On the one hand, you want to reverse some of the sedative effectives with naloxone so that they aren’t near-apneic and hypoxic. You also want to be able to take a history from them. On the other hand, you don’t want to abruptly withdraw them with naloxone such that they become violent and agitated. It is a fine balancing act.
Long-acting opiates present a separate challenging because naloxone wears off fairly quickly in 30-45 minutes. These patients may require repeat dosings and/or a naloxone IV drip.
Trick of the Trade
The beauty of naloxone is that it can be administered through a variety of routes which includes IV, IM, and intranasal. Reported in 2003 in the Journal of EM, the nebulized route is also effective.
- Nebulized naloxone does not require an IV, which is often difficult to establish in IV drug users.
- Instead of administering multiple doses of naloxone for long-acting opiates, nebulized naloxone can provide a steady, low maintenance dose similar to an IV drip but without needing an IV.
- Nebulized naloxone is a self-titrating medication because when the patient awakens, s/he often will pull off the mask.
A good starting regimen is 1-2 mg naloxone in a total volume of 3-5 mL. You may need to add normal saline to reach the target volume. I recently used 1 mg naloxone in 3 mL with great success. The patient was able to give a brief history and remained non-agitated. For longer-term naloxone treatment, you will need to refill the nebulizer canister intermittently or request a large-volume nebulizer canister.
Note: If you need to reverse opiates more quickly, you might consider giving an intranasal dose of naloxone first, followed by a maintenance dose using the nebulizer.
Thanks to Dr. Ethan Cowane (Jacobi Medical Center) for this tip!
Reference (update 5/14/13)
- Mycyk MB, Szyszko AL, Aks SE. Nebulized naloxone gently and effectively reverses methadone intoxication. J Emerg Med. 2003 Feb;24(2):185-7.
- Baumann BM, Patterson RA, Parone DA, Jones MK, Glaspey LJ, Thompson NM, Stauss MP, Haroz R. Use and efficacy of nebulized naloxone in patients with suspected opioid intoxication. Am J Emerg Med. 2013 Mar;31(3):585-8. PMID 23347721