Poisoning Due to Analgesics

Overview

Poisoning due to analgesics represents one of the most common types of drug poisoning worldwide, accounting for thousands of emergency department visits and hospitalizations annually. Analgesics, or pain relief medications, include a diverse group of drugs such as acetaminophen (paracetamol), nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids, each with distinct mechanisms of toxicity.

Acetaminophen poisoning is the leading cause of acute liver failure in many developed countries, while NSAID overdoses primarily affect the kidneys and gastrointestinal system. Opioid poisoning, increasingly common due to the opioid crisis, primarily affects the central nervous system and respiratory function. These poisonings can result from intentional overdose, accidental ingestion, chronic overuse, or drug interactions.

The severity of analgesic poisoning varies widely depending on the specific medication, amount consumed, timing of ingestion, and individual patient factors such as age, underlying health conditions, and concurrent medications. Early recognition and appropriate treatment are crucial, as delayed intervention can lead to irreversible organ damage or death.

While many analgesic poisonings are preventable through proper medication management and education, the widespread availability of these drugs, particularly over-the-counter preparations, contributes to their frequent involvement in poisoning cases. Understanding the signs, symptoms, and appropriate response to analgesic poisoning is essential for both healthcare providers and the general public.

Symptoms

Symptoms of analgesic poisoning vary significantly depending on the specific medication involved, the amount consumed, and the time elapsed since ingestion. Recognition of these symptoms is crucial for prompt treatment and preventing serious complications.

Common Early Symptoms

Acetaminophen Poisoning Symptoms

Stage 1 (0-24 hours)

• Nausea and vomiting
• Loss of appetite
• Abdominal pain
• Excessive sweating
• Malaise and fatigue
• May be asymptomatic in some cases

Stage 2 (24-72 hours)

• Right upper quadrant abdominal pain
• Elevated liver enzymes
• Possible improvement in nausea
• Decreased urine output
• Tender liver on examination

Stage 3 (72-96 hours)

• Jaundice (yellowing of skin and eyes)
• Severe liver dysfunction
• Confusion and altered mental status
• Bleeding or bruising easily
• Kidney failure
• Potentially fatal liver failure

NSAID Poisoning Symptoms

• Gastrointestinal: Nausea, vomiting, abdominal pain, GI bleeding
• Renal: Decreased urination, fluid retention, high blood pressure
• Cardiovascular: High blood pressure, heart palpitations
• Neurological: Headache, dizziness, tinnitus (ringing in ears)
• Respiratory: Rapid breathing, shortness of breath
• Skin: Rash, swelling, allergic reactions

Opioid Poisoning Symptoms

• Central nervous system: Drowsiness, confusion, coma
• Respiratory: Slow, shallow breathing or respiratory arrest
• Cardiovascular: Slow heart rate, low blood pressure
• Physical signs: Constricted pupils, blue lips or fingernails
• Gastrointestinal: Nausea, vomiting, constipation
• Muscle: Muscle rigidity or limpness

Severe Poisoning Warning Signs

• Difficulty breathing or stopping breathing
• Loss of consciousness or unresponsiveness
• Seizures
• Severe dehydration
• Signs of liver failure (jaundice, confusion, bleeding)
• Signs of kidney failure (no urination, severe swelling)
• Severe allergic reactions (widespread rash, difficulty swallowing)

Chronic Poisoning Symptoms

Long-term overuse of analgesics can cause:

• Chronic kidney disease
• Liver damage
• Gastrointestinal ulcers
• Increased risk of heart attack and stroke
• Physical dependence and withdrawal symptoms
• Medication overuse headaches

Causes

Analgesic poisoning can result from various circumstances, ranging from accidental overdose to intentional self-harm. Understanding these causes helps in prevention and appropriate treatment approaches.

