NaloxoneOverdoses of long-acting opiates, such as oxycodone and methadone, are challenging to manage, especially if these patients are chronically on opiates.

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

NebulizerMaskNebulized naloxone

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.

Naloxone Administration

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
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD