present
 Plant

Lab synthesis is difficult so it is still obtained from opium.

MP, UP and Rajasthan

Central bureau of narcotics (CBN)

MQY - most important criteria

Rigours imprisonment 10 - 20 years and fine 1- 2 lakhs.

 Extraction
Sown early winter

Unripe fruit is incised

White milky juice

Scraped and collected next morning

Direction of incision, depth of incision, multiple incisions

Poppy tears
 Classification

Natural: morphine and codeine

Semi - synthetic: heroin and pholcodeine.

Synthetic: Dextropropoxyphene, diphenoxylate, fentanyl, methadone, pethidine,

tramadol.
 Metabolism

Absorbed from GI tract - lipophilic - codeine, fentanyl, heroin, methadone;

hydrophilic - morphine.

Metabolism by liver.

Excretion is mainly in urine with morphine excreted in urine and faeces.

 Mechanism of action
Mu, kappa, delta, noci and zeta.

Analgesia.

Delta - anti depressant

Kappa - psychotic, sedation

Mu - physical dependance, sedation

Noci - depression and development of tolerance.

 Acute Poisoning - opium
Taken by mouth, never by IV

On contact - erythema, itching dermatitis, urticaria

Ingestion:

A. Stage of excitement

B. Stage of stupor

C. Stage of narcosis or coma

 Diagnosis
7 signs

A. Pupils - pinpoint

B. R/R - decreased

C. Pulse - decreased

D. Temp - Decreased

E. Odour - characteritic

F. Skin - Moist, perspiring

G. Coma
Fatal Dose
 Management
ABCDE of resuscitation

Decontamination

Activated charcoal

Naloxone, naltrexone, nalmefene

Physostigmine

Coma cocktail
 PM appearance
Pm staining - well marked, cyanotic

Smell - opium. Not felt if body is decomposed

Signs of asphyxia

Mouth - froth

Trachea - froth, congested, vomit

Lungs - oedematous

Stomach - lumps of opium

Brain - congested

Viscera - congested

Blood - dark and fluid.

 Pneumonic
M - muscle relaxation

O - orthostatic hypertension

R - respiratory depression, reflexes absent

P - pin point pupil

H - hallucinations

I - irregular feeble pulse

N - Nausea

E - euphoria

S - sedation
 ML importance

Suicide - ideal poison

Homicide - rare

Accidental
 Heroin

Semi synthetic - mixing morphine with acetic anhydride

Rapidly metabolised to morphine and 6 monoacetyl morphine

Vinegar like smell

Forms - base and salt

Grades
 Heroin

Additives - dope, junk or smack

Combinations - speed ball - heroin and cocaine

Administration - smoking and injection

Metabolism - same as opium

 Signs and Symptoms
If taken by mouth same as opium

IV all stages are merged

Intense euphoria - several minutes

Sedation - 1 hr

Effects lost in 3-6hrs

Systemic reactions - dirty hits

 Signs and symptoms
Emaciation

Anorexia, constipation

Impotence

Hepatitis, HIV, Malaria and other infections

Skin - needle marks, tattoos, cigarette burns, dermal abscesses, ulceration

Hands - Chronic edema due to occlusive thrombophlebitis - puffy hand syndrome

Acute on chronic
 Signs and symptoms

Cool to touch, unresponsive to pain, hunger diminished and scars over veins,
pupils pinpointed, blood pressure low, urine diminished and breathing is slow.
 Management

Acute - gastric lavage. Rest is same as opium

Chronic - detoxification
 PM appearance

Signs of wasting self neglect

Needle, syringe, tourniquet

Findings related to attempts at revival

Mouth and nostrils - Froth

Skin and hands - same in chronic poisoning

 PM appearance
URT - Froth

Veins - phlebitis, thrombosis and perivenous haemorrhage

Lungs - heavy, oedematous, petechial haemorrhages

Heart - myocardial damage, valvular disease, RVH

Effusions - all major cavities.

Liver - congested enlarged, hepatitis, cirrhosis

Spleen enlarged

Brain - cerebral oedema

 Medicolegal aspects

Accident

Suicide

Homicide
 Desomorphine

Synthetic opioid - Krokodil

Skin becomes dark green and scaly

Cheap substitute for heroin - light brown liquid

Home made
 Fentanyl

Synthetic - used as pain medication

Drug abuse

Highly addictive

MLI
Question 1
A 28 year old male patient is brought to casualty in comatose state with pin point
pupils, reduced respiration and bradycardia. Most likely diagnosis:

A. Tricyclic antidepressant poisoning

B. Opioid poisoning

C. Benzodiazepine poisoning

D. Organophosphorus poisoning
Question 2

Route not used by addicts of morphine:

A. Intravenous

B. Intramuscular

C. Subcutaneous

D. Oral
Question 3

Condition of pupil in opium poisoning:

A. Miosis

B. Mydriasis

C. Irregular

D. No change
Question 4
A person after ingesting a toxic agent is in a state of narcosis. The pupils are
contracted. However on pinching the neck, the pupils dilate initially and slowly
return to their original size. The toxic agent is

A. Barbiturate

B. Opium

C. Alcohol

D. Organophosphate
Thank You