What is the treatment for opioid (op) poisoning?

Treatment of Opioid Poisoning

For opioid poisoning, prioritize airway management and respiratory support first, then administer naloxone titrated to restore adequate ventilation—not full consciousness—while preparing for potential recurrent respiratory depression. 1, 2

Immediate Life Support Measures

Respiratory Management

• Provide rescue breathing or bag-mask ventilation immediately for patients in respiratory arrest, maintaining support until spontaneous breathing returns 1, 2
• Secure airway and establish adequate ventilation before focusing on antidote administration 2
• If cardiac arrest is suspected, high-quality CPR takes absolute priority over naloxone administration 1, 2
• Consider endotracheal intubation for definitive airway management if respiratory status deteriorates despite naloxone and supportive measures 3

Emergency Activation

• Activate emergency response systems immediately without delay, even while awaiting the patient's response to naloxone 1, 2
• Do not wait to see if naloxone works before calling for help—naloxone is ineffective in non-opioid overdoses and cardiac arrest from any cause 1

Naloxone Administration

Indications and Dosing

• For patients with definite pulse but no normal breathing or only gasping, administer naloxone in addition to standard BLS/ALS care 1, 2
• Adult dosing: 0.2–2 mg IV/IO/IM, titrated to reversal of respiratory depression and restoration of protective airway reflexes 1
• Pediatric dosing: 0.1 mg/kg 1
• Intranasal route: 2–4 mg, repeated every 2–3 minutes as needed 1

Route Selection

• Intravenous route is preferred to facilitate dose titration 4
• Intranasal and intravenous routes are equally recommended, with route selection based on clinical circumstances 4
• Intramuscular route is disfavored due to difficulty with titration, slower time to clinical effect, and needle exposure risk 4
• Intranasal naloxone provides rapid response (average 3.4 minutes) and may eliminate need for IV access in 64% of cases 5

Titration Strategy

• Use the lowest effective dose to minimize withdrawal symptoms and complications 2
• Titrate to adequate ventilation and protective airway reflexes, not to full consciousness 1, 2
• Excessive doses may cause significant reversal of analgesia and agitation in postoperative patients 6

Post-Naloxone Management

Monitoring Requirements

• Observe patients in a healthcare setting until risk of recurrent opioid toxicity is low and vital signs have normalized 1, 2
• The duration of naloxone action (30-90 minutes) is often shorter than the respiratory depressive effect of opioids, particularly long-acting formulations 1, 2
• Abbreviated observation periods (2 hours) may be adequate for fentanyl, morphine, or heroin overdose 2
• Longer observation periods are required for long-acting or sustained-release opioid overdoses 1, 2

Recurrent Toxicity

• If recurrent opioid toxicity develops, administer repeated small doses or initiate a naloxone infusion 1, 2
• Maintenance infusion: two-thirds of the waking dose per hour 1
• Prepare for potential deterioration even when initial vital signs appear stable 3

Special Considerations

Non-Response to Naloxone

• Non-response may indicate polysubstance overdose involving non-opioid substances such as benzodiazepines or xylazine 2, 3
• Consider metabolic insults (hypoxia, hypercarbia) or presence of synthetic opioids requiring higher or repeated doses 3
• Xylazine, an α-2 agonist veterinary sedative increasingly found in opioid supply, is not reversed by naloxone 3
• Continue airway and breathing support as primary intervention even if naloxone is ineffective 3

Combined Opioid-Benzodiazepine Poisoning

• If combined opioid and benzodiazepine poisoning is suspected, administer naloxone first (before other antidotes) for respiratory depression 1
• Benzodiazepine overdose alone should not preclude timely naloxone administration when opioid overdose is suspected 1

Adverse Effects

• Potential adverse effects include precipitating opioid withdrawal syndrome 2
• Sudden-onset pulmonary edema can occur but responds to positive pressure ventilation 2
• Abrupt reversal may cause nausea, vomiting, tachycardia, hypertension, seizures, ventricular arrhythmias, and rarely cardiac arrest 6
• Use with caution in patients with pre-existing cardiovascular disease 6

Critical Pitfalls to Avoid

• Do not delay emergency activation while awaiting response to naloxone 2, 3
• Do not focus solely on opioid reversal when polysubstance overdose may be present 3
• Do not administer excessive naloxone doses attempting to achieve full consciousness rather than adequate ventilation 3
• Do not discharge patients too early after naloxone administration, especially with long-acting opioid ingestions 2, 3
• Do not delay definitive airway management when naloxone is ineffective 3
• Do not assume stable vital signs and good oxygenation will persist—deterioration can occur rapidly 3