Opioid overdose

Last updated: January 16, 2023

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Opioid overdose results from the toxic effects of exogenous opioids. Deaths related to opioid overdose have been steadily increasing in the United States over the past two decades because of a sharp increase in the prescription of opioids for chronic pain and increasing amounts of illegally manufactured fentanyl. Common clinical features of opioid overdose include respiratory depression, CNS depression, and miosis. Treatment of suspected opioid overdose requires airway management and prompt assessment of the need for naloxone to counter opioid-induced respiratory depression, which can be fatal. Inpatient admission is indicated for patients with ongoing respiratory depression, overdose from long-acting opioids, or medical complications from an opioid overdose. All patients with a noniatrogenic opioid overdose should undergo an assessment for substance use disorder (SUD) and be discharged with take-home intranasal naloxone.

  • Opioid overdose is the most common cause of drug overdose death. [1]
    • From 2015 to 2022, annual opioid overdose deaths nearly tripled. [1]
    • Deaths typically involve high-potency synthetic opioids (e.g., fentanyl).

Epidemiological data refers to the US, unless otherwise specified.

Iatrogenic overdose occurs when a prescribed dose exceeds an individual's tolerance for opioids. Noniatrogenic overdose (i.e., in the setting of unhealthy drug use) may be intentional or unintentional (e.g., use of a higher dose than intended).

Risk factors for opioid overdose [2][3]

Opioid-induced CNS depression is intensified when combined with other sedative-hypnotics (e.g., alcohol, benzodiazepines).

Altered mental status, respiratory depression, and miosis are the classic triad of opioid intoxication. However, the absence of miosis does not rule out opioid intoxication.

Respiratory depression is the most common cause of death in opioid overdose.

Acute management [5][6]

See “Approach to the poisoned patient” for a stepwise approach to patients with known or suspected poisoning.

If possible, perform basic airway maneuvers prior to administering naloxone to reduce the risk of pulmonary edema or acute lung injury after the reversal of apnea. [6]

Naloxone administration [6][8]

There is no consensus on the optimal naloxone dosage for in-hospital settings; follow local protocols when available.

Do not administer naloxone to patients with opioid intoxication who do not have respiratory depression (e.g., patients with a spontaneous respiratory rate ≥ 12 breaths/minute) or those who are already intubated and on a ventilator. [8]

Naloxone has a dose-dependent duration of action that is shorter than most opioids and does not shorten the duration of opioid toxicity. Monitor patients for 4–6 hours after administering naloxone for a resumption of opioid effects. [6]

There is no direct correlation between the dose of naloxone required to reverse opioid-induced respiratory depression and the severity of opioid intoxication. Start low to avoid precipitated withdrawal and increase the dose as needed. [6]

Diagnostics [5][6]

Consider the following to identify comorbid conditions.

Disposition [5][6]

We list the most important complications. The selection is not exhaustive.

Provide take-home naloxone kits to all patients with risk factors for opioid overdose. Train patients and close contacts on the use of naloxone for treating opioid overdose. [3]

  1. Provisional drug overdose death counts. https://web.archive.org/web/20220928030415/https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Updated: September 14, 2022. Accessed: September 29, 2022.
  2. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  3. Boyer EW. Management of Opioid Analgesic Overdose. N Engl J Med. 2012; 367 (2): p.146-155. doi: 10.1056/nejmra1202561 . | Open in Read by QxMD
  4. Miller SC, Fiellin DA, Rosenthal RN, Saitz R. The ASAM Principles of Addiction Medicine. LWW ; 2018
  5. Crotty K, Freedman KI, Kampman KM. Executive Summary of the Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. J Addict Med. 2020; 14 (2): p.99-112. doi: 10.1097/adm.0000000000000635 . | Open in Read by QxMD
  6. Clarke SFJ. Naloxone in opioid poisoning: walking the tightrope. Emerg Med J. 2005; 22 (9): p.612-616. doi: 10.1136/emj.2003.009613 . | Open in Read by QxMD
  7. Connors NJ, Nelson LS. The Evolution of Recommended Naloxone Dosing for Opioid Overdose by Medical Specialty. J Med Toxicol. 2016; 12 (3): p.276-281. doi: 10.1007/s13181-016-0559-3 . | Open in Read by QxMD
  8. Manini AF, Nair AP, Vedanthan R, Vlahov D, Hoffman RS. Validation of the Prognostic Utility of the Electrocardiogram for Acute Drug Overdose. J. Am. Heart Assoc. 2017; 6 (2). doi: 10.1161/jaha.116.004320 . | Open in Read by QxMD
  9. Heaton JD, Bhandari B, Faryar KA, Huecker MR. Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal. J Emerg Med. 2019; 56 (6): p.642-651. doi: 10.1016/j.jemermed.2019.02.015 . | Open in Read by QxMD
  10. Weiner SG, El Ibrahimi S, Hendricks MA, et al. Factors Associated With Opioid Overdose After an Initial Opioid Prescription. JAMA Netw Open. 2022; 5 (1): p.e2145691. doi: 10.1001/jamanetworkopen.2021.45691 . | Open in Read by QxMD
  11. Park TW, Lin LA, Hosanagar A, Kogowski A, Paige K, Bohnert ASB. Understanding Risk Factors for Opioid Overdose in Clinical Populations to Inform Treatment and Policy. J Addict Med. 2016; 10 (6): p.369-381. doi: 10.1097/adm.0000000000000245 . | Open in Read by QxMD
  12. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016; 65 (1): p.1-49. doi: 10.15585/mmwr.rr6501e1 . | Open in Read by QxMD
  13. Theisen-Toupal J, Ronan MV, Moore A, Rosenthal ES. Inpatient Management of Opioid Use Disorder: A Review for Hospitalists. Journal of Hospital Medicine. 2017; 12 (5): p.369-374. doi: 10.12788/jhm.2731 . | Open in Read by QxMD

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