What is the treatment for an adult patient, 18-65 years old, with no known medical history of seizure disorders, presenting with an opioid overdose?

Treatment of Opioid Overdose in Adults

For an adult patient presenting with suspected opioid overdose, immediately activate emergency services, assess breathing and pulse, provide high-quality CPR if no pulse is present, and administer naloxone 0.4-2 mg intramuscular or intranasal while continuing resuscitation efforts. 1

Immediate Assessment and Activation

• Check for responsiveness and activate emergency medical services immediately without waiting to assess the full clinical picture 1, 2
• Assess breathing and pulse for less than 10 seconds to avoid delays in treatment 2
• The progression to cardiac arrest in opioid overdose occurs through loss of airway patency and respiratory failure, not primary cardiac pathology 3

Treatment Algorithm Based on Clinical Presentation

Patient with Pulse but No Normal Breathing (Respiratory Arrest)

This is the most common presentation and requires immediate airway management:

• Open the airway and provide rescue breathing immediately using bag-mask ventilation with a barrier device 3
• Administer naloxone 0.4-2 mg intramuscular or intranasal while maintaining ventilation 1, 3
• For healthcare providers, intramuscular or intranasal naloxone is reasonable as an adjunct to standard BLS care (Class IIa recommendation) 1
• Repeat naloxone every 2-3 minutes if respiratory function does not improve 3, 4
• If no response after 10 mg total naloxone, question the diagnosis of opioid toxicity 4

Patient Without Pulse (Cardiac Arrest)

Standard resuscitation takes absolute priority:

• Begin high-quality CPR immediately with 30 compressions to 2 breaths 1
• Standard resuscitative measures take priority over naloxone administration (Class I recommendation) 1, 2
• It may be reasonable to administer naloxone based on the possibility the patient is not truly in cardiac arrest (Class IIb recommendation) 1
• Use an automated external defibrillator (AED) as soon as available 1, 2

Naloxone Dosing and Administration

Initial Dosing

• Adult initial dose: 0.4-2 mg administered intramuscularly, intranasally, or intravenously 1, 3, 4
• Intranasal route delivers 2 mg per standard formulation 1
• Intramuscular route delivers 0.4 mg per standard dose 1
• Intravenous administration provides the most rapid onset but should not delay treatment if IV access is difficult 4

Repeat Dosing

• Repeat doses every 2-3 minutes if inadequate response 3, 4
• The goal is to restore respiratory rate to normal, not necessarily full consciousness 4
• Titrate to effect to minimize cardiovascular stress and precipitated withdrawal 4

Route Comparison

• Intranasal naloxone has approximately 50% bioavailability compared to intramuscular 5
• Time to maximum concentration is 15-30 minutes for intranasal versus 13.6 minutes for intramuscular 6
• Intramuscular or subcutaneous administration may be necessary if intravenous route is unavailable 4

Critical Safety Considerations

Naloxone Safety Profile

• Naloxone has an excellent safety profile and is unlikely to cause harm even if opioid overdose is not present 7
• Major complications are rare and dose-related 1, 7
• Naloxone is not contraindicated during cardiac arrest, though CPR takes priority 7

Withdrawal Syndrome Risk

• Opioid-dependent patients may experience acute withdrawal after naloxone administration 7, 4
• Withdrawal symptoms include hypertension, tachycardia, vomiting, agitation, and anxiety 7
• This is not a contraindication to naloxone use, but symptoms can be minimized by using the lowest effective dose 7
• Avoid complete reversal of analgesia by titrating carefully 4

Post-Resuscitation Management

Monitoring Requirements

• Observe patients for at least 2 hours after naloxone administration 7, 3
• Longer observation periods are required for long-acting or sustained-release opioids 1, 7
• Monitor continuously until risk of recurrent toxicity is low and vital signs have normalized 2, 3

Recurrent Respiratory Depression

• Naloxone duration of action (60-120 minutes) is shorter than most opioids 5
• If respiratory depression recurs, administer repeated small doses or continuous infusion 3
• Continuous infusion dosing: Add 2 mg naloxone to 500 mL normal saline or 5% dextrose 3, 4
• Infusion rate should be two-thirds of the initial waking dose per hour 3, 8

Special Considerations

Fentanyl and Synthetic Opioids

• Fentanyl overdoses likely require higher doses of naloxone than heroin overdoses 5
• Consider having at least two doses available for synthetic opioid overdoses 5

Buprenorphine Overdose

• Naloxone remains the primary treatment for buprenorphine overdose despite buprenorphine's partial agonist properties 2
• Standard resuscitation protocols with airway management and ventilatory support are primary interventions 2

Common Pitfalls to Avoid

• Do not delay CPR or emergency activation to administer naloxone 1
• Do not use excessive doses that may cause complete reversal of analgesia and cardiovascular stress 4
• Do not assume a single dose is sufficient—be prepared for repeat dosing 1, 3
• Do not discharge patients prematurely—recurrent depression is common 1, 7