Intranasal Naloxone (Narcan) Administration for Suspected Opioid Overdose
For suspected opioid overdose, administer intranasal naloxone at a fixed dose of 2 mg (one spray in one nostril), and repeat in 3-5 minutes if there is inadequate response. 1, 2
Assessment and Initial Management
When approaching a patient with suspected opioid overdose:
- Assess responsiveness and breathing pattern
- Look for clinical signs of opioid toxicity:
- Respiratory depression
- CNS depression
- Miosis (pinpoint pupils)
- Hypotension
- Decreased gastrointestinal motility
Administration Technique for Intranasal Naloxone
- Position the patient on their back
- Use a nasal mucosal atomizer device (MAD) or FDA-approved intranasal device
- Administer 2 mg (typically one spray) into one nostril
- If no response within 3-5 minutes, administer a second dose
- Continue respiratory support throughout
Advantages of Intranasal Administration
- Eliminates risk of needlestick injuries to healthcare providers 3, 4
- Easy to administer by both healthcare providers and laypersons 5
- Similar effectiveness to intramuscular/intravenous routes 4, 6
- Average response time of approximately 3-4 minutes 3
Important Considerations
- Always ensure airway patency and provide assisted ventilation while waiting for naloxone to take effect 2
- For patients in cardiac arrest, initiate CPR first before administering naloxone 1
- Be aware that the onset of action for intranasal naloxone may be slightly longer than injectable routes 6
- The need for a rescue dose is approximately 2 times higher with intranasal compared to IM/IV administration 6
- Monitor for at least 4-6 hours after the last naloxone dose, with extended observation (12-24 hours) required for long-acting opioid overdose 2
Potential Adverse Effects
- Naloxone may precipitate acute withdrawal syndrome in opioid-dependent patients
- Signs of withdrawal include hypertension, tachycardia, piloerection, vomiting, agitation, and drug cravings
- These symptoms are rarely life-threatening and can be minimized by using appropriate dosing 1
Special Situations
- For patients with known opioid dependence, consider starting with lower doses (though this is less practical with fixed-dose intranasal devices)
- Be prepared for polysubstance overdose and be ready to treat multiple toxidromes 2
- Remember that naloxone will not reverse effects of non-opioid substances, including xylazine (often found in adulterated opioids) 2
Intranasal naloxone has been shown to be safe and effective in reversing opioid overdose, with success rates comparable to injectable routes (82.5% vs 80.4%) 6, making it an excellent first-line intervention in both healthcare and community settings.