Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

without retained drug packages

1st line – CPR and advanced life support

Back
ACUTE
|
without retained drug packages
|
signs of opioid overdose or toxicity: in cardiac arrest
1st line – 

CPR and advanced life support

If the patient is in cardiac arrest, start CPR immediately according to local advanced life support protocols.[49][58]​​  

Consider – naloxone

Back
ACUTE
|
without retained drug packages
|
signs of opioid overdose or toxicity: in cardiac arrest
Consider – 

naloxone

Treatment recommended for SOME patients in selected patient group

The opioid antagonist, naloxone, is unlikely to be beneficial if the patient is definitely pulseless and receiving CPR. For these patients, standard resuscitation alone is indicated due to the theoretical basis for harm.[48] However, if there is uncertainty as to whether there is a pulse, naloxone should be given.[48] 

The endpoint of therapy is the restoration of adequate spontaneous ventilation but not necessarily complete arousal.[2][57]​​

If intravenous access can be safely obtained, this administration route is likely to be the safest in terms of patient management due to the ability to titrate the dose.[2][57]​​

Intranasal administration is often used in the prehospital setting. Intranasal naloxone has been shown to be safe and effective in the prehospital setting in a number of trials.[64][65][66] The intramuscular route provides a slower onset of action and a prolonged duration of effect, which may minimize rapid onset of withdrawal symptoms in patients with suspected opioid dependence. A handheld autoinjector is available in some countries and can be used by lay people in a prehospital setting. The subcutaneous route can be used if intravenous access cannot be safely obtained.

Use in opioid-dependent/tolerant patients may precipitate acute opioid withdrawal, and naloxone should be used with caution in these patients. A lower dose of naloxone with slow titration to response is recommended. Consult a specialist for further guidance.[2]

Most patients respond with a return of spontaneous respirations and minimal withdrawal symptoms. Repeat doses of naloxone can be given every 2-3 minutes. The duration of effect of naloxone is 30-90 minutes, and patients should be observed after this time frame for resedation. Higher doses may be required before a response is seen in patients who have taken overdoses of buprenorphine or propoxyphene. Fentanyl and its analogs (e.g., 3-methylfentanyl, carfentanil) are potent opioids; patient response may require the administration of multiple doses of naloxone.[11][51]​ Counterfeit hydrocodone/acetaminophen tablets containing fentanyl have been associated with delayed, recurrent toxicity.[67]

Some patients exposed to long-acting or very potent opioids may require further intravenous bolus doses or an infusion of naloxone.[67][68] The dose or infusion rate should be titrated to the smallest effective dose that maintains spontaneous normal respiratory drive.​[2]

Patients should be monitored for recurrence of toxicity for at least 4 hours from the last naloxone dose or discontinuation of naloxone infusion. Patients exposed to long-acting or very potent opioids should have more prolonged monitoring.

Primary options

naloxone: (standard syringe) 0.4 to 2 mg intravenously/intramuscularly/subcutaneously initially, repeat dose every 2-3 minutes according to response, maximum 10 mg/total dose; (autoinjector 5 mg/0.5 mL) 5 mg intramuscularly/subcutaneously initially, may repeat every 2-3 minutes according to response

More

OR

naloxone nasal: (3 mg/0.1 mL) 3 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response; (4 mg/0.1 mL) 4 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response; (8 mg/0.1 mL) 8 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response

More

1st line – initial ventilation

Back
ACUTE
|
without retained drug packages
|
signs of opioid overdose or toxicity: not in cardiac arrest
1st line – 

initial ventilation

Ventilatory support is the most important intervention and may be life-saving on its own.[58]

The primary focus should be to support the airway and breathing, particularly for patients with stupor and a respiratory rate of 12 breaths/minute or less.[59] In these patients, maintain the airway through chin-lift, head-tilt, or jaw-thrust maneuvers.[59] Breathing may require additional ventilatory support through the use of a bag-valve mask with supplemental oxygen in order to maintain oxygen saturations within target range.[79] It is important to adequately ventilate the patient prior to administration of naloxone, to decrease the likelihood of precipitating acute respiratory distress syndrome, which may be associated with reversal in the presence of hypercarbia.[59][60][61] Patients who present with acute respiratory distress syndrome may require higher concentrations of supplemental oxygen and should be managed with supportive care, low tidal volume ventilation, and positive end-expiratory pressure.[62][63]

Consider – naloxone

Back
ACUTE
|
without retained drug packages
|
signs of opioid overdose or toxicity: not in cardiac arrest
Consider – 

naloxone

Treatment recommended for SOME patients in selected patient group

If the patient has signs of opioid-induced respiratory depression but has a pulse, or if there is uncertainty as to whether there is a pulse, naloxone should be given.[48] If the patient has reduced level of consciousness but is breathing normally, naloxone treatment should be considered.[48]

