What are the adverse reactions to Naloxone (Narcan) infusion?

From the Guidelines

Adverse reactions to a Narcan (naloxone) drip can be minimized by carefully titrating the dose, typically starting with 0.04-0.4 mg/hour, and monitoring vital signs and withdrawal symptoms 1. The most common adverse reactions to a Narcan drip include precipitation of opioid withdrawal symptoms, such as agitation, anxiety, body aches, sweating, runny nose, yawning, nausea, vomiting, diarrhea, increased heart rate, and elevated blood pressure. These symptoms occur because naloxone rapidly displaces opioids from their receptors. In rare cases, more severe reactions can include pulmonary edema, cardiac arrhythmias, and seizures. Patients with cardiovascular disease may experience hypertension, hypotension, ventricular tachycardia, or fibrillation.

Key Considerations

• The severity of withdrawal depends on the patient's level of opioid dependence and the dose of naloxone administered 1.
• Healthcare providers should monitor vital signs and withdrawal symptoms closely during administration.
• To minimize adverse reactions, the goal should be to improve respiratory status without precipitating severe withdrawal.
• Once stabilized, the drip can be gradually tapered rather than abruptly discontinued to prevent rebound opioid toxicity.

Administration Guidelines

• The ideal dose of naloxone is not known, but a starting dose of 0.04 to 0.4 mg IV or intramuscular (IM) is recommended to avoid provoking severe opioid withdrawal in patients with opioid dependency 1.
• Repeat doses or dose escalation to 2 mg IV or IM may be necessary if the initial response is inadequate.
• The duration of action of naloxone is approximately 45 to 70 minutes, but respiratory depression caused by ingestion of a long-acting opioid may last longer, requiring repeat doses of naloxone 1.

From the FDA Drug Label

ADVERSE REACTIONS Postoperative The following adverse events have been associated with the use of naloxone hydrochloride injection in postoperative patients: hypotension, hypertension, ventricular tachycardia and fibrillation, dyspnea, pulmonary edema, and cardiac arrest. Adverse events associated with the postoperative use of naloxone hydrochloride injection are listed by organ system and in decreasing order of frequency as follows: Cardiac Disorders: pulmonary edema, cardiac arrest or failure, tachycardia, ventricular fibrillation, and ventricular tachycardia. Gastrointestinal Disorders: vomiting, nausea Nervous System Disorders: convulsions, paraesthesia, grand mal convulsion Psychiatric Disorders: agitation, hallucination, tremulousness Respiratory, Thoracic, and Mediastinal Disorders: dyspnea, respiratory depression, hypoxia Skin and Subcutaneous Tissue Disorders: nonspecific injection site reactions, sweating Vascular Disorders: hypertension, hypotension, hot flushes, or flushing.

The adverse reactions to a Narcan drip (naloxone hydrochloride injection) may include:

• Cardiac disorders: pulmonary edema, cardiac arrest or failure, tachycardia, ventricular fibrillation, and ventricular tachycardia
• Gastrointestinal disorders: vomiting, nausea
• Nervous system disorders: convulsions, paraesthesia, grand mal convulsion
• Psychiatric disorders: agitation, hallucination, tremulousness
• Respiratory disorders: dyspnea, respiratory depression, hypoxia
• Skin and subcutaneous tissue disorders: nonspecific injection site reactions, sweating
• Vascular disorders: hypertension, hypotension, hot flushes, or flushing 2

From the Research

Adverse Reactions to Narcan Drip

• Adverse reactions to Narcan (naloxone) drip can include precipitation of opioid withdrawal syndrome, as seen in a case report where a patient experienced naloxone-precipitated opioid withdrawal after receiving naloxone for opioid toxicity 3.
• The use of naloxone can also lead to inadequate response or re-narcotization after administration, particularly in patients who have taken large doses or long-acting opioid formulations 4.
• There is limited information available on the specific adverse reactions to Narcan drip, but it is known that naloxone can cause opioid withdrawal symptoms, including abdominal cramping, diarrhea, and vomiting 3.
• The management of opioid withdrawal syndrome, including that precipitated by naloxone, can involve the use of medications such as buprenorphine, which has been shown to be effective in reducing withdrawal symptoms 3, 5.
• Other medications, such as clonidine, may also be used to manage opioid withdrawal symptoms, although their use can be controversial and requires careful consideration 6, 5.

Management of Adverse Reactions

• The management of adverse reactions to Narcan drip should involve careful monitoring of the patient's symptoms and vital signs, as well as the use of medications to manage opioid withdrawal symptoms as needed.
• Buprenorphine has been shown to be effective in reducing opioid withdrawal symptoms and may be considered as a treatment option for patients experiencing adverse reactions to Narcan drip 3.
• Clonidine may also be used to manage opioid withdrawal symptoms, although its use requires careful consideration and monitoring due to the potential for abuse and adverse effects 6, 5.
• The use of oxycodone/naloxone combinations has been shown to be effective in managing pain and opioid-induced bowel dysfunction, and may be considered as a treatment option for patients experiencing adverse reactions to Narcan drip 7.