Standard urine opioid immunoassays detect morphine and related opiates. They often miss fentanyl and its analogues, tramadol, methadone, buprenorphine, kratom alkaloids and newer synthetic opioids.
In a patient with pinpoint pupils, reduced consciousness and slow breathing, treat the clinical toxidrome. Give naloxone in titrated doses to restore breathing, and observe long enough for longer-acting agents to wear off.
- Treat the toxidrome, not the screen result.
- Titrate naloxone to breathing, not full wakefulness, in opioid-dependent patients.
- Observe after naloxone for recurrent respiratory depression.
- Ask about non-prescribed products, including kratom and online opioids.
Why it matters
Many of the opioids now causing harm are invisible to standard screens.
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