What is the treatment for suspected opioid poisoning?

Treatment of Suspected Opioid Poisoning

For suspected opioid poisoning, immediately activate emergency services, prioritize airway management and high-quality CPR if needed, and administer naloxone for patients with respiratory depression or arrest who have a pulse—titrating to restore adequate ventilation, not full consciousness. 1

Immediate Assessment and Response

Check responsiveness and activate 9-1-1 immediately without delay while simultaneously assessing breathing and pulse for less than 10 seconds. 2, 1 Do not wait for the patient's response to naloxone before calling for emergency assistance—this is a critical pitfall that can lead to preventable deaths. 1, 3

For Patients with a Pulse but Abnormal Breathing

• Provide rescue breathing or bag-mask ventilation immediately for patients who have a definite pulse but no normal breathing or only gasping. 1, 3
• Maintain respiratory support until spontaneous breathing returns, as this takes priority over naloxone administration. 1
• Administer naloxone in addition to standard BLS/ALS care for these patients. 1, 3

For Patients in Cardiac Arrest

• Start high-quality CPR immediately with focus on compressions plus ventilation. 3
• Standard resuscitative measures take priority over naloxone administration, as it may be difficult to identify the underlying cause of cardiac arrest and naloxone is only effective for opioid-induced arrest. 2, 1
• Continue standard BLS/ACLS measures if spontaneous breathing does not occur after naloxone. 1, 3

Naloxone Administration

The goal of naloxone is to restore adequate respiratory effort and protective airway reflexes, NOT to achieve full consciousness. 1, 3 Excessive dosing that fully awakens the patient increases the risk of severe withdrawal complications and agitation. 4, 5, 6

Dosing Recommendations

• Adults: 0.2-2 mg IV/IO/IM initially, or 2-4 mg intranasally. 1
• Pediatric patients: 0.1 mg/kg. 1
• Repeat every 2-3 minutes as needed to achieve adequate ventilation. 1
• Titrate to the lowest effective dose to minimize withdrawal symptoms in opioid-dependent patients. 1

Route Selection

• Intravenous route is preferred to facilitate dose titration. 7
• Intranasal and intravenous routes are equally recommended, with route selection based on clinical circumstances. 7
• Intramuscular route is disfavored due to difficulty with titration, slower time to clinical effect, and needle exposure risk. 7
• The intranasal route using a mucosal atomizer device has shown 91% response rate with average response time of 3.4 minutes, and may decrease paramedic blood-borne disease exposure. 8

Critical Precautions and Adverse Effects

In addition to naloxone, maintain availability of other resuscitative measures including airway management, artificial ventilation, cardiac massage, and vasopressor agents. 4, 5, 6

Potential Complications

• Abrupt reversal can precipitate: nausea, vomiting, sweating, tremulousness, tachycardia, hypertension, seizures, ventricular arrhythmias, pulmonary edema, and cardiac arrest. 4, 5, 6
• Use caution in patients with pre-existing cardiac disease or those who have received medications with adverse cardiovascular effects. 4, 5, 6
• Pulmonary edema associated with naloxone is thought to result from a centrally mediated catecholamine surge causing dramatic shift of blood volume into pulmonary vasculature, but responds to positive pressure ventilation. 1, 4, 5, 6

Post-Naloxone Management and Observation

Observe all patients in a healthcare setting until the risk of recurrent opioid toxicity is low and vital signs have normalized. 1

Observation Duration

• Minimum 2 hours after the last naloxone dose for short-acting opioids like fentanyl, morphine, or heroin. 1, 9
• Extended observation required for long-acting or sustained-release opioids, as the duration of naloxone action (30-90 minutes) is often shorter than the respiratory depressive effect of the opioid. 1, 9

Management of Recurrent Toxicity

• Administer repeated small doses or continuous infusion of naloxone if respiratory depression recurs. 1, 9
• Maintenance infusion should be two-thirds of the waking dose per hour. 1
• Continue monitoring vital signs including respiratory rate, blood pressure, heart rate, oxygen saturation, and temperature. 9

Special Considerations for Polysubstance Overdose

Non-response to naloxone strongly suggests polysubstance overdose involving non-opioid substances such as benzodiazepines or xylazine. 1, 3

• Never withhold naloxone when opioid overdose is suspected, even if benzodiazepine co-ingestion is present, due to the prevalence of opioid-adulterated illicit drugs. 1
• Administer naloxone first for respiratory depression in cases of suspected combined opioid and benzodiazepine poisoning. 1
• Xylazine, an α-2 agonist veterinary sedative increasingly found in the opioid supply, is not reversed by naloxone. 1, 9
• Large doses of naloxone are required to antagonize buprenorphine due to its slow dissociation from opioid receptors. 4, 5, 6

Common Pitfalls to Avoid

• Delaying emergency services activation while awaiting response to naloxone. 1, 3
• Discharging patients too early, especially with long-acting opioid ingestions. 1, 9
• Administering excessive naloxone doses attempting to achieve full consciousness rather than adequate ventilation. 1, 3
• Failing to consider co-ingestions that may require specific management approaches. 1, 3
• Focusing solely on opioid reversal when polysubstance overdose may be present. 3