What is the treatment for suspected opioid poisoning?

Treatment for Suspected Opioid Poisoning

The treatment for suspected opioid poisoning requires immediate administration of naloxone while ensuring adequate ventilation and airway support, as naloxone is an adjunct to respiratory support, not a replacement. 1

Initial Assessment and Management

• Recognize opioid toxidrome: CNS depression, respiratory depression, and miotic (pinpoint) pupils 1
• Ensure airway patency: Position patient appropriately and clear airway
• Provide respiratory support: Assisted ventilation with bag-mask device before or concurrent with naloxone administration 1, 2, 3, 4
• Activate emergency response system immediately without delay 1
• Maintain cardiovascular support: Cardiac massage and vasopressor agents if needed 2, 3, 4

Naloxone Administration

Dosing Strategy

• Initial dose: 0.04-0.4 mg IV/IM for opioid-dependent patients (to avoid severe withdrawal) 1
• Titration: Up to 2 mg as needed if inadequate response 1
• Repeat doses: Every 2-3 minutes if inadequate response 1
• Higher doses: May be required for atypical opioids or massive overdose 1

Route of Administration

1. IV/IO route: Preferred for rapid response 1
2. IM route: Alternative when IV access unavailable 1
3. Intranasal route: Higher-concentration intranasal naloxone (2 mg/mL) has similar efficacy to IM naloxone 5

Post-Naloxone Monitoring

• Observation period: At least 4-6 hours after last naloxone dose 1
• Extended monitoring: 12-24 hours for long-acting opioid overdose (e.g., methadone) 1
• Monitor for resedation: Naloxone's duration of action (45-70 minutes) may be shorter than the opioid effect 1
• Vital signs monitoring: Level of consciousness, respiratory status, blood glucose levels 1
• Watch for complications: Withdrawal syndrome, pulmonary edema, aspiration pneumonia 1, 2, 3, 4

Potential Complications and Management

• Acute withdrawal syndrome: Can include hypertension, tachycardia, vomiting, agitation 1
• Cardiovascular complications: Hypotension, hypertension, ventricular tachycardia, fibrillation 2, 3, 4
• Pulmonary edema: Monitor closely, especially in patients with pre-existing cardiac disease 2, 3, 4
• Co-ingestions: May require additional management strategies 1

Special Considerations

• Buprenorphine overdose: Requires larger doses of naloxone due to slow dissociation from opioid receptors 2, 3, 4
• Concurrent opioid and insulin overdose: Administer naloxone first, then glucose 1
• Severe cases: Transfer to intensive care unit; consider toxicology or anesthesiology consultation 1
• QRS prolongation >100 ms: Consider sodium bicarbonate 1-2 mEq/kg IV bolus 1

Common Pitfalls to Avoid

• Delaying ventilatory support while waiting for naloxone to take effect 1
• Premature discharge before adequate observation period (risk of resedation) 1
• Excessive naloxone doses in opioid-dependent patients (precipitates severe withdrawal) 1, 2, 3, 4
• Delaying CPR while searching for or administering naloxone in cardiac arrest patients 1
• Failing to recognize that naloxone's duration of action is shorter than many opioids 1

Prevention and Follow-up

• Take-home naloxone: Consider prescribing for high-risk individuals 1, 6
• Connect to treatment: Link patients to addiction treatment services after acute management 1
• Education: Train potential witnesses in overdose recognition and response 1, 6