Management of Heroin Overdose
The management of heroin overdose requires immediate administration of naloxone along with ventilatory support, followed by a period of observation to monitor for resedation due to the shorter half-life of naloxone compared to opioids. 1
Initial Assessment and Management
Immediate Actions
- Assess for opioid toxidrome: CNS depression, respiratory depression, and miotic (pinpoint) pupils 1
- Ensure airway patency and provide assisted ventilation with bag-mask device 1, 2
- Administer naloxone while continuing ventilatory support 1
- Activate emergency response system without delay 2
Naloxone Administration
- Initial dose: Start with low dose (0.04-0.4 mg IV/IO/IM) to avoid precipitating withdrawal in opioid-dependent individuals 1, 2
- Route options:
- IV/IO: Preferred for rapid response in severe overdose
- IM: Effective alternative when IV access is difficult
- Intranasal: 2-4 mg when parenteral administration not immediately available 2
- Dose titration: If inadequate response after 2-3 minutes, escalate dosing up to 2 mg 1
- Higher doses: May be required for overdoses involving atypical opioids (e.g., propoxyphene) or massive overdose 1, 3
Post-Naloxone Management
Monitoring
- Observation period: All patients should be observed in a healthcare setting until risk of recurrent toxicity is low 1
- Duration of monitoring:
- Monitor for:
- Respiratory status (rate, depth, oxygen saturation)
- Level of consciousness
- Vital signs 2
Management of Resedation
- Repeat dosing: If respiratory depression recurs, administer repeated small doses of naloxone 1
- Naloxone infusion: Consider for persistent or recurrent respiratory depression, particularly with long-acting opioids 1
- Calculate infusion rate based on effective bolus dose (typically 2/3 of the effective dose per hour) 3
Complications and Special Considerations
Potential Complications
- Acute withdrawal syndrome: Can occur in opioid-dependent individuals, presenting with agitation, hypertension, tachycardia, vomiting 1, 2
- Minimize by using appropriate initial low dosing (0.04 mg) with careful titration 3
- Pulmonary complications: Monitor for non-cardiogenic pulmonary edema, aspiration pneumonia 4, 5
- Co-ingestions: Assess for concurrent use of other substances (particularly alcohol, benzodiazepines) which increase mortality risk 4
Hospital Admission Criteria
- Multiple naloxone doses required
- Persistent altered mental status
- Complications (pulmonary edema, aspiration pneumonia)
- Suspected long-acting opioid overdose
- Approximately 3-7% of treated patients require hospital admission 4
Prevention Strategies
- Education: Train potential witnesses of overdose in recognition and response 1, 6
- Naloxone distribution: Consider prescribing take-home naloxone for high-risk individuals 6
- Referral: Connect patients to addiction treatment services after acute management 5
Pitfalls to Avoid
- Delaying ventilatory support while waiting for naloxone to take effect 1, 2
- Administering excessive naloxone doses initially, which can precipitate severe withdrawal 3
- Premature discharge before adequate observation period, risking resedation after naloxone wears off 1
- Focusing solely on opioid reversal without addressing potential co-ingestions or complications 4