Types of Analgesic Poisoning

Acetaminophen (Paracetamol) Poisoning

• Mechanism: Depletion of liver glutathione leading to toxic metabolite accumulation
• Toxic dose: >150 mg/kg in adults, >200 mg/kg in children
• Time-dependent: Effectiveness of treatment decreases with time
• Risk factors: Alcohol use, malnutrition, certain medications

NSAID Poisoning

• Mechanism: COX enzyme inhibition affecting prostaglandin production
• Effects: Kidney damage, GI irritation, cardiovascular effects
• Common drugs: Ibuprofen, naproxen, diclofenac, aspirin
• Dose-related: Higher doses increase toxicity risk

Opioid Poisoning

• Mechanism: Central nervous system depression via opioid receptors
• Primary risk: Respiratory depression and death
• Common drugs: Morphine, oxycodone, fentanyl, heroin
• Tolerance: Regular users may require higher doses for toxicity

Common Circumstances Leading to Poisoning

Accidental Overdose

• Taking multiple products containing the same active ingredient
• Misreading dosing instructions
• Confusion about medication strength
• Pediatric accidental ingestion
• Elderly confusion with medications
• Double-dosing due to forgotten previous dose

Intentional Overdose

• Suicide attempts
• Self-harm behaviors
• Recreational drug abuse
• Attention-seeking behavior
• Mental health crises

Chronic Overuse

• Escalating doses for chronic pain
• Medication overuse headaches
• Self-medication for untreated conditions
• Physical dependence leading to increased use
• Inadequate pain management leading to self-escalation

Contributing Factors

Drug Interactions

• Acetaminophen + alcohol: Increased liver toxicity risk
• NSAIDs + anticoagulants: Increased bleeding risk
• Opioids + CNS depressants: Enhanced respiratory depression
• Multiple analgesics: Additive toxic effects

Patient-Specific Risk Factors

• Liver disease (increased acetaminophen risk)
• Kidney disease (increased NSAID risk)
• History of substance abuse
• Mental health conditions
• Age extremes (very young or elderly)
• Malnutrition or dehydration

Environmental and Social Causes

• Easy access: Over-the-counter availability
• Multiple formulations: Confusion about different preparations
• Lack of education: Insufficient knowledge about safe use
• Cultural factors: Beliefs about medication safety
• Economic factors: Self-medication to avoid medical costs
• Internet purchases: Unregulated online medication sources

Special Populations

Pediatric Poisoning

• Accidental ingestion of adult medications
• Incorrect dosing of pediatric formulations
• Flavored medications appearing as candy
• Confusion between different concentrations

Elderly Poisoning

• Cognitive impairment affecting medication management
• Multiple medications increasing confusion
• Age-related changes in drug metabolism
• Visual impairment affecting label reading

Risk Factors

Several factors increase the likelihood of analgesic poisoning or worsen its effects. Identifying these risk factors helps in prevention strategies and clinical management.

Demographic Risk Factors

• Age extremes: Children under 5 and adults over 65
• Gender: Females slightly higher risk for intentional overdoses
• Adolescents and young adults: Higher risk for intentional poisoning
• Occupational exposure: Healthcare workers with access to medications

Medical Risk Factors

Pre-existing Conditions

• Liver disease: Increased susceptibility to acetaminophen toxicity
• Kidney disease: Reduced drug clearance and increased NSAID risk
• Cardiovascular disease: Increased risk from NSAID-related effects
• Gastrointestinal disorders: Higher risk of NSAID-related complications
• Respiratory conditions: Increased opioid sensitivity
• Diabetes: May affect drug metabolism

Mental Health Conditions

• Depression and suicidal ideation
• Anxiety disorders
• Bipolar disorder
• Borderline personality disorder
• Substance use disorders
• Eating disorders

Medication-Related Risk Factors

• Polypharmacy: Taking multiple medications
• Prescription drug abuse: History of misusing medications
• Chronic pain conditions: Long-term analgesic use
• Previous overdose: History of drug poisoning
• Medication hoarding: Accumulating unused medications

Lifestyle and Social Risk Factors

• Alcohol use: Increases liver toxicity risk with acetaminophen
• Illicit drug use: Higher risk behavior patterns
• Social isolation: Delayed discovery of overdose
• Stress and life events: Job loss, relationship problems, bereavement
• Low socioeconomic status: Limited healthcare access
• Educational level: Lower health literacy

Access and Availability Factors

• Easy medication access: Large quantities at home
• Multiple prescribers: Doctor shopping or uncoordinated care
• Internet pharmacies: Unregulated medication sources
• Sharing medications: Using others' prescriptions
• Expired medications: Unpredictable potency

Physiological Risk Factors

• Malnutrition: Depleted glutathione stores
• Dehydration: Affects drug distribution and elimination
• Pregnancy: Changed drug metabolism
• Genetic factors: Variations in drug metabolism
• Body weight extremes: Very low or high body weight

