What is the treatment for a patient in opium (opioid) poisoning?

Treatment of Opioid Poisoning

For patients with opioid poisoning, immediately prioritize airway management and rescue breathing while administering naloxone, followed by mandatory observation in a healthcare setting until vital signs normalize and risk of recurrent toxicity is eliminated. 1, 2

Immediate Management Algorithm

Step 1: Airway and Breathing (Primary Priority)

• Focus first on opening the airway and delivering rescue breaths using bag-mask ventilation or barrier device - this takes absolute priority over naloxone administration 1, 2
• Maintain rescue breathing or bag-mask ventilation until spontaneous breathing returns 2
• If cardiac arrest is suspected, initiate high-quality CPR immediately - naloxone should not delay resuscitative efforts 1, 2
• Activate emergency response systems immediately without waiting for response to naloxone 1, 2

Step 2: Naloxone Administration

• Administer naloxone for patients with definite pulse but absent or abnormal breathing (gasping only) 1, 2
• Titrate naloxone to restore respiratory effort, NOT consciousness - the goal is reversal of respiratory depression and restoration of protective airway reflexes, not full arousal 2
• Use initial doses of 0.2-2 mg IV/IO/IM for adults, 0.1 mg/kg for pediatric patients, or 2-4 mg intranasally 2
• Repeat every 2-3 minutes as needed to achieve adequate respiratory rate (≥10 breaths/min) 2, 3
• In addition to naloxone, maintain availability of cardiac massage and vasopressor agents as necessary 4, 5, 6

Step 3: Post-Naloxone Monitoring (Class I Recommendation)

• After return of spontaneous breathing, patients MUST be observed in a healthcare setting until risk of recurrent opioid toxicity is low and vital signs have normalized 1, 2
• Monitor for at least 2 hours after discontinuation of naloxone to detect recurrent respiratory depression 3
• Watch specifically for decreased respiratory rate/effort, altered consciousness, and hypotension 3

Management of Recurrent Toxicity

• If recurrent opioid toxicity develops, administer repeated small doses or continuous infusion of naloxone 1, 2
• Use maintenance infusion of two-thirds of the waking dose per hour 2
• The duration of naloxone action (45-70 minutes) is shorter than most opioids, particularly long-acting formulations, necessitating repeat dosing 3

Observation Period Based on Opioid Type

Short-Acting Opioids (Fentanyl, Morphine, Heroin)

• Abbreviated observation periods may be adequate 1, 2
• Immediate-release morphine has elimination half-life of 2-4 hours with peak concentration at 0.25-1.0 hours 3

Long-Acting or Sustained-Release Opioids

• Require longer observation periods due to prolonged drug release and absorption 1, 2, 3
• Long-acting morphine has delayed peak plasma concentration at 2-4 hours despite similar elimination half-life 3

Special Considerations and Pitfalls

Polysubstance Overdose

• Non-response to naloxone strongly suggests polysubstance overdose involving non-opioid substances such as benzodiazepines or xylazine 2
• Administer naloxone first for respiratory depression even if benzodiazepine co-ingestion is suspected 2
• Never withhold naloxone when opioid overdose is suspected, even with known co-ingestions 2
• Xylazine as an adulterant complicates treatment as naloxone is ineffective against xylazine's effects, though it will reverse the opioid component 7

Adverse Effects of Naloxone

• Potential complications include precipitating opioid withdrawal, sudden-onset pulmonary edema (responds to positive pressure ventilation), nausea, vomiting, tachycardia, hypertension, seizures, ventricular arrhythmias, and cardiac arrest 1, 2, 4, 5, 6
• Use with caution in patients with pre-existing cardiac disease 4, 5, 6
• Pulmonary edema pathogenesis is similar to neurogenic pulmonary edema - a centrally mediated catecholamine response causing blood volume shift into pulmonary vasculature 4, 5, 6
• Serious adverse effects like pulmonary edema are rare at doses consistent with labeled use 2

Critical Pitfalls to Avoid

• Do not delay emergency system activation while awaiting naloxone response 1, 2
• Do not discharge patients prematurely, even if fully recovered - recurrent toxicity can occur hours after initial response 2, 3
• Do not assume brief observation is adequate for all opioid overdoses - formulation type dictates observation duration 3
• Do not focus solely on naloxone administration while neglecting airway management and ventilatory support 1, 2
• Do not administer excessive naloxone doses that cause complete reversal of analgesia and precipitate severe withdrawal 4, 5, 6

Community and Lay Responder Role

• Lay rescuers should receive training in opioid overdose response, including naloxone provision 1, 2
• Training with skills practice leads to improved clinical performance compared to education alone 1, 2
• Education improves risk awareness, overdose recognition, willingness to administer naloxone, and attitudes toward calling emergency services 1, 2