Multiple drugs Agitation and lack of efficacy: case reportA 43-year-old woman developed agitation secondary to naloxone withdrawal following an overdose of naloxone. She also exhibited lack of efficacy following treatment with buprenorphine, diphenhydramine, haloperidol and lorazepam for agitation.The woman was brought to emergency department by emergency medical services due to agitation. She had a history of opioid abuse. Prior to presentation, she was found unconscious and apneic, and a family member administered intranasal naloxone 4mg. However, no immediate response was observed. Hence, her family member administered five additional cartridges of naloxone 4 mg without a pause. She had received 24mg of naloxone and after a brief period, she was awake but in a severely agitated state. She was transferred to the emergency department. Her vital examination was significant for tachycardia and tachypnea. She was disoriented, screaming incoherently, diaphoretic and retching. Laboratory tests showed decreased platelet count and haemoglobin. The overdose of naloxone likely led to prolonged increased concentrations of naloxone and resulted in severe precipitated withdrawal manifesting as agitation. Also, her clinical opiate withdrawal scale score was 25.The woman was treated with a total of IV buprenorphine 1.2 mg along with lorazepam 10mg, haloperidol 10mg and diphenhydramine 50 mg for over 3 hours [not all routes stated]. However, no resolution the symptoms were observed. She was shifted to the ICU and intubated with propofol sedation. On the next day, her mental status normalised. She was extubated without any complication. Her urine toxicology test was positive for cocaine and fentanyl metabolites and she confirmed using cocaine 4 days prior. Eventually, she was discharged with outpatient resources for substance abuse and prescription for naloxone.