Environmental Risk Factors

• Seasonal factors: Holiday periods with increased substance use
• Geographic location: Areas with limited healthcare access
• Cultural factors: Attitudes toward medication use
• Economic stress: Financial hardship affecting decision-making

High-Risk Situations

• Recent prescription changes or dose adjustments
• Discharge from hospital with new pain medications
• Dental procedures with opioid prescriptions
• Surgical recovery periods
• Chronic pain flare-ups
• Stressful life events or anniversaries
• Holiday periods or vacation times

Protective Factors

• Strong social support systems
• Good relationship with healthcare providers
• Medication management systems
• Mental health treatment compliance
• Education about medication safety
• Regular medical follow-up

Diagnosis

Diagnosing analgesic poisoning requires a combination of clinical history, physical examination, and laboratory testing. Rapid and accurate diagnosis is crucial for implementing appropriate treatment and preventing complications.

Initial Assessment

History Taking

• Medication history: Type, amount, timing of ingestion
• Symptoms timeline: Onset and progression of symptoms
• Intent assessment: Accidental vs. intentional overdose
• Concurrent medications: All prescription and OTC drugs
• Substance use: Alcohol, illicit drugs
• Past medical history: Liver, kidney, heart disease
• Previous overdoses: History of drug poisoning

Physical Examination

• Vital signs: Blood pressure, heart rate, respiratory rate, temperature
• Mental status: Consciousness level, orientation
• Neurological exam: Pupil size, reflexes, coordination
• Cardiovascular assessment: Heart sounds, peripheral circulation
• Respiratory evaluation: Breathing pattern, oxygen saturation
• Abdominal examination: Tenderness, liver size
• Skin assessment: Color, rash, signs of jaundice

Laboratory Tests

Drug Levels

• Acetaminophen level: Essential for treatment decisions
• Salicylate level: If aspirin overdose suspected
• Opioid screening: Urine or blood toxicology
• Other analgesics: Specific levels when available

Organ Function Tests

• Liver function: ALT, AST, bilirubin, PT/INR
• Kidney function: Creatinine, BUN, electrolytes
• Complete blood count: Looking for anemia or infection
• Arterial blood gas: Acid-base status
• Lactate level: Indicator of cellular dysfunction

Additional Tests

• Urinalysis: Kidney function, protein, blood
• Pregnancy test: In women of childbearing age
• Therapeutic drug monitoring: For chronic users
• Toxicology screen: Comprehensive drug testing

Diagnostic Tools and Nomograms

Rumack-Matthew Nomogram

• Used for acetaminophen poisoning assessment
• Plots serum level vs. time since ingestion
• Determines need for N-acetylcysteine treatment
• Most accurate 4-24 hours post-ingestion

Clinical Severity Scales

• Glasgow Coma Scale: Level of consciousness
• Richmond Agitation-Sedation Scale: Sedation level
• Poisoning Severity Score: Overall toxicity assessment

Imaging Studies

• Abdominal X-ray: If tablets visible (rare)
• Chest X-ray: Pulmonary edema, aspiration
• CT head: If altered mental status unexplained
• Ultrasound: Liver assessment in severe cases

Differential Diagnosis

• Other drug poisonings: Antidepressants, anticonvulsants
• Alcohol intoxication: Similar neurological symptoms
• Metabolic disorders: Hypoglycemia, uremia
• Infectious diseases: Encephalitis, sepsis
• Psychiatric conditions: Conversion disorder, malingering
• Liver disease: Acute hepatitis, cirrhosis

Special Considerations

Pediatric Diagnosis

• Different dosing calculations
• Age-appropriate symptom assessment
• Caregiver history reliability
• Developmental considerations

Elderly Diagnosis

• Multiple comorbidities affecting presentation
• Polypharmacy complications
• Cognitive impairment affecting history
• Atypical presentations common

Monitoring and Follow-up

• Serial drug levels: Track elimination
• Liver function trends: Early detection of hepatotoxicity
• Kidney function monitoring: Detect nephrotoxicity
• Continuous assessment: Mental status, vital signs
• Response to treatment: Antidote effectiveness

Treatment Options

Treatment of analgesic poisoning depends on the specific drug involved, amount ingested, time since ingestion, and patient's clinical condition. Early intervention significantly improves outcomes and reduces complications.

