Opioids cause a well-recognized toxidrome including respiratory depression, decreased conscious level, constricted pupils and hypotension. In overdose, their toxicity relates to both the amount ingested and the speed of absorption. People who regularly misuse opioids develop tolerance to the pharmacological effects over time and may seek higher doses to achieve the same desired effect. This also has important implications for users following periods of abstinence (e.g. while in custody), when tolerance can be lost, resulting in unanticipated toxic clinical effects when users return to their ‘normal’ dose. Similarly, variability in the potency of illegally obtained opioid drugs, which may or may not contain adulterants, leads to unpredictable pharmacological effects. Naloxone is the opioid antagonist of choice, and its dose should be titrated according to clinical response. The duration of action of naloxone is relatively short, and repeated doses or a continuous infusion may be required.
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