What is the treatment for opioid (op) poisoning?

Treatment for Opioid Poisoning

Immediate administration of naloxone (0.04-0.4 mg IV/IM initial dose, titrating up to 2 mg as needed) along with supportive respiratory measures is the cornerstone of managing opioid poisoning. 1

Initial Management

Airway and Breathing Support

• Ensure airway patency and provide rescue breathing or bag-mask ventilation for respiratory arrest 2, 1
• For patients in respiratory arrest, maintain rescue breathing or bag-mask ventilation until spontaneous breathing returns 2
• Standard BLS, ALS, and/or pediatric ALS measures should continue if spontaneous breathing does not occur 2

Naloxone Administration

• Routes of administration: IV/IO (preferred), IM, or intranasal 1
• Initial dosing:
  • Start with 0.04-0.4 mg IV/IM in opioid-dependent patients to avoid precipitating severe withdrawal 1
  • Titrate up to 2 mg as needed 1
  • Higher-concentration intranasal naloxone (2 mg/mL) has similar efficacy to intramuscular naloxone 3

Cardiac Arrest Considerations

• For patients in cardiac arrest, focus on high-quality CPR (compressions plus ventilation) as the priority 2
• Naloxone can be administered along with standard care if it does not delay components of high-quality CPR 2

Monitoring and Continued Care

Post-Naloxone Observation

• Continue observation in a healthcare setting until risk of recurrent toxicity is low and vital signs have normalized 1
• Monitor for at least 4-6 hours after the last naloxone dose 1
• Be aware that naloxone's duration of action (45-70 minutes) may be shorter than the respiratory depressive effect of many opioids 1

Extended Care Requirements

• Extended observation (12-24 hours) is required for long-acting opioid overdose 1
• If respiratory depression recurs, administer repeated small doses of naloxone or start naloxone infusion 1
• Monitor vital signs, level of consciousness, and respiratory status to detect potential complications 1

Important Considerations

Potential Complications

• Naloxone may precipitate acute withdrawal syndrome in opioid-dependent patients (signs include hypertension, tachycardia, piloerection, vomiting, agitation, and drug cravings) 1
• Watch for pulmonary complications including non-cardiogenic pulmonary edema and aspiration pneumonia 1
• Abrupt reversal of opioid depression may result in nausea, vomiting, sweating, tremulousness, tachycardia, increased blood pressure, seizures, ventricular arrhythmias, pulmonary edema, and cardiac arrest 4

Additional Interventions

• Consider toxicology screening and monitor blood glucose levels frequently, especially with concurrent insulin overdose 1
• For QRS prolongation >100 ms, administer sodium bicarbonate (1-2 mEq/kg IV bolus, followed by infusion to maintain arterial pH 7.45-7.55) 1

Post-Overdose Care

Referral and Follow-up

• Refer patients who respond to naloxone to advanced healthcare services due to risk of recurrent respiratory depression 1
• Connect patients to addiction treatment services after acute management 1
• Consider prescribing take-home naloxone for high-risk individuals 1, 5

Treatment Options

• For long-term management of opioid use disorder, consider medication-assisted treatment with methadone, buprenorphine, or naltrexone 6, 7
• Methadone and buprenorphine act by suppressing withdrawal symptoms and attenuating effects of other opioids 6
• Naltrexone blocks the effects of opioid agonists 6

Pitfalls to Avoid

• Do not delay activating emergency response systems while awaiting patient's response to naloxone 2
• Do not use ipecac syrup under any circumstances for opioid poisoning 8
• Avoid excessive doses of naloxone in postoperative patients as it may cause significant reversal of analgesia and agitation 4
• Do not discharge patients prematurely after naloxone administration, as the duration of action of many opioids exceeds that of naloxone 1