General Emergency Management

Initial Stabilization

• Airway management: Ensure patent airway, consider intubation if needed
• Breathing support: Oxygen therapy, mechanical ventilation if required
• Circulation support: IV access, fluid resuscitation
• Disability assessment: Neurological status, glucose check
• Exposure/Environment: Prevent hypothermia, examine for trauma

Decontamination Measures

Activated Charcoal

• Timing: Most effective within 1-2 hours of ingestion
• Dose: 1 g/kg (up to 50-100g in adults)
• Contraindications: Altered mental status, risk of aspiration
• Effectiveness: Variable depending on the drug

Gastric Lavage

• Rarely used due to limited effectiveness
• Consider only within 1 hour of massive ingestion
• Requires protected airway
• Risk of aspiration and complications

Specific Antidotes and Treatments

Acetaminophen Poisoning

• N-acetylcysteine (NAC): Primary antidote
• Oral protocol: 140 mg/kg loading dose, then 70 mg/kg every 4 hours
• IV protocol: 150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours
• Timing: Most effective within 8 hours, beneficial up to 24+ hours
• Side effects: Nausea, rash, anaphylactoid reactions

NSAID Poisoning

• Supportive care: No specific antidote available
• Gastric protection: Proton pump inhibitors
• Fluid management: Monitor kidney function carefully
• Alkaline diuresis: For salicylate poisoning
• Hemodialysis: Severe salicylate or other NSAID poisoning

Opioid Poisoning

• Naloxone (Narcan): Opioid receptor antagonist
• Initial dose: 0.4-2 mg IV/IM/intranasal
• Repeat dosing: Every 2-3 minutes as needed
• Continuous infusion: May be needed for long-acting opioids
• Duration: Monitor for re-sedation as naloxone wears off

Supportive Care

Respiratory Support

• Oxygen therapy for hypoxia
• Mechanical ventilation for respiratory failure
• PEEP for pulmonary edema
• Positioning to prevent aspiration

Cardiovascular Support

• IV fluids for hypotension
• Vasopressors if fluid-resistant hypotension
• Cardiac monitoring for arrhythmias
• Electrolyte monitoring and correction

Neurological Support

• Seizure management with benzodiazepines
• Intracranial pressure monitoring if needed
• Temperature management
• Frequent neurological assessments

Advanced Treatments

Liver Support for Acetaminophen

• Liver transplant evaluation: For fulminant hepatic failure
• King's College criteria: Transplant assessment guidelines
• Artificial liver support: Bridge to transplant or recovery
• Coagulopathy management: Fresh frozen plasma, vitamin K

Extracorporeal Treatments

• Hemodialysis: For salicylate, methanol, ethylene glycol
• Hemoperfusion: For some drug removals
• Continuous renal replacement: Kidney support and drug removal
• Plasmapheresis: Rarely indicated

Monitoring During Treatment

• Vital signs: Continuous cardiac and respiratory monitoring
• Drug levels: Serial monitoring to track elimination
• Organ function: Liver enzymes, kidney function, coagulation
• Neurological status: Frequent mental status assessments
• Fluid balance: Intake and output monitoring
• Response to antidotes: Effectiveness of specific treatments

Disposition and Follow-up

• ICU admission: Severe poisoning, organ dysfunction
• Medical ward: Moderate poisoning, stable patients
• Observation: Mild poisoning, awaiting drug levels
• Psychiatric evaluation: Intentional overdoses
• Outpatient follow-up: Liver function monitoring
• Social services: Child protection, elder abuse concerns

Prevention

Preventing analgesic poisoning requires a multi-faceted approach involving patient education, safe medication practices, healthcare provider awareness, and public health measures. Prevention is far more effective than treatment after poisoning occurs.

