What are the symptoms and treatment of opioid (narcotic analgesic) overdose?

From the Guidelines

Opioid overdose is a life-threatening emergency that requires immediate intervention with naloxone, which is the antidote for opioid overdose, as stated in the 2024 American Heart Association and American Red Cross guidelines for first aid 1. When suspecting an opioid overdose, characterized by unconsciousness, slow or stopped breathing, blue/gray lips or fingernails, and pinpoint pupils, administering naloxone immediately is crucial. The standard dose is 0.4-2 mg intravenously or 2-4 mg intranasally, which can be repeated every 2-3 minutes if needed, as recommended by the guidelines 1.

After administering naloxone, it is essential to:

• Call emergency services (911) immediately
• Place the person in the recovery position (on their side)
• Stay with them until help arrives Naloxone works by competitively binding to opioid receptors, displacing the opioid and temporarily reversing respiratory depression, as explained in the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1.

It is crucial to be aware that naloxone's effects last only 30-90 minutes, while many opioids remain active longer, so the person may return to an overdose state after naloxone wears off. This is why medical follow-up is essential even if the person seems to recover. Anyone who regularly uses opioids or knows someone who does should keep naloxone on hand and know how to use it, as rapid administration significantly increases survival chances, as highlighted in the 2024 guidelines 1.

Key points to consider:

• Naloxone has an excellent safety profile and can rapidly reverse CNS and respiratory depression in a patient with an opioid-associated resuscitative emergency 1
• The ideal dose of naloxone is not known, but the recommended dose is 0.4-2 mg intravenously or 2-4 mg intranasally, which can be repeated every 2-3 minutes if needed 1
• Naloxone administration may precipitate acute withdrawal syndrome in patients with opioid dependency, but this is rarely life-threatening 1

From the FDA Drug Label

Usage in Adults: Opioid Overdose—Known or Suspected: An initial dose of 0. 4 mg to 2 mg of naloxone hydrochloride may be administered intravenously. If the desired degree of counteraction and improvement in respiratory functions are not obtained, it may be repeated at two to three minute intervals If no response is observed after 10 mg of naloxone hydrochloride have been administered, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned Repeat AdministrationThe patient who has satisfactorily responded to naloxone should be kept under continued surveillance and repeated doses of naloxone should be administered, as necessary, since the duration of action of some opioids may exceed that of naloxone

For opioid overdose, the recommended initial dose of naloxone is 0.4 mg to 2 mg administered intravenously. If there is no response, the dose may be repeated at 2 to 3 minute intervals. The patient should be kept under continued surveillance and repeated doses of naloxone should be administered as necessary, since the duration of action of some opioids may exceed that of naloxone 2.

• Key points:
  • Initial dose: 0.4 mg to 2 mg intravenously
  • Repeat dose: every 2 to 3 minutes as needed
  • Maximum dose: 10 mg before questioning the diagnosis of opioid-induced toxicity
  • Surveillance: continue to monitor the patient after administration of naloxone 2

From the Research

Opioids Overdose Symptoms and Management

• Opioid overdose occurs when the central nervous system and respiratory drive are suppressed due to excessive consumption of the drug, leading to symptoms such as drowsiness, slow breathing, pinpoint pupils, cyanosis, loss of consciousness, and death 3.
• The management of opioid overdose requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest 4.
• Naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest 4, 5.

Epidemiology of Opioid-Associated Out-of-Hospital Cardiac Arrest

• Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans 4.
• The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids 4.
• Worldwide, approximately 69,000 people die of opioid overdose each year, and approximately 15 million people have opioid addiction 3.

Treatment Strategies and Limitations

• The management strategies for opioid overdose include airway management, use of reversal agents, assessing and treating coingestions and associated complications, treatment of opioid withdrawal with alpha-agonists, and psychosocial support to help with opiate addiction and withdrawal 3.
• Naloxone is currently the only available treatment for reversing the negative effects of opioids, including respiratory depression, but its effectiveness varies depending on the pharmacokinetics and pharmacodynamics of the opioid that was overdosed 5.
• Long-acting opioids, and those with a high affinity at the µ-opioid receptor and/or slow receptor dissociation kinetics, are particularly resistant to the effects of naloxone 5.

Education and Prevention

• Opioid education and naloxone distribution programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing 4.
• Opioid overdose prevention training with naloxone, as an adjunct to basic life support training, can increase knowledge about and preparedness to respond to opioid overdoses among medical students 6.
• Despite widespread availability of naloxone to consumers, a minority of patients with opioid overdose reported access to naloxone, and those who had access stated that their frequency and dosage of opioid use did not change 7.