Treatment of Opioid Overdose

Recognition - The Classic Triad

Opioid overdose presents with three hallmark signs:

Unconsciousness / severely reduced consciousness
Respiratory rate < 12 breaths/min (the most dangerous feature)
Pinpoint (miotic) pupils

Other signs: cyanosis, cold clammy skin, hypotension.

Immediate Management

Step 1 - Call Emergency Services

Call emergency services (911 / 999) immediately.

Step 2 - Airway and Breathing

Position the patient (recovery position if breathing, supine if not)
Open airway, provide basic life support: 30 chest compressions + 2 rescue breaths
Supplemental oxygen via bag-valve mask if available
Endotracheal intubation if the patient cannot protect their airway

Step 3 - Administer Naloxone

Naloxone is an opioid receptor antagonist - it rapidly reverses respiratory depression, sedation, and miosis.

Naloxone Administration Flowchart - adapted from WHO 2014

Naloxone Dosing

Route	Dose	Notes
IV (preferred)	0.2-0.4 mg	Fastest onset; titrate to restore breathing
IM	400 mcg	Pre-loaded syringes; equally effective to IN
Intranasal (IN)	2 mg (spray)	2 mg/mL IN equivalent to 2 mg IM; slower onset, no needle stick risk
SC	400 mcg	Use if IV/IM access is difficult
Apnea / arrest	1-2 mg	Higher initial dose needed

Repeat dosing: If no response in 2-3 minutes, repeat at 2-3 minute intervals. Signs of response = increased respiratory rate and pupil dilation.

No response after 10 mg total - reconsider the diagnosis; consider co-ingestion of alcohol, benzodiazepines, or other sedatives.

Special Considerations

Fentanyl, Buprenorphine, and Nitazenes

These have high receptor affinity and may require multiple repeated naloxone boluses. Fentanyl overdose in particular may require higher doses administered sooner compared to heroin overdose. - Miller's Anesthesia, 10e

Naloxone Half-life Problem

Naloxone has a short half-life of 60-90 minutes. If the causative opioid has a longer half-life (e.g., extended-release oxycodone, methadone), the patient can relapse into coma after naloxone wears off. In these cases: give continuous IV infusion and observe for at least 6 hours after the last naloxone dose.

Precipitated Withdrawal

Rapid, high-dose naloxone can precipitate acute opioid withdrawal - agitation, vomiting, tachycardia. The goal is NOT full alertness, but adequate ventilation:

Target respiratory rate > 10 breaths/min
Target SpO2 > 92%

Titrate gradually to minimize withdrawal risk.

Acute Lung Injury

Rapid reversal in patients with marked hypoventilation can rarely cause acute pulmonary edema with hypoxia, rales, and frothy secretions.

The Primary Goal

Restore adequate ventilation (RR >10/min) and oxygenation (SpO2 >92%) - NOT necessarily full alertness. - Kaplan & Sadock's Comprehensive Textbook of Psychiatry

After Stabilization

Observe for at least 6 hours post-last naloxone dose
Patients on long-term opioids should be prescribed take-home naloxone on discharge
Warn about loss of tolerance after a period of abstinence
Consider referral to opioid use disorder (OUD) treatment - MOUD (methadone/buprenorphine) significantly reduces future overdose risk
Co-prescribe naloxone for patients on chronic opioids ≥50 MME/day or with concurrent benzodiazepine use (CDC guideline)

Sources: Maudsley Prescribing Guidelines in Psychiatry 15e (p. 523) | Kaplan & Sadock's Comprehensive Textbook of Psychiatry (p. 4270) | Miller's Anesthesia 10e (p. 2884)

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