Patient Education

Safe Medication Use

• Read labels carefully: Check active ingredients and dosing instructions
• Avoid combination products: Don't take multiple medications with same ingredients
• Maximum daily doses: Never exceed recommended amounts
• Timing between doses: Wait appropriate intervals between doses
• Duration limits: Don't use OTC analgesics longer than recommended

Recognition of Risk

• Understand that OTC doesn't mean risk-free
• Know personal risk factors (liver disease, kidney disease)
• Recognize drug interaction risks
• Understand alcohol interaction dangers
• Learn early warning signs of toxicity

Safe Storage Practices

• Secure storage: Locked cabinets, especially with children or at-risk individuals
• Original containers: Keep medications in original labeled bottles
• Proper disposal: Safe disposal of unused medications
• Inventory management: Regular medication reviews and cleanouts
• Separate storage: Keep different medications clearly separated

Healthcare Provider Responsibilities

Prescribing Practices

• Appropriate dosing: Prescribe lowest effective doses
• Duration limits: Limit prescription quantities
• Patient assessment: Evaluate risk factors before prescribing
• Drug interactions: Check for potential interactions
• Monitoring plans: Establish follow-up for high-risk patients

Patient Counseling

• Explain proper use and risks
• Discuss signs of toxicity
• Review all current medications
• Assess understanding and compliance
• Provide written instructions

Special Population Prevention

Pediatric Prevention

• Child-resistant packaging: Use appropriate closures
• Safe storage: Up and away from children
• Proper dosing: Use weight-based calculations
• Age-appropriate formulations: Avoid adult medications
• Caregiver education: Teach proper administration

Elderly Prevention

• Medication management systems: Pill organizers, reminders
• Regular medication reviews: Assess ongoing need
• Caregiver involvement: Family or professional support
• Simplified regimens: Reduce complexity when possible
• Vision considerations: Large print labels

Mental Health Prevention

• Risk assessment: Screen for suicidal ideation
• Mental health treatment: Address underlying conditions
• Crisis intervention: Available support systems
• Medication monitoring: Limit access during high-risk periods
• Family involvement: Support network engagement

Public Health Measures

Regulatory Approaches

• Package size limits: Reduce quantity available
• Labeling requirements: Clear warnings and instructions
• Prescription monitoring: Track opioid prescribing
• Age restrictions: Limit access for certain age groups

Community Programs

• Medication take-back programs
• Public education campaigns
• Suicide prevention initiatives
• Healthcare provider training
• Emergency response preparedness

Technology Solutions

• Electronic health records: Drug interaction checking
• Smartphone apps: Medication tracking and reminders
• Smart packaging: Sensors and alerts
• Poison control access: Easy contact information
• Online resources: Reliable medication information

High-Risk Situation Prevention

• Post-surgical periods: Clear opioid instructions
• Chronic pain management: Multi-modal approaches
• Substance abuse treatment: Address underlying addiction
• Crisis periods: Increased monitoring during stress
• Medication transitions: Careful management during changes

When to Seek Emergency Care

Analgesic poisoning can be life-threatening and requires immediate medical attention. Recognizing the signs early and taking prompt action can save lives and prevent permanent organ damage.

Call 911 Immediately If You Experience:

• Difficulty breathing: Slow, shallow, or absent breathing
• Loss of consciousness: Unresponsive or difficult to wake
• Seizures: Convulsions or repetitive muscle contractions
• Severe allergic reactions: Widespread rash, swelling, difficulty swallowing
• Signs of liver failure: Yellow skin/eyes, severe abdominal pain
• Cardiovascular collapse: Very low blood pressure, weak pulse
• Altered mental status: Severe confusion, hallucinations

Contact Poison Control Immediately:

Call 1-800-222-1222 (US) for immediate guidance

• Any suspected overdose, even if feeling well
• Accidental ingestion by children
• Uncertainty about medication safety
• Questions about potential interactions
• Guidance on seeking further medical care

Seek Immediate Medical Attention For:

Opioid-Related Symptoms

• Slow or absent breathing (less than 12 breaths per minute)
• Blue lips, fingernails, or skin
• Pinpoint pupils
• Extreme drowsiness or inability to wake
• Weak pulse or low blood pressure
• Cold, clammy skin

Acetaminophen-Related Symptoms

• Persistent nausea and vomiting after large dose
• Right upper abdominal pain
• Loss of appetite persisting more than 24 hours
• Any yellowing of skin or eyes
• Dark urine or light-colored stools
• Unusual bleeding or bruising

NSAID-Related Symptoms

• Severe stomach pain or burning
• Vomiting blood or coffee-ground material
• Black, tarry stools
• Significantly decreased urination
• Severe swelling of face, hands, or feet
• Severe headache or ringing in ears

