Will a patient who overdosed on fentanyl and was administered Narcan (naloxone) eventually experience withdrawal symptoms, despite currently not exhibiting any?

From the Guidelines

A patient who overdoses on fentanyl and receives Narcan (naloxone) but is not experiencing withdrawal symptoms will not develop withdrawal symptoms days later from this specific intervention. The administration of naloxone, as described in the study by 1, is a potent opioid receptor antagonist that can rapidly reverse CNS and respiratory depression in a patient with an opioid-associated resuscitative emergency. However, the key point to consider is that Narcan has a short half-life of 30-90 minutes, while fentanyl's effects typically last 4-6 hours, as noted in the example answer. Once Narcan wears off, any remaining fentanyl in the system will reattach to opioid receptors, but this doesn't reset the clock on physical dependence. Withdrawal symptoms would only occur if the patient was already physically dependent on opioids before the overdose and then completely stops using them. In that case, withdrawal typically begins 8-24 hours after the last opioid dose and peaks within 1-3 days, as generally understood in medical practice. The Narcan administration itself doesn't cause delayed withdrawal; it only temporarily blocks opioid effects. Medical monitoring for 4-6 hours after Narcan administration is important to ensure the patient doesn't experience "renarcotization" when the Narcan wears off but fentanyl remains active, as cautioned in the study by 1. Some key points to consider in the management of such patients include:

• The dose and route of naloxone administration, with typical doses ranging from 0.04 to 0.4 mg IV or IM, as recommended in the study by 1.
• The potential for naloxone to precipitate acute withdrawal syndrome in patients with opioid dependency, with signs and symptoms including hypertension, tachycardia, piloerection, vomiting, agitation, and drug cravings, as noted in the study by 1.
• The importance of using the lowest effective dose of naloxone to minimize the risk of precipitating severe opioid withdrawal, as suggested in the study by 1.

From the FDA Drug Label

At doses of 2 mg/kg in normal subjects, cognitive impairment and behavioral symptoms, including irritability, anxiety, tension, suspiciousness, sadness, difficulty concentrating, and lack of appetite have been reported. In addition, somatic symptoms, including dizziness, heaviness, sweating, nausea, and stomachaches were also reported Although complete information is not available, behavioral symptoms were reported to often persist for 2 to 3 days.

The patient may eventually start to experience withdrawal symptoms in a few days. The text suggests that behavioral symptoms can persist for 2 to 3 days after naloxone administration. However, it is essential to note that the information provided is based on the effects of naloxone itself, not specifically on the context of fentanyl overdose and subsequent naloxone treatment. Therefore, the answer is not definitive, but it is possible that the patient may experience withdrawal symptoms in the coming days 2.

• Key points:
  • Naloxone can cause behavioral symptoms
  • These symptoms can persist for 2 to 3 days
  • The information is not specific to fentanyl overdose treatment

From the Research

Fentanyl Overdose and Withdrawal Symptoms

• The patient in question has overdosed on fentanyl and been given Narcan, but is not currently experiencing withdrawal symptoms.
• According to the study 3, fentanyl status at admission was not significantly associated with Clinical Opioid Withdrawal Scale (COWS) or Short Opiate Withdrawal Scale (SOWS) scores after adjusting for sex, site, and polysubstance use.
• However, the study 3 also found that participants with a higher body mass index (BMI) had significantly higher odds of testing positive for fentanyl and higher SOWS maximum scores.
• The study 4 suggests that managing opioid withdrawal symptoms during the fentanyl crisis can be complicated due to the high potency and lipophilicity of fentanyl, but it does not provide direct evidence on whether the patient will eventually experience withdrawal symptoms.
• The study 5 found that patients with uncomplicated presumed fentanyl overdose can be discharged after brief observation, but it does not address the specific question of withdrawal symptoms.

Potential for Withdrawal Symptoms

• The study 3 implies that withdrawal symptoms may occur, but the severity and timing are not clearly predicted by fentanyl status at admission.
• The study 4 highlights the importance of therapeutic interventions, such as buprenorphine and naltrexone, in managing opioid withdrawal symptoms, but it does not provide direct evidence on the patient's likelihood of experiencing withdrawal symptoms.
• The study 6 discusses the efficacy of naloxone in reversing opioid overdose, but it does not address the specific question of withdrawal symptoms after Narcan administration.