The Evolution of Recommended Naloxone Dosing for Opioid Overdose by Medical Specialty

Connors, Nicholas J.; Nelson, Lewis S.

doi:10.1007/s13181-016-0559-3

Cited by 37 publications

(20 citation statements)

References 14 publications

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“…While our administered dose of naloxone (0.4mg/70kg initial and 0.8mg/70kg secondary if necessary) was lower than the 10mg/70kg dose used by Compton et al, (2004) and in our pilot study (Chu et al, 2009) we observed statistically significant subjective and objective signs of OW suggesting our selected doses were effective. Interestingly, there is currently no universally agreed upon dose of naloxone for use in rescue situations suggesting that little is known concerning individual variation in response to naloxone dosing (Connors & Nelson, 2016). …”

Section: Discussionmentioning

confidence: 99%

Ondansetron Does Not Reduce Withdrawal in Patients With Physical Dependence on Chronic Opioid Therapy

Chu

Sun

Clemenson

et al. 2017

Journal of Addiction Medicine

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Objectives Individuals taking opioids for an extended period of time may become physically dependent, and will therefore experience opioid withdrawal should they stop taking the medication. Previous work in animal and human models has shown that the serotonin (5-HT3) receptor may be implicated in opioid withdrawal. In this study, we investigated if ondansetron, a 5-HT3-receptor antagonist, could reduce the symptoms of opioid withdrawal after chronic opioid exposure in humans. Methods In this double-blinded, randomized crossover study, thirty-three chronic back pain patients (N=33) were titrated onto sustained-release oral morphine for 30 days. Following titration, participants attended two study sessions, one week apart, in which opioid withdrawal was induced with intravenous naloxone, with or without 8mg intravenous ondansetron pretreatment. Opioid withdrawal symptoms were assessed by a blinded research assistant (objective opioid withdrawal score - OOWS) and by the research participant (subjective opioid withdrawal score - SOWS). Results Clinically significant signs of withdrawal were observed during both the ondansetron (ΔOOWS = 3.58 ± 2.22, p < .0001; ΔSOWS = 12.48 ± 11.18, p < .0001) and placebo sessions (ΔOOWS = 3.55 ± 2.39, p < .0001; ΔSOWS = 12.21 ± 10.72, p < .0001), but no significant differences were seen between the treatment sessions in either the OOWS or SOWS scores. Conclusion We hypothesized that ondansetron would reduce opioid withdrawal symptoms in human subjects, but found no difference in withdrawal severity between ondansetron and placebo sessions. These findings suggest that more investigation may be necessary to determine if 5-HT3-receptor antagonists are suitable treatment options for opioid withdrawal.

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Section: Discussionmentioning

confidence: 99%

Ondansetron Does Not Reduce Withdrawal in Patients With Physical Dependence on Chronic Opioid Therapy

Chu

Sun

Clemenson

et al. 2017

Journal of Addiction Medicine

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“…Rationale. Naloxone rescue should be initiated at a dose less than or equal to 0.05 mg intravenous or intramuscular over 1 minute and repeated frequently based on institutional protocol and patient response until sedation and respiratory issues resolve (Connors & Nelson, 2016). The panel recommends that when naloxone reversal is required, clinicians consider the duration of action of naloxone and the duration of action of the opioid and implement frequent monitoring of the patient for any ongoing signs of OIUAS and OIRD.…”

Section: Recommendation 11mentioning

confidence: 99%

American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions

Jungquist

Quinlan-Colwell

Vallerand

et al. 2020

Pain Management Nursing

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a b s t r a c tObjectives: This report presents up-to-date evidence and expert consensus-based revisions to the ASPMN 2011 guidelines that inform interprofessional clinical decision-making for hospitalized adults receiving opioid analgesics. Design: Systematic review of the literature. Methods: A 14-member expert panel was charged with reviewing and grading the strength of scientific evidence published in peer reviewed journals and revising the ASPMN 2011 existing guidelines. Panel members formulated recommendations based on the strength of evidence and reached consensus through discussion, reappraisal of evidence, and voting by majority when necessary. The American Society of Anesthesiologists evidence categories for grading and classifying the strength of the evidence were used. Recommendations were subjected to a critical review by ASPMN members as well as external reviews. Results: The 2011 guidelines were found to still be relevant to clinical practice, but new evidence substantiated refinement and more specific recommendations for electronic monitoring. The revised guidelines present risk factors divided into three categories: patient-specific, treatment-related, and environment of care. Specific recommendations for the use of electronic monitoring are delineated. Conclusions: All hospitalized patients that are administered opioids for acute pain are at risk of opioid induced advancing sedation and respiratory depression, but some patients are at high risk and require extra vigilance to prevent adverse events. All patients must be assessed for level of risk. Adaptations to the plan of care and monitoring strategies should be driven by iterative re-assessments according to level of risk.

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“…Within the medical literature there is wide variation in naloxone dosing recommendations . Connors et al . examined a convenience sample of 25 sources.…”

Section: Introductionmentioning

confidence: 99%

“…Of these references, 12 (48%) suggested starting doses <50 μg while nine (36%) recommended dosages 10 times higher. More conservative dosing protocols dominated recent toxicology specific publications …”

Section: Introductionmentioning

confidence: 99%

One single large intramuscular dose of naloxone is effective and safe in suspected heroin poisoning

Harris

Page

Samantray

et al. 2019

Emerg Medicine Australasia

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Objective Naloxone is an established antidote for the treatment of heroin poisoning; however, dosing regimens vary widely, with a current trend towards small titrated intravenous dosing. This study aims to characterise naloxone use in the treatment of patients presenting with suspected heroin poisoning. Methods This was a retrospective review of poisoned patients presenting to a clinical toxicology unit in Brisbane from January 2015 to December 2017. Patient demographics, clinical effects, naloxone dosing, observation periods and complications were extracted from the patient's medical records. Results There were 117 presentations accounted for by 108 patients. Prehospital naloxone was provided to 57 (49%) patients, 46 of which received a standardised 1.6 mg i.m. dose. The remaining 60 (51%) patients received their first naloxone in hospital, with 58 (97%) receiving this by titrated i.v. doses. A subsequent naloxone infusion was required significantly more often in those treated with i.v. titrated naloxone compared to i.m. dose (27/69 [39%] vs 5/48 [10%], P = 0.0006). The need for parenteral sedation to manage acute behavioural disturbance following naloxone provision was rare (3/117 [3%]). Conclusions In this retrospective observational study, a single large i.m. dose of naloxone reversed the toxicity of suspected heroin overdose in the majority of patients. In addition, patients were less likely to require repeated intermittent doses or naloxone infusion than those treated solely with i.v. naloxone. Further comparison in a prospective study is warranted to validate these observations in confirmed heroin overdose. Requirement for sedation secondary to acute behavioural disturbance was rare regardless of the route.

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The Evolution of Recommended Naloxone Dosing for Opioid Overdose by Medical Specialty

Abstract: There are variations in the recommended doses for naloxone with ranges spanning an order of magnitude. Further exploration is needed to determine the dose that balances reversal of respiratory depression with mitigation of withdrawal.

Cited by 37 publications

References 14 publications

Ondansetron Does Not Reduce Withdrawal in Patients With Physical Dependence on Chronic Opioid Therapy

Ondansetron Does Not Reduce Withdrawal in Patients With Physical Dependence on Chronic Opioid Therapy

American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions

One single large intramuscular dose of naloxone is effective and safe in suspected heroin poisoning

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