A Review of Acute Opiate Poisoning in the South West of Iran

Research Article

J Drug Discov Develop and Deliv. 2017; 4(1): 1026.

A Review of Acute Opiate Poisoning in the South West of Iran

Jalali A1¹*, Hasan Rahmani A², Moosavi M¹, Mehrabi L², Saki A³ and Rowan EG4

¹Department of Pharmacology and Toxicology, School of Pharmacy and Toxicology Research Center, Ahvaz Jundishapur University of Medical Science, Iran

2Department of Clinical Toxicology, Razi Hospital and Toxicology Research Center, Ahvaz Jundishapur University of Medical Science, Iran

3Department of Statistics, School of Health, Ahvaz Jundishapur University of Medical Science, Iran

4Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, UK

*Corresponding author: Jalali A, Department of Pharmacology and Toxicology, School of Pharmacy and Toxicology Research Center, Ahvaz Jundishapur University of Medical Science, Iran

Received: February 02, 2017; Accepted: March 13, 2017; Published: March 21, 2017


Background: Evidences on the exact burden and pattern of acute opiate poisoning in the southwest of Iran (Ahvaz, Khuzestan province) are limited.

Objectives: We aimed to characterize acute opiate poisoning with regard to demographic and epidemiological factors of cases registered at Razi General Teaching Hospital, Jundishapur University; main referral poisoning ward in the southwest of Iran.

Methods: This was a retrospective collection of data on all acute opiate poisoning cases recorded from January to December 31 2007.

Results: Of 264 cases (84.8% male, 15.2% female, mean age of 28.5±14 years), 62.5% were aged between 4-25, 22% between 26-40 and 15.5% of patients were 40 years and over. The main drugs implicated in opioid overdosing were tramadol in 69.3% (183 cases), opium in 27.3% (72 cases), and heroin in 2.7% (7 cases). The most common symptom of the intoxication was, decreased consciousness (54.5%) followed by nausea and vomiting (17.8%), drowsiness (15.2%) and seizure (12.5%). Seizure was more common in the group of patients who were taking tramadol and were less than 25 years of age. Most cases were referred to hospital within six hours; the death rate was 1.9%. Acute opiate poisoning was associated with not high mortality rate than reported elsewhere. Analysis of cases with seizure (male 90.9% vs. female, 9.1%) showed that most seizures happened in age group less than 25.

Conclusion: This demonstrates a pressing need from policy-makers for awareness that tramadol using may increase the mortality in young adults - the most affected group and further calls for the use family approaches in raising this awareness.

Keywords: Opioid; Tramadol; Age-dependent; Seizure; Poisoning


Acute opiate poisoning remains a significant public health problem in many developing countries. Furthermore, there are almost a couple of millions suicides each year, and a significant number of deaths are related to opiate poisoning. Overdose deaths from acute opiate poisoning become more prevalent in developing countries [1-6]. In the southwest of Iran, Khuzestan province, acute opiate poisoning has not been identified well as a significant cause of both morbidity and mortality with hospital referral. Tramadol is a centrally acting opioid-receptor agonist that is extensively dispensed analgesic in more than 100 countries. Tramadol has been marketed in Iran since 1995. This drug was employed to accelerate opioid detoxification by displacing opiate and as a maintenance agent for detoxified formerly opiate-dependent patients who want to remain opioid-free [1]. It is being abused by opioid addicted subjects. Its main effects including multimodal antinociceptive and analgesic via two mechanisms: opioid through μ-opioid receptors and nonopioid component related to inhibition of neuronal 5-hydroxytryptamine (5-HT; serotonin) [2]. Tramadol like other opioid drugs (opiates) is an agonist of the μ receptor. Its affinity is moderate and weaker than morphine. This low affinity at receptor causes relieving properties are about 10 times less than morphine. Tramadol prevents the reuptake of noradrenaline and serotonin in the synapses like antidepressants and act consumer awareness and active unlike morphine. This synthetic drug has two significant adverse reactions: seizure and serotonin syndrome [3-6]. These adverse reactions may occur even during normal doses in animals and humans [4,6].

Seizure is a serious complication that may associate with medication or drug use [7]. Clinical factors for complications of drug-induced seizures are stimulant exposure, suicide attempt, initial hypotension, and admission acidosis or hypoglycemia [8]. Drug overdose or ethanol which is responsible for 18% cases in seizure occurrence has fatality rate over 20% [9].

The lack of up-to-date information concerning acute opiate poisoning in the southwest of Iran, Khuzestan province can be attributed to the unavailability of published data in accessible databases, a deficiency in national surveillance systems, including the non-mandatory notification of poisoning cases. This lack of information is a barrier to effective poisoning prevention and targeted intervention programmers. The aim of the present study was twofold. Firstly, this study sought to evaluate the frequency of signs and symptoms of opium and opioid poisoning patients. The study also aimed to identify the risk factors of opioid-induced seizures among all hospitalized opioid poisoning cases. So, all consecutive referred to center involving seizures were forwarded to more investigations.

Materials and Methods

Patients and sample

This retrospective observational study was performed at Razi General Hospital over three years period (from 1 January 2005 to 31 December 2007) on 264 opioid overdose cases whether the intention was accidental or recreational. Center of Toxic Emergency in Razi General Hospital has the largest caseload of seriously admission of Acute Opiate Overdose (AOO) in the southwest of Iran, Khuzestan. This teaching hospital is the main referral center for poisoning in the metropolitan city of Ahvaz, and serves population of about 2 million. This ward receives cases from Ahvaz city and health centres within and outside Khuzestan. All cases have been registered due to acute opiate poisoning recorded in hospital covering the period of the study were listed and included. The patients diagnosed with any form of epilepsy and other types of seizures one year before admission were excluded.

Opiates included heroin, opium, tramadol, morphine, methadone and tamjizak. Tamjizak is sometimes used to treat and prevent withdrawal symptoms. This drug was made for the first time by a pharmaceutical company and is a combination of industrial morphine hydrochloride and other synthetic drugs. All subjects completely informed to take part in this study. The criteria for diagnosis of acute opiate overdose, was defined as altered level of consciousness, miotic pupils, decreased respiration and symptoms responding to naloxane. Altered level of consciousness was defined according to physiologic depression grading (Table 1) [10]. The primary outcome of the study was seizure attack and secondary outcomes were the demographic characteristics, history of drug use, poisoning agents, intent of poisoning, route of exposure, place of poisoning, admission status and hallmarks of overdose. All the information was obtained from hospital files and recorded in a standardized form.