Time-Sensitive Situations

• Recent overdose: Within 4 hours for acetaminophen (treatment most effective)
• Large quantities: Any ingestion exceeding maximum daily dose
• Intentional overdose: Always requires emergency evaluation
• Child ingestion: Any amount in young children
• High-risk patients: Those with liver/kidney disease

What NOT to Do

• Don't induce vomiting: May cause additional harm
• Don't give activated charcoal at home: Risk of aspiration
• Don't wait for symptoms: Some effects are delayed
• Don't give milk or food: Won't neutralize the poison
• Don't assume feeling well means safety: Toxicity can be delayed

Information to Provide to Healthcare Providers

• Medication details: Name, strength, quantity taken
• Timing: When the medication was taken
• Current symptoms: What the person is experiencing
• Medical history: Liver disease, kidney disease, allergies
• Other medications: All current medications
• Weight: Patient's approximate weight
• Intent: Accidental vs. intentional

Emergency Preparation

Keep Readily Available

• Poison Control number programmed in phone
• List of all medications and doses
• Medical history information
• Emergency contact information
• Transportation plan to hospital

For Opioid Users

• Keep naloxone (Narcan) available
• Train family members on naloxone use
• Know signs of opioid overdose
• Have emergency action plan

Special Situations

If Someone is Unconscious

1. Call 911 immediately
2. Check for breathing and pulse
3. Position on side to prevent choking
4. If trained, administer naloxone for suspected opioid overdose
5. Stay with person until help arrives

For Pregnant Women

• Any suspected overdose requires immediate evaluation
• Consider effects on both mother and fetus
• Inform healthcare providers about pregnancy
• May require specialized treatment approaches

Related Conditions

Analgesic poisoning is associated with various medical conditions and can lead to multiple complications affecting different organ systems. Understanding these relationships is important for comprehensive care.

Underlying Conditions

• Chronic pain disorders - Often lead to analgesic overuse
• Depression - Risk factor for intentional overdose
• Substance use disorders - Increases poisoning risk
• Chronic liver disease - Increases acetaminophen toxicity risk
• Chronic kidney disease - Increases NSAID toxicity

Complications and Sequelae

• Hepatic encephalopathy - Brain dysfunction from liver failure
• Coagulopathy - Bleeding disorders from liver damage
• Pulmonary edema - Fluid in lungs from heart failure
• Metabolic acidosis - Acid-base imbalance
• Shock - Cardiovascular collapse

Co-occurring Poisonings

• Alcohol poisoning - Often combined with analgesics
• Benzodiazepine overdose - Dangerous with opioids
• Antidepressant overdose - Common in poly-drug ingestions
• Carbon monoxide poisoning - Similar altered mental status

Long-term Consequences

• Chronic liver disease or cirrhosis
• Chronic kidney disease requiring dialysis
• Medication overuse headaches
• Physical dependence and addiction
• Cognitive impairment from hypoxic brain injury
• Post-traumatic stress disorder

Mental Health Conditions

• Suicidal ideation - Often underlying intentional overdoses
• Anxiety disorders - May lead to medication misuse
• Bipolar disorder - Increased overdose risk during episodes
• Personality disorders - Higher risk behaviors

Differential Diagnoses

• Other drug overdoses (tricyclic antidepressants, anticonvulsants)
• Acute hepatitis from other causes
• Sepsis or septic shock
• Diabetic ketoacidosis
• Stroke or intracranial hemorrhage
• Psychiatric emergencies

Prevention-Related Conditions

• Medication errors - System failures leading to overdose
• Low health literacy - Poor understanding of medication risks
• Polypharmacy - Multiple medications increasing interaction risk
• Cognitive impairment - Difficulty managing medications safely

Frequently Asked Questions

References

1. Yoon E, et al. Acetaminophen-Induced Hepatotoxicity: a Comprehensive Update. J Clin Transl Hepatol. 2016;4(2):131-42.
2. Chiew AL, et al. Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand. Med J Aust. 2020;212(4):175-183.
3. Temple AR, et al. Acute and chronic effects of aspirin toxicity and their treatment. Arch Intern Med. 1981;141(3):364-9.
4. Boyer EW, et al. Management of opioid analgesic overdose. N Engl J Med. 2012;367(2):146-55.
5. Heard KJ. Acetylcysteine for acetaminophen poisoning. N Engl J Med. 2008;359(3):285-92.
6. American Association of Poison Control Centers. Annual Report 2022. Clinical Toxicology. 2023.