What is the management approach for a patient with an opioid overdose?

Management of Opioid Overdose

For patients with suspected opioid overdose who are unresponsive and not breathing normally, immediately activate emergency services, provide high-quality CPR with compressions plus ventilation, and administer naloxone. 1

Initial Assessment and Response

Assess responsiveness and breathing in less than 10 seconds. 2 The management pathway diverges based on whether the patient has respiratory arrest versus cardiac arrest:

Respiratory Arrest (Has Pulse, Not Breathing Normally)

Immediately open the airway, reposition, and provide rescue breathing or bag-mask ventilation—this is your primary life-saving intervention. 1, 3 Ventilatory support must be maintained until spontaneous breathing returns. 1

Administer naloxone in addition to ventilatory support for patients with a definite pulse but absent or abnormal breathing. 1, 3 This is a Class I recommendation with moderate-quality evidence. 1

Cardiac Arrest (No Pulse)

Focus exclusively on high-quality CPR with compressions and ventilation following standard ACLS protocols—this is the only intervention proven to matter in cardiac arrest. 3 Standard resuscitative measures take absolute priority over naloxone administration. 1, 3

Naloxone has no proven benefit in cardiac arrest and should only be given if it does not delay or interrupt CPR. 1, 3 No studies demonstrate improvement in patient outcomes from naloxone administration during cardiac arrest. 1, 3

Naloxone Administration

Dosing Strategy

Start with 0.4-0.8 mg IV/IM for non-opioid-dependent patients, titrating to restore respiratory rate to normal—not full consciousness. 4, 5 The goal is a controlled reversal that restores breathing while minimizing cardiovascular stress and withdrawal symptoms. 6

• Initial dose for non-dependent patients: 0.5 mg/70 kg, followed by 1 mg/70 kg after 2-5 minutes if needed 6
• For suspected opioid-dependent patients: challenge dose of 0.1 mg/70 kg initially, waiting 2 minutes to assess for withdrawal before proceeding 6
• Low-dose naloxone (0.04 mg) with appropriate titration is prudent in opioid-dependent populations to avoid precipitated withdrawal 5

Route of Administration

Higher-concentration intranasal naloxone (2 mg/mL) has similar efficacy to intramuscular naloxone at the same dose. 7 However, nasal uptake is slower (mean Tmax 15-30 minutes) with approximately 50% bioavailability compared to parenteral routes. 4

• Intramuscular or subcutaneous administration is effective within 5-15 minutes if IV access is unavailable 6
• Lower-concentration intranasal formulations (2 mg/5 mL) are less effective than intramuscular but associated with decreased agitation 7

Special Considerations for Fentanyl

Fentanyl overdoses likely require higher doses of naloxone than heroin overdoses. 4, 8 As a competitive antagonist, naloxone may not be powerful enough to adequately reverse overdoses involving potent synthetic opioids like fentanyl and its analogues. 8

Laypeople should always have access to at least two dose kits for interim intervention. 4

Post-Resuscitation Management

Observe all patients in a healthcare setting until the risk of recurrent opioid toxicity is low and vital signs have normalized. 1, 3 This is critical because naloxone's duration of action (approximately 2 hours for 1 mg IV) is shorter than many opioids. 1, 4

Monitoring Duration

• Minimum 2 hours after naloxone administration for short-acting opioids 2
• Longer observation periods are mandatory for long-acting or sustained-release opioid overdoses 1
• Abbreviated observation may be adequate for fentanyl, morphine, or heroin overdose 1

Recurrent Toxicity

If recurrent opioid toxicity develops, administer repeated small doses or a continuous naloxone infusion. 1 Titrate incrementally with 2-5 minute intervals between doses to allow full effect. 6

Critical Pitfalls to Avoid

Never delay activating emergency services while awaiting response to naloxone or other interventions. 1, 3 Rescuers cannot be certain the clinical condition is solely due to opioid-induced respiratory depression—naloxone is ineffective for non-opioid overdoses and cardiac arrest from any cause. 1

Never delay or interrupt CPR to administer naloxone during cardiac arrest. 3 High-quality chest compressions take absolute priority.

Avoid over-reversal by using higher doses or shorter intervals between incremental doses, as this increases the incidence and severity of acute withdrawal symptoms including nausea, vomiting, elevated blood pressure, and anxiety. 6

Do not assume adequate reversal means safe discharge—patients who respond to naloxone may develop recurrent CNS and respiratory depression requiring prolonged observation. 1

Training Recommendations

First aid providers and lay rescuers should receive training in responding to opioid overdose, including naloxone provision. 1 Interventions that include hands-on skills practice in naloxone administration are more likely to lead to improved clinical performance compared to video-only training. 1