Oxycodone overdose causes naloxone responsive coma and QT prolongation

Background: Although there are limited data on oxycodone overdose, it has been suggested that, in addition to central nervous system (CNS) depression, oxycodone may cause QT prolongation. Given the high prescription rate and increasing use of oxycodone, an understanding of its effects and treatment in overdose is necessary. Aim: To investigate the clinical features, electrocardiogram (ECG) parameters and treatment of oxycodone overdose. Design: Retrospective review of a clinical database. Methods: One hundred and thirty-seven oxycodone overdoses were identified from admissions to a toxicology unit between January 2001 and May 2011. Demographic information, details of ingestion, clinical effects, ECG parameters [heart rate (HR), QT and QRS], naloxone use and length of stay (LOS) were extracted from a clinical database. QT was measured manually and plotted on a QT nomogram. LOS was extracted for all overdoses over the same period. Results: From 137 oxycodone overdoses, 79 (58%) ingested immediate release (IR) and 58 (42%) ingested sustained release (SR) or a combination of IR and SR. The median age was 40 years [interquartile range (IQR): 33–49 years], and 87 were female (64%). The median ingested dose of IR oxycodone was 70 mg (IQR: 40–100, range: 5–200), compared to 240 mg (IQR: 80–530, range: 30–1600) for SR oxycodone. Benzodiazepines were the most frequent co-ingested drug in 52 (38%) cases. No arrhythmias were recorded. Twenty-four patients (18%) had bradycardia of which five had a HR < 50 beats/min. From 116 available ECGs, the median QRS was 95 ms (IQR: 90–102 ms), and there were 20 (17%) abnormal QT–HR pairs. Naloxone boluses were required in 65 admissions (47%), and 34 (25%) required a naloxone infusion. There was higher overall naloxone use with SR and IR + SR (32/58, 55%) compared to IR oxycodone (33/79, 42%). The median LOS was 18 h (IQR: 12–35), which was greater than the median LOS for all toxicology admissions at 15 h (IQR: 8–24) over the same period. Patients requiring a naloxone infusion had an even greater LOS of 36 h (IQR: 20–62 h). Conclusion: In addition to the expected CNS depression, the opioid oxycodone can cause bradycardia and QT prolongation in overdose. The SR formulation is associated with the use of naloxone infusions and a longer LOS.