What is the immediate treatment for suspected opioid (op) poisoning?

Immediate Treatment for Suspected Opioid Poisoning

For suspected opioid poisoning, immediately open the airway and provide rescue breathing or bag-mask ventilation while simultaneously administering naloxone if the patient has a pulse but is not breathing normally. 1

Critical First Steps

Airway and breathing support takes absolute priority — this is the foundation of opioid overdose management regardless of naloxone availability. 1

Immediate Actions (in order):

1. Activate emergency response systems immediately — do not delay while attempting interventions or awaiting naloxone response. 1

2. Open the airway and assess breathing (less than 10 seconds). 2

3. For respiratory arrest with pulse present:

   • Begin rescue breathing or bag-mask ventilation immediately 1
   • Administer naloxone while continuing ventilatory support 1
   • Maintain ventilation until spontaneous breathing returns 1

4. For cardiac arrest:

   • Standard high-quality CPR takes priority over naloxone 1
   • Naloxone can be given alongside CPR but should never delay compressions 1

Naloxone Administration

Titrate naloxone to restore respiratory effort, NOT consciousness — the goal is reversal of respiratory depression and restoration of protective airway reflexes, not full arousal. 3

Dosing:

• Adults: 0.2-2 mg IV/IM/IO, or 2-4 mg intranasal 3
• Pediatric: 0.1 mg/kg 3
• Repeat every 2-3 minutes as needed if respiratory function does not improve 3, 2

Route Selection:

Higher-concentration intranasal naloxone (2 mg/mL) has similar efficacy to intramuscular naloxone, while lower-concentration formulations (2 mg/5 mL) are less effective. 4

Critical Pitfalls to Avoid

Do not use excessive naloxone doses attempting to achieve full consciousness — this precipitates severe withdrawal without improving outcomes. 3, 5 The FDA label warns that abrupt reversal can cause nausea, vomiting, tachycardia, hypertension, seizures, ventricular arrhythmias, pulmonary edema, and cardiac arrest. 6

Never withhold naloxone due to suspected benzodiazepine co-ingestion — opioid-adulterated drugs are ubiquitous, and naloxone should be administered first for any respiratory depression. 1, 3

Do not discharge patients prematurely — observe for at least 2 hours after naloxone administration, with longer periods (several hours) for long-acting or sustained-release opioids. 3, 2

Post-Naloxone Management

If Patient Responds:

• Continue observation in healthcare setting until vital signs normalize and risk of recurrent toxicity is low 3, 2
• Recurrent respiratory depression is common because naloxone's duration (30-90 minutes) is shorter than most opioids 3, 7
• If toxicity recurs, administer repeated small doses or continuous infusion at two-thirds of the waking dose per hour 3

If Patient Does NOT Respond to Naloxone:

Non-response strongly suggests polysubstance overdose involving benzodiazepines, xylazine (increasingly common and not reversed by naloxone), or other non-opioid CNS depressants. 3, 5

• Continue airway and ventilatory support as primary intervention 5
• Consider escalating to bag-mask ventilation or endotracheal intubation 5
• Some synthetic opioids may require higher or repeated naloxone doses 5
• Long-acting opioids like buprenorphine are particularly resistant to naloxone due to slow receptor dissociation 6, 7

Special Considerations

Naloxone-induced pulmonary edema is rare at standard overdose reversal doses, but when it occurs, it responds readily to positive pressure ventilation. 1, 3 The mechanism involves centrally-mediated catecholamine surge causing pulmonary vascular congestion. 6

In opioid-dependent patients, use the lowest effective dose (starting at 0.04 mg with titration) to minimize precipitated withdrawal while still reversing respiratory depression. 8