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

• 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.

• 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.

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

• 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.

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

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

• If patient requires ICU care not available locally.

• 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.

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?

   
   

1. Boyer EW. Management of opioid analgesic overdose. New England Journal of Medicine. 2012 Jul 12;367(2):146-55.

   
   

2. Clarke, Simon FJ, Paul I. Dargan, and Alison L. Jones. Naloxone in opioid poisoning: walking the tightrope. Emergency Medicine Journal. 22.9 (2005): 612-616.

   
   

3. Schumann H, Erickson T, Thompson TM, Zautcke JL, Denton JS. Fentanyl epidemic in Chicago, Illinois and surrounding Cook County. Clinical Toxicology. 2008 Jan 1;46(6):501-6.

   
   

4. Adams, A. P., and D. A. Pybus. “Delayed respiratory depression after use of fentanyl during anaesthesia.” Br Med J 1.6108 (1978): 278-279.

   
   

5. Burns, Glenn, et al. Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?. Clinical Toxicology. 54.5 (2016): 420-423.

   
   

6. Information about harm reduction and take home naloxone – towardtheheart.com

   
   

7. Kent DA, editor. Poison management manual. Vancouver: British Columbia Drug and Poison Information Centre; 2015.