Opioid Overdose 💉
UK inpatient opioid overdose management based on NHS Borders naloxone protocol: high- and low-dose naloxone pathways, escalation, monitoring, and observation. Follow your local Trust protocol.
🚨 Immediate priorities
- Assess with ABCDE. Prioritise airway and ventilation, then circulation support.
- Follow your local Trust protocol, including escalation and observation requirements.
- 12-lead ECG and monitor cardiac rhythm where toxicity is significant.
- If life-threatening respiratory failure or arrest, follow ALS and treat as severe opioid toxicity with urgent naloxone.
- Aim for adequate respiratory effort and oxygenation, not necessarily full reversal to GCS 15.
🩺 High-dose IV naloxone regimen (rapid reversal)
- Adult start: 400 micrograms IV.
- If no response after 1 minute: 800 micrograms IV; may repeat 800 micrograms once more at 1-minute interval.
- If still no response: give 2 mg IV and reassess diagnosis.
- In severe poisoning, up to 4 mg may be required before concluding poor response.
⚖️ Low-dose IV naloxone regimen (withdrawal risk / therapeutic opioid use)
- Adult start: 100-200 micrograms IV.
- If no response: additional 100 micrograms at 1-minute intervals (up to 2 further doses), continue careful titration to adequate ventilation.
- If still no response after titration to 2 mg total, give a further 2 mg and reassess diagnosis.
- Use this pathway when abrupt full reversal may be harmful (e.g. chronic opioid therapy, palliative care, post-op analgesia).
💉 Practical delivery notes
- Naloxone effect is shorter than many opioids: monitor for recurrent respiratory depression.
- If repeated boluses are needed, consider naloxone infusion with senior support (HDU/ICU-level monitoring where needed).
- If IV access is delayed, IM naloxone can be used as rescue while establishing definitive access.
- Large cumulative doses may be needed in potent synthetic opioid exposure.
📈 Monitoring and observation
- Continue close respiratory and consciousness monitoring after initial response due to rebound toxicity risk.
- If recurrent depression occurs, repeat naloxone and escalate early for infusion strategy.
- Suggested observation: around 6 hours for short-acting opioids, 12 hours for long-acting or modified-release agents.
- Escalate to senior/critical care if repeated boluses are required, diagnosis is unclear, or ventilation remains unstable.
🌿 Harm reduction and discharge planning
- Before discharge, reassess safety, social context, and recurrence risk.
- Consider take-home naloxone and brief overdose prevention advice for at-risk patients.
- Signpost to local substance use services and community follow-up where appropriate.
📎 Official guideline
Educational reference only. Medical disclaimer