II. Indications: Narcotic Overdose management

  1. Respiratory Depression (Hypoxia, apnea)
  2. Severe Sedation (e.g. comatose)

III. Epidemiology

  1. Opioids have been implicated in 16,000 deaths per year in U.S. as of 2013
    1. (2015) MMWR Morb Mortal Wkly Rep 64(1): 32 [PubMed]

V. Findings: Symptoms and Signs

  1. Altered Level of Consciousness (CNS depression or Sedation)
    1. Coma
    2. Lethargy
    3. Stupor
  2. Hypotension
  3. Miosis (except Demerol which causes Mydriasis)
  4. Pulmonary edema
  5. Respiratory depression
  6. Seizures

VI. Precautions

  1. Close monitoring must be continued after antidote
    1. Narcotic half-life might exceed that of Naloxone
  2. Consider Very Low Dose Naloxone Protocol
    1. Indicated for Cancer Pain or Chronic Pain (prevents severe Rebound Pain)

VII. Differential Diagnosis: Suspected Opioid Overdose not reversing with Naloxone

  1. Clonidine Overdose
  2. Drugs of Abuse often have very high potency
    1. Krokodil (use Naloxone 2 mg)
    2. Fentanyl derivative (may require Naloxone up to 10 mg )

VIII. Management: General

  1. Naloxone at doses below
  2. Consider for long acting Opioids (Oxycontin, MS Contin, Methadone, Zohydro)
    1. Naloxone continuous infusion
    2. Nalmefene (Revex)

IX. Management: Naloxone (Narcan)

  1. Adults
    1. Initial
      1. No respiratory depression: 0.1 to 0.4 mg IV or IM
      2. Respiratory depression: 1 to 2 mg IV or IM
    2. Next, if no response or incomplete response
      1. Give 2 mg IV or IM every 3-5 minutes to a total of 10-20 mg
    3. Infusion
      1. Naloxone 2 mg in 500 ml D5W or NS (0.004 mg/ml) titrating to response
  2. Children
    1. Initial
      1. No respiratory depression: 0.01 mg/kg IV or IM
      2. Respiratory depression: 0.1 mg/kg IV or IM
    2. Next, if no response or incomplete response
      1. Give 0.1 mg/kg IV or IM

X. Prevention

  1. Prescribe Home Naloxone in case of Overdose for those on high dose Opioids
  2. Keep equianalgesic doses in mind when administering parenteral Opioids
    1. Hydromorphone (Dilaudid) 1 mg is equivalent to up to 10 mg of Morphine Sulfate
  3. Exercise caution when combining agents that blunt respiratory drive (e.g. Opioids with Benzodiazepines)
    1. Benzodiazepines
    2. Muscle relaxants
  4. Analgesic tolerance occurs before tolerance to respiratory depression
    1. Opioid tolerant patients are at increased risk of apnea due to high dose Opioids
  5. Exercise caution in already compromised respiratory status
    1. COPD
    2. Sleep Apnea

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Ontology: Overdose of opiate (C0579142)

Concepts Injury or Poisoning (T037)
SnomedCT 242253008
English opiate overdose, Overdose of opiate, Overdose of opiate (disorder)
Spanish sobredosis de opiáceos (trastorno), sobredosis de opiáceos