Treatment of Opioid Poisoning
Administer naloxone immediately for suspected opioid poisoning while simultaneously implementing resuscitative measures including airway maintenance, artificial ventilation, and cardiac support. 1, 2
Immediate Life-Saving Interventions
Naloxone administration is the cornerstone of acute opioid poisoning treatment, reversing respiratory depression and CNS depression that characterize opioid toxicity. 1, 2, 3 The FDA drug label specifies that naloxone should be accompanied by other resuscitative measures including maintenance of a free airway, artificial ventilation, cardiac massage, and vasopressor agents when necessary. 1, 2
Critical Airway and Breathing Management
- Effective ventilation is the priority in opioid-associated cardiac arrest, as the pathophysiology involves asphyxial death and prolonged hypoxemia leading to global ischemia rather than primary cardiac pathology. 4
- Position unconscious patients in the left lateral head-down position to protect the airway. 3
- Provide respiratory support immediately if breathing is inadequate or absent. 1, 2, 3
- For cardiac arrest, deliver high-quality compressions coupled with effective ventilation. 4
Naloxone Dosing and Administration
Intravenous naloxone has the fastest onset but intramuscular and intranasal routes are effective when IV access is unavailable. 1, 2 The FDA label emphasizes that naloxone's duration of action is often shorter than that of opioids, making continuous monitoring absolutely necessary. 1, 2
Common pitfall: Naloxone's short half-life (compared to many opioids) means patients can re-develop respiratory depression after initial reversal, particularly with long-acting opioids like methadone or fentanyl analogs. 1, 2
Special Considerations for Opioid-Tolerant Patients
Administer naloxone cautiously in opioid-tolerant patients to avoid precipitating acute opioid withdrawal syndrome, which can include nausea, vomiting, sweating, tremulousness, tachycardia, increased blood pressure, and seizures. 5, 1, 2 The NCCN guidelines specifically warn that naloxone is an effective antidote but must be titrated carefully in patients with chronic opioid exposure. 5
Cardiovascular Monitoring
The FDA label documents that abrupt reversal can cause severe cardiovascular complications including:
- Ventricular tachycardia and fibrillation 1, 2
- Pulmonary edema (via centrally mediated massive catecholamine response) 1, 2
- Cardiac arrest 1, 2
- Hypotension or hypertension 1, 2
Use particular caution in patients with pre-existing cardiac disease or those who have received medications with potential adverse cardiovascular effects. 1, 2
Additional Acute Management
- Administer glucose injection if the patient is unconscious to address potential hypoglycemia. 3
- Give diazepam for status epilepticus if seizures occur. 3
- Administer atropine for severe bradycardia. 3
- Elevate legs for hypotension as an initial measure. 3
- Activated charcoal should be given as soon as possible (preferably within 2 hours) if oral opioid ingestion is suspected, provided the patient is fully conscious and can swallow safely. 3
Critical caveat: Gastric lavage carries serious risks and is only justified in rare life-threatening cases involving drugs not adsorbed by activated charcoal. 3 Ipecac syrup should never be used. 3
Post-Resuscitation Management and Risk Stratification
Immediate Post-Overdose Period
The first 2 days and particularly the first month after overdose represent the highest-risk period for death. 6 Among patients treated for nonfatal opioid overdose, 0.25% died within 2 days, 1.1% within 1 month, and 5.5% within 1 year. 6
Hospital Admission Criteria
Hospital monitoring is warranted for potentially severe poisoning, including patients at increased risk, those who have taken a potentially lethal substance at toxic or unknown dose, and when delayed effects are possible. 3 Continuous monitoring is essential given naloxone's short duration of action relative to many opioids. 1, 2
Buprenorphine Considerations
Large doses of naloxone are required to antagonize buprenorphine due to its slow dissociation from opioid receptors, with reversal characterized by gradual onset and decreased duration of action. 1, 2 This is particularly relevant for patients on medication-assisted treatment.
Secondary Prevention and Treatment Engagement
Offer buprenorphine, counseling, and referral to treatment before ED discharge for patients who survive opioid overdose. 6 The CDC recommends evidence-based treatment (medication-assisted treatment with buprenorphine or methadone combined with behavioral therapies) for patients with opioid use disorder. 5, 7
Responding to an overdose event increases interest in treatment for opioid use disorder, with treatment importance scores increasing significantly after naloxone use (from 3.03 to 3.39, p=0.02). 8 This represents a critical window for treatment engagement.
Naloxone Distribution
Provide take-home naloxone and overdose education to patients and their contacts before discharge. 4, 6 The American Heart Association recommends that laypeople initiate CPR for any unconscious person not breathing normally, and administer naloxone if opioid overdose is suspected. 4
Suicide Risk Assessment
In cases of intentional self-poisoning, evaluate the risk of short-term relapse even when the patient's condition is not immediately life-threatening. 3 Hospital admission should be proposed or imposed until the acute suicide risk has subsided. 3
Substance Use History Considerations
For patients with chronic pain or substance abuse history, avoid abrupt opioid discontinuation based solely on an overdose event. 5, 9 The CDC explicitly warns against abruptly discontinuing opioid therapy unless there are indications of life-threatening issues such as impending overdose. 9 Instead, work with patients to reduce opioid dosage when possible while incorporating enhanced monitoring and risk mitigation strategies. 5