What is the management for opium (opioid) poisoning?

Management of Opioid Poisoning

For suspected opioid poisoning, immediately prioritize airway management and ventilation while administering naloxone titrated to restore respiratory effort (not full consciousness), using initial doses of 0.4-2 mg IV for adults or 0.1 mg/kg for children, repeated every 2-3 minutes as needed. 1

Initial Resuscitation and Assessment

Airway and breathing take absolute priority over naloxone administration. 1

• For patients in respiratory arrest, provide rescue breathing or bag-mask ventilation immediately and maintain until spontaneous breathing returns 1
• If cardiac arrest is suspected, focus on high-quality CPR (compressions plus ventilation) as the primary intervention, with standard resuscitative measures taking priority over naloxone 1
• Activate emergency response systems immediately without delay—do not wait for the patient's response to naloxone 1
• For patients with a definite pulse but no normal breathing or only gasping, administer naloxone in addition to standard BLS/ALS care 1

Naloxone Administration Protocol

The goal is reversal of respiratory depression and restoration of protective airway reflexes, NOT full arousal. 1

Dosing by Patient Population

Adults:

• Initial dose: 0.4-2 mg IV/IO/IM 1, 2
• Intranasal: 2-4 mg 1
• Repeat every 2-3 minutes as needed 1, 2
• If no response after 10 mg total, strongly question the diagnosis of opioid toxicity and consider polysubstance overdose 1, 2

Pediatric patients:

• Initial dose: 0.1 mg/kg IV 1
• Alternative: 0.01 mg/kg IV if initial approach; if inadequate response, give subsequent dose of 0.1 mg/kg 2
• May use IM or SC routes if IV access unavailable 2

Neonates:

• Initial dose: 0.01 mg/kg IV, IM, or SC 2
• Repeat according to adult postoperative guidelines 2

Route Selection

• IV administration provides the most rapid onset and is recommended in emergency situations 2
• IM or SC administration may be necessary if IV route is unavailable 1, 2
• Intranasal administration (2-4 mg) is appropriate for lay responders 1

Post-Naloxone Management and Monitoring

The duration of naloxone action (30-90 minutes) is often shorter than the respiratory depressive effects of opioids, particularly long-acting formulations. 1, 2

• Observe patients in a healthcare setting until risk of recurrent opioid toxicity is low and vital signs have normalized 1
• For recurrent toxicity, administer repeated small doses or continuous infusion of naloxone at two-thirds of the waking dose per hour 1
• Tailor observation periods to the specific opioid: shorter periods (4-6 hours) may suffice for fentanyl, morphine, or heroin, while long-acting or sustained-release opioids require extended monitoring (12-24 hours or longer) 1

Continuous Infusion Preparation

• Dilute 2 mg naloxone in 500 mL normal saline or 5% dextrose (concentration: 0.004 mg/mL) 2
• Use mixtures within 24 hours; discard remaining solution after 24 hours 2
• Titrate rate according to patient response 2

Special Considerations and Complications

Polysubstance Overdose

Non-response to naloxone strongly suggests polysubstance overdose involving non-opioid substances such as benzodiazepines or xylazine. 1

• Administer naloxone first for respiratory depression even if benzodiazepine co-ingestion is suspected, given the prevalence of opioid-adulterated illicit drugs 1
• Never withhold naloxone when opioid overdose is suspected, regardless of suspected co-ingestions 1

Adverse Effects and Withdrawal

Naloxone can precipitate acute opioid withdrawal syndrome in opioid-dependent patients, characterized by nausea, vomiting, sweating, tremulousness, tachycardia, hypertension, and agitation. 2

• Use the lowest effective dose to minimize withdrawal symptoms 1
• Titrate to respiratory effort restoration, not full consciousness, to reduce withdrawal severity 1
• More serious adverse reactions include seizures, ventricular tachycardia/fibrillation, pulmonary edema, and cardiac arrest 2

Naloxone-Associated Pulmonary Edema

• Pulmonary edema is rare at doses consistent with labeled use 1
• Pathogenesis involves centrally mediated massive catecholamine response causing dramatic shift of blood volume into pulmonary vasculature 2
• Responds to positive pressure ventilation 1

High-Risk Cardiac Patients

Use naloxone with caution in patients with pre-existing cardiovascular disease or those receiving medications with potential adverse cardiovascular effects. 2

• Abrupt reversal can cause hypotension, hypertension, ventricular arrhythmias, pulmonary edema, and cardiac arrest 2
• Death, coma, and encephalopathy have been reported as sequelae in patients with pre-existing cardiac disorders 2

Community Response and Lay Rescuer Training

Lay rescuers should receive training in opioid overdose response, including naloxone provision. 1

• Training that includes skills practice leads to improved clinical performance compared to interventions without skills practice 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

Critical Pitfalls to Avoid

• Delaying emergency response activation while awaiting naloxone response 1
• Discharging patients too early after naloxone administration, especially with long-acting opioid ingestions 1
• Failing to consider co-ingestions that may require specific management approaches 1
• Using excessive naloxone doses in postoperative patients, causing significant analgesia reversal and agitation 2
• Focusing solely on naloxone administration while neglecting airway management and ventilation 1, 2