What is the recommended dose of naloxone (opioid antagonist) for suspected opioid overdose?

Recommended Naloxone Dosing for Suspected Opioid Overdose

For suspected opioid overdose, the recommended initial dose of naloxone is 0.04-0.4 mg IV/IM, titrating up to 2 mg as needed if there is inadequate response, with higher doses potentially required for atypical opioids or massive overdose. 1

Adult Dosing

Initial Dosing

• IV/IO route (preferred): 0.04-0.4 mg initially 2, 1
• IM route: 0.4 mg initially (if IV access unavailable) 3
• Intranasal route: 2-4 mg (comparable efficacy to IM route) 1, 4

Titration and Repeat Dosing

• Repeat doses every 2-3 minutes if inadequate response 2, 3
• Escalate dosing up to 2 mg if initial dose ineffective 2
• Consider higher doses for atypical opioids (e.g., propoxyphene) or massive overdose 2
• If no response after 10 mg total, question opioid-induced toxicity 3

Pediatric Dosing

• Initial dose: 0.01 mg/kg IV/IM/SC 3
• If inadequate response: May administer subsequent dose of 0.1 mg/kg 3
• Neonates: 0.01 mg/kg IV/IM/SC 3

Route Selection Considerations

• IV route advantages: Allows for titration, faster onset of action 4
• Intranasal advantages: Needle-free administration, comparable efficacy to IM 1, 4
• IM route disadvantages: Difficult to titrate, slower onset, needle exposure risk 4

Important Clinical Considerations

Balancing Reversal vs. Withdrawal

• Start with lower doses (0.04-0.4 mg) in opioid-dependent patients to avoid precipitating severe withdrawal 2, 1, 5
• Higher initial doses may be appropriate in non-opioid-dependent patients with life-threatening overdose 3

Duration of Action

• Naloxone's duration of action is approximately 45-70 minutes 2
• Long-acting opioids (e.g., methadone) may cause respiratory depression outlasting naloxone's effects 2, 1
• Continuous observation for at least 4-6 hours after the last naloxone dose is recommended 1

Potential Complications

• Acute withdrawal syndrome: May include agitation, hypertension, tachycardia, vomiting 2, 6
• Resedation: Can occur as naloxone wears off, especially with long-acting opioids 2, 1
• Pulmonary complications: Including non-cardiogenic pulmonary edema 1, 6

Monitoring After Administration

• Continue respiratory support even after naloxone administration 1
• Monitor vital signs, level of consciousness, and respiratory status 1
• Be prepared to administer repeated doses if respiratory depression recurs 2, 1
• Consider extended observation (12-24 hours) for long-acting opioid overdose 1

Pitfalls to Avoid

• Delaying ventilatory support while waiting for naloxone to take effect 1
• Administering excessive initial doses to opioid-dependent patients 1, 5
• Premature discharge before adequate observation period 1
• Focusing solely on opioid reversal without addressing potential co-ingestions 1

Remember that naloxone is an adjunct to respiratory support, not a replacement. Always ensure adequate ventilation while administering naloxone for suspected opioid overdose.