What is the management of opioid (op) poisoning?

Management of Opioid Poisoning

The management of opioid poisoning requires immediate airway support, administration of naloxone, and continued monitoring, with rescue breathing or bag-mask ventilation maintained until spontaneous breathing returns. 1

Initial Assessment and Management

• For patients in respiratory arrest, rescue breathing or bag-mask ventilation should be maintained until spontaneous breathing returns, and standard BLS/ALS measures should continue if spontaneous breathing does not occur 1
• For patients suspected to be in cardiac arrest, standard resuscitative measures should take priority over naloxone administration, with focus on high-quality CPR 1
• Emergency response systems should be activated immediately without delay while awaiting the patient's response to naloxone 1
• For patients with suspected opioid overdose who have a definite pulse but no normal breathing or only gasping (respiratory arrest), naloxone should be administered in addition to standard BLS/ALS care 1

Naloxone Administration

• Naloxone, a μ-opioid receptor antagonist, can restore spontaneous respirations and protective airway reflexes in patients with opioid overdose 1
• Potential adverse effects of naloxone include precipitating opioid withdrawal; sudden-onset pulmonary edema can occur but responds to positive pressure ventilation 1
• In addition to naloxone, other resuscitative measures such as maintenance of a free airway, artificial ventilation, cardiac massage, and vasopressor agents should be available and employed when necessary 2

Post-Naloxone Management

• After return of spontaneous breathing, patients should be observed in a healthcare setting until the risk of recurrent opioid toxicity is low and vital signs have normalized 1
• If recurrent opioid toxicity develops, repeated small doses or an infusion of naloxone can be beneficial 1
• The duration of action of naloxone may be shorter than the respiratory depressive effect of the opioid, particularly with long-acting formulations, requiring repeat doses or a naloxone infusion 1
• Observation periods should be tailored to the type of opioid involved - shorter periods may be adequate for fentanyl, morphine, or heroin overdose, while longer periods are needed for long-acting or sustained-release opioids 1

Special Considerations

• Non-response to naloxone may indicate polysubstance overdose involving non-opioid substances, such as benzodiazepines or xylazine 3
• Xylazine, an α-2 agonist veterinary sedative increasingly found in the opioid supply, is not reversed by naloxone 3
• Large doses of naloxone are required to antagonize buprenorphine due to its long duration of action and slow dissociation from the opioid receptor 2

Community and Lay Responder Training

• It is reasonable for lay rescuers to receive training in responding to opioid overdose, including provision of naloxone 1
• Educating patients with opioid use disorder and their close contacts improves risk awareness, overdose recognition, willingness to administer naloxone, and attitudes toward calling emergency services 1
• Training that includes skills practice (naloxone administration) leads to improved clinical performance compared to interventions without skills practice 1

Common Pitfalls to Avoid

• Delaying activation of emergency response systems while awaiting response to naloxone 1
• Focusing solely on naloxone administration rather than providing adequate ventilation support 1, 3
• Failing to consider co-ingestions that may require specific management approaches 3
• Administering excessive naloxone doses in an attempt to achieve full consciousness rather than adequate ventilation 3
• Discharging patients too early after naloxone administration, especially with long-acting opioid ingestions 1