Opioid Poisoning/Overdose

Table of Contents

Aliases

Carfentanil, Dilaudid®, drug abuse, EVZIO®, fentanyl, heroin, hydrocodone, hydromorphone, methadone, morphine, naloxone, Narcan®, opiate, opioid, overdose, oxycodone, Oxycontin®, Percocet®, Percodan®, Suboxone, U-47700, Vicodin®

Patient Care Goals

  1. Rapid recognition and intervention of a clinically significant opioid poisoning or overdose
  2. Prevention of respiratory and/or cardiac arrest

Patient Presentation

Inclusion Criteria

Patents exhibiting miosis (pinpoint pupils), decreased mental status, and respiratory depression of all age groups with known or suspected opioid use or abuse.

Exclusion Criteria:

Patients with altered mental status exclusively from other causes (e.g. head injury, or hypoglycemia).

Patient Management

  1. Don the appropriate PPE
  2. Therapeutic interventions to support the patient’s airway, breathing, and circulation should be initiated prior to the administration of naloxone
  3. If possible, identify specific medication taken (including immediate release versus sustained release) time of ingestion, and quantity
  4. Obtain and document pertinent cardiovascular history or other prescribed medications for underlying disease
  5. Be aware that unsecured hypodermic needles may be on scene if the intravenous route may have been used by the patient, and that there is a higher risk of needle sticks during the management of this patient population which may also have an increased incidence of blood-borne pathogens
  6. Naloxone, an opioid antagonist, should be considered for administration to patients with respiratory depression in a confirmed or suspected opioid overdose
  7. Naloxone administration via the intravenous route provides more predictable bioavailability and flexibility in dosing and titration
  8. Naloxone administration via the intranasal or intramuscular routes provide additional options of medication delivery
  9. If naloxone was administered to the patient prior to the arrival of EMS, obtain the dose and route through which it was administered and, if possible, bring the devices containing the dispensed naloxone with the patient along with all other medications on scene

Assessment

  1. Assess the patient’s airway, breathing, circulation, and mental status
  2. Support the patient’s airway by positioning, oxygen administration, and ventilator assistance with a bag valve mask if necessary
  3. Assess the patient for other etiologies of altered mental status including hypoxia (pulse oximetry less than 94%), hypoglycemia, hypotension, and traumatic head injury
  4. Legally prescribed opioids are also manufactured as an adhesive patch for transdermal absorption, and if found, should be removed from the skin

Treatments and Interventions

  1. Critical resuscitation (opening and/or maintaining the airway, provision of oxygen, ensuring adequate circulation) should be performed prior to naloxone administration
  2. If the patient has respiratory depression from a confirmed or suspected opioid overdose, consider naloxone administration
    1. The administration of the initial dose or subsequent doses can be incrementally titrated until respiratory depression is reversed
  3. The patient must have a pulse to receive naloxone
  4. The goal of naloxone is adequate ventilation
    1. Normal mental status is not required.
  5. Naloxone can be administered via the IV, IM, IN, or ETT routes
    1. Adults: The typical initial adult dose ranges between 0.4-2 mg IV, IM, or ETT or up to a dose of 4 mg IN
    2. Pediatrics: The pediatric dose of naloxone is 0.1 mg/kg IV, IM, IN, or ETT
      1. Maximum dose of 2 mg IV, IM, or ETT
      2. Maximum dose of 4 mg IN
    3. Naloxone provided to laypersons and non-medical first responders via public access programs or prescriptions may be provided as a pre-measured dose in an auto-injector or nasal spray or as a pre-measured, but variable, dose and/or concentration in a needleless syringe with a mucosal atomization device (MAD) on the hub
    4. Naloxone auto-injectors contain 0.4 mg/0.4 mL or 2 mg/0.4 mL
      1. The cartons of naloxone auto-injectors prescribed to laypersons contain two naloxone auto-injectors and one trainer
    5. Naloxone nasal spray is manufactured in a single-use bottle that contains 4 mg/0.1 mL
    6. For the intranasal route when naloxone is administered via a needleless syringe (preferably with MAD on the hub), divide administration of the dose equally between the nostrils to a maximum of 1 mL per nostril
    7. The administration of naloxone can be titrated until adequate respiratory effort is achieved if administered with a syringe IV, IM, IN, or ETT
  6. If apnea remains after 8 mg total, with 4 mg of Naloxone given by EMS, place advanced airway and ventilate patient while transporting to the closest Emergency Department.
  7. High-potency opioids [see Key Considerations] may require higher and/or more frequently administered doses of naloxone to reverse respiratory depression and/or to maintain adequate respirations
  8. Regardless of the doses of naloxone administered, airway management with provision of adequate oxygenation and ventilation is the primary goal in patients with confirmed or suspected opioid overdose
  9. Consider transporting patients to ED that can provide resources for Substance Use Disorder
    1. Referral to rehabilitation and medication-assisted therapy
  10. Consider requesting community resources that can assist with the initiation of medication-assisted therapy for substance abuse (buprenorphine, methylnatrexone, methadone, etc)

Notes – Opioid Poisoning/Overdose