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Review
. 2012 Jul 12;367(2):146-55.
doi: 10.1056/NEJMra1202561.

Management of opioid analgesic overdose

Edward W Boyer  1
Affiliations
Review

Management of opioid analgesic overdose

Edward W Boyer. N Engl J Med. .
No abstract available

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Conflict of interest statement

Dr. Boyer reports reviewing medical malpractice documents for CRICO (Controlled Risk Insurance Company) Vermont, MCIC Vermont, and PMSLIC (Pennsylvania Medical Group Management Association). No other potential conflict of interest relevant to this article was reported.

Figures

Figure 1
Figure 1. Onset and Duration of Action in Therapeutic Dosing and Overdose of Selected Opioid Analgesic Agents
Information about the toxic effects of opioid analgesic overdose often must be synthesized from case reports, the clinical observations of medical toxicologists, and forensic data.- The difference between the clinical effects of therapeutic use and poisoning for these selected agents arises from the toxicokinetics of overdose, patterns of abuse, and the variation in drug effects in special populations.
Figure 2
Figure 2. Clinical Findings in Opioid Analgesic Intoxication
The sine qua non of opioid intoxication is respiratory depression, but miosis and stupor are often observed in poisoned patients. Hypoxemia or ingestion of drugs that are coformulated with acetaminophen can cause hepatic injury; acute renal failure can result from hypoxemia or precipitation of myoglobin due to rhabdomyolysis. Opioid analgesics decrease intestinal peristalsis by binding to opioid receptors in the gut. Patients with stupor who are motionless often have compressed fascia-bounded muscle groups, culminating in the compartment syndrome; they may also have hypothermia as a result of environmental exposure or misguided attempts at reversing intoxication. Since fentanyl can be a source of overdose, patients should be examined for the presence of fentanyl patches.
Figure 3
Figure 3. Naloxone Dosing
Empirical trials are needed to determine the effective dose of naloxone. Patients who do not have a response to an initial dose of naloxone should receive escalating doses until respiratory effort is restored. Naloxone, which is frequently dispensed as an injectable solution in doses of 0.4 mg per milliliter and 1 mg per milliliter for adults, is almost devoid of adverse effects. Pediatric patients are defined as children up to the age of about 5 years or with a body weight of up to 20 kg. Pediatric patients with opioid intoxication frequently require larger doses of naloxone to reverse the effects of overdose because of the relatively higher ingested dose per kilogram of body weight.
Figure 4
Figure 4. Decision Tree for Managing Opioid Analgesic Overdose in Adults
Because of the long duration of action of many opioid analgesic formulations, the brief effectiveness of naloxone, and the potential lethality of an opioid analgesic overdose, there should be a low threshold for admitting intoxicated patients to a hospital unit that provides close monitoring, such as an intensive care unit.,, Published guidelines for the management of opioid intoxication were developed on the basis of data from patients with heroin overdose and should not be applied to patients with opioid analgesic overdose.,
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Comment in

  • Management of opioid analgesic overdose.
    Brown EN, Solt K. Brown EN, et al. N Engl J Med. 2012 Oct 4;367(14):1370-1; author reply 1372-3. doi: 10.1056/NEJMc1209707. N Engl J Med. 2012. PMID: 23034040 No abstract available.
  • Management of opioid analgesic overdose.
    Throckmorton DC, Compton WM, Lurie P. Throckmorton DC, et al. N Engl J Med. 2012 Oct 4;367(14):1371; author reply 1372-3. doi: 10.1056/NEJMc1209707. N Engl J Med. 2012. PMID: 23034041 No abstract available.
  • Management of opioid analgesic overdose.
    Kim HK, Nelson LS. Kim HK, et al. N Engl J Med. 2012 Oct 4;367(14):1371-2; author reply 1372-3. doi: 10.1056/NEJMc1209707. N Engl J Med. 2012. PMID: 23034042 No abstract available.
  • Management of opioid analgesic overdose.
    Picetti E, Rossi I, Caspani ML. Picetti E, et al. N Engl J Med. 2012 Oct 4;367(14):1372; author reply 1372-3. doi: 10.1056/NEJMc1209707. N Engl J Med. 2012. PMID: 23034043 No abstract available.

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