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    Opioid Overdoses – Management

    Special Populations, Toxicology

    Last Updated Oct 23, 2017
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    Context

    • Ultrapotent opioids such as fentanyl are now ubiquitous. Opioid overdoses are becoming increasingly common and represented almost half of illicit overdose deaths in 2016.

    Signs and Symptoms

    • Usually presents as sedation, miosis with progression to respiratory depression, coma and death.
    • Less commonly chest wall rigidity (fentanyl and derivatives), acute lung injury, QT prolongation and Torsades de Pointes.
    • Rapid onset following IV injection or insufflation.
    • Peak effect within 1 hour of ingesting regular-release products or crushed/adulterated sustained-release tablets.
    • May be significantly delayed with massive ingestion and sustained-release products.
    • Absorption may be delayed up to 24 hours with ingested fentanyl patches.

    Duration of Action

    • The duration of action depends on dose, ongoing absorption, and the half-life
    • Duration of action in overdose can be significantly longer than therapeutic dosing.
    • Short/moderate half-life (2-4 hours):
      • Heroin,
      • morphine,
      • hydrocodone,
      • hydromorphone,
      • oxycodone,
      • meperidine, and
      • fentanyl* (duration of action of fentanyl may exceed 24 hours in overdose).
    • Long half-life (>12 hours):
      • Buprenorphine,
      • Methadone,
      • Oral extended-release preparations.

    Diagnostic Process

    • Opioid toxidrome, history of drug use, paraphernalia found with the patient, and response to naloxone.

    Recommended Treatment

    • Do not induce vomiting.
    • Supplemental oxygen with assisted ventilations as required.
    • Consider activated charcoal if ingested within 1-2 hours and there is no concern for aspiration.
    • Protect airway as needed.
    • Hypotension typically responds to IV fluids.
    • Chest x-ray if persistent low O2 sats, abnormal chest sounds or fever.
    • Obtain an EKG to rule out significant QT prolongation or other dysrhythmias if methadone or loperamide is suspected.
    • Call the poison centre if there are any management or diagnostic questions.
    • Offer patients take-home naloxone and access to addictions services at discharge.

     

    Indications for naloxone:

    • Respiratory rate < 10 /min OR
    • Saturation < 92% on room air, inability of patient to protect their airway OR,
    • Fentanyl induced chest wall rigidity.

     

    Goals of naloxone:

    • RR ≥ 10/min,
    • GCS > 10,
    • Protecting airway,
    • No acute withdrawal symptoms precipitated.

     

    Routes: IV/IO preferred. IM/SC otherwise.

     

    Dosing:

    • Adults: 0.1 mg IV/IO or 0.4 mg IM if no IV/IO
    • Pediatrics: 0.1 mg/kg IV/IO/IM of body weight

     

    • If insufficient response, subsequent IV doses should be administered every 2 minutes (q3 minutes IM): 0.4 mg, 2.0 mg, 4.0 mg, and then 10 mg as a final dose if there is a high clinical suspicion of opioid intoxication.
    • If no response, look for alternate causes for symptoms.

      

    Naloxone infusion:

    • Consider infusion if there is recurrence of symptoms.
    • Bolus, then 0.4-0.8 mg/hr. titrated to clinical effect.
    • Infants = 0.04-0.16 mg/kg/hr.
    • Alternatively, administer two-thirds of the initial effective bolus dose per hour to keep the patient alert.

     

    Observation

    • Asymptomatic patients who have ingested opiate and NOT received naloxone:
      • Monitor for 4 hours following regular release opioids and 12 hours following ingestion of sustained release opioids or methadone.
    • Lower risk patients:
      • Did not require more than 0.9 mg naloxone for reversal.
      • Opioid smoked, insufflated or injected (not ingested).
      • Did not require repeat doses or infusion of naloxone.
      • Observe for a minimum of 2 hours following naloxone administration.
    • Higher risk patients:
      • Oral overdose
      • More than 0.9 mg of naloxone required for reversal.
      • Observe for a minimum of 6 hours following last dose of naloxone.
    • Naloxone infusion: Observe for at least 12 hours after naloxone infusion has been stopped.

    Criteria For Safe Discharge Home

    • Awake, alert with normal vital signs and oxygen saturation on room air and can mobilize as usual without verbal or physical stimulation.

    Criteria For Hospital Admission

    • Acute lung injury,
    • Inadequate response to antidote therapy,
    • Ongoing naloxone infusion needed.

    Criteria For Transfer To Another Facility

    • If patient requires ICU care not available locally.

    Consult

    • BC Drug and Poison Information Centre 604-682-5050, or 1-800-567-8911.
    • Consult should be obtained for all pediatric or body packing/stuffing exposures as well as any supratherapeutic exposure to methadone, buprenorphine or fentanyl patches.

    Quality Of Evidence?

    Justification

    Case reports, case series and retrospective chart reviews.

    Low

    Related Information

    OTHER RELEVANT INFORMATION

    1. Take Home Naloxone  – www.naloxonetraining.com

      Tool for patients to learn how to use a Take Home Naloxone Kit. It can also be used in centres where staff members are not very familiar with dispensing a THN kit. (St. Paul’s Hospital ED Project).


    2. UBC Department of Emergency Medicine Grand Rounds – Dec. 13, 2017

      PDF: Opioid Epidemic: What role does the ED have?


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