The endpoint of therapy is the restoration of adequate spontaneous ventilation but not necessarily complete arousal.[2][57]​​

If intravenous access can be safely obtained, this administration route is likely to be the safest in terms of patient management due to the ability to titrate the dose.[2][57]​​​ Intranasal administration is often used in the prehospital setting. Intranasal naloxone has been shown to be safe and effective in the prehospital setting in a number of trials.[64][65][66]​ The intramuscular route provides a slower onset of action and a prolonged duration of effect, which may minimize rapid onset of withdrawal symptoms in patients with suspected opioid dependence. A handheld autoinjector is available in some countries and can be used by lay people in a prehospital setting.[65]​ The subcutaneous route can be used if intravenous access cannot be safely obtained.

Use in opioid-dependent/tolerant patients may precipitate acute opioid withdrawal, and naloxone should be used with caution in these patients. A lower dose of naloxone with slow titration to response is recommended. Consult a specialist for further guidance.

Most patients respond with return of spontaneous respirations and minimal withdrawal symptoms. Repeat doses of naloxone can be given every 2-3 minutes. The duration of effect of naloxone is 30-90 minutes, and patients should be observed after this time frame for resedation. Higher doses may be required before a response is seen in patients who have taken overdoses of buprenorphine or propoxyphene. Fentanyl and its analogs (e.g., 3-methylfentanyl, carfentanil) are potent opioids; patient response may require the administration of multiple doses of naloxone.[11][51]​​ Counterfeit hydrocodone/acetaminophen tablets containing fentanyl have been associated with delayed, recurrent toxicity.[67]

Some patients exposed to long-acting or very potent opioids may require further intravenous bolus doses or an infusion of naloxone.[67][68] The dose or infusion rate should be titrated to the smallest effective dose that maintains spontaneous normal respiratory drive.[2]

Patients should be monitored for recurrence of toxicity for at least 4 hours from the last naloxone dose or discontinuation of naloxone infusion. Patients exposed to long-acting or very potent opioids should have more prolonged monitoring.

Primary options

naloxone: (standard syringe) 0.4 to 2 mg intravenously/intramuscularly/subcutaneously initially, repeat dose every 2-3 minutes according to response, maximum 10 mg/total dose; (autoinjector 5 mg/0.5 mL) 5 mg intramuscularly/subcutaneously initially, may repeat every 2-3 minutes according to response

More

OR

naloxone nasal: (3 mg/0.1 mL) 3 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response; (4 mg/0.1 mL) 4 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response; (8 mg/0.1 mL) 8 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response

More

with retained drug packages

1st line – CPR and advanced life support

Back
ACUTE
|
with retained drug packages
|
signs of opioid overdose or toxicity: in cardiac arrest
1st line – 

CPR and advanced life support

If the patient is in cardiac arrest, start CPR immediately according to local advanced life support protocols.[49][58]

Suspected body packers should be monitored closely as there is a high risk of death. In the event of cardiac arrest, CPR should be continued for at least an hour. Prolonged resuscitation, even for several hours, may be appropriate following opioid overdose as recovery with good neurologic outcome may occur.[53]

Consider – naloxone

Back
ACUTE
|
with retained drug packages
|
signs of opioid overdose or toxicity: in cardiac arrest
Consider – 

naloxone

Treatment recommended for SOME patients in selected patient group

The opioid antagonist, naloxone, is unlikely to be beneficial if the patient is definitely pulseless and receiving CPR. For these patients, standard resuscitation alone is indicated due to the theoretical basis for harm.[48]​ However, if there is uncertainty as to whether there is a pulse, naloxone should be given.[48]

The endpoint of therapy is the restoration of adequate spontaneous ventilation but not necessarily complete arousal.[2][57]​​

If intravenous access can be safely obtained, this administration route is likely to be the safest in terms of patient management due to the ability to titrate the dose.[2][57]​​

Intranasal administration is often used in the prehospital setting. Intranasal naloxone has been shown to be safe and effective in the prehospital setting in a number of trials.[64][65][66] The intramuscular route provides a slower onset of action and a prolonged duration of effect, which may minimize rapid onset of withdrawal symptoms in patients with suspected opioid dependence. A handheld autoinjector is available in some countries and can be used by lay people in a prehospital setting. The subcutaneous route can be used if intravenous access cannot be safely obtained.

Use in opioid-dependent/tolerant patients may precipitate acute opioid withdrawal, and naloxone should be used with caution in these patients. A lower dose of naloxone with slow titration to response is recommended. Consult a specialist for further guidance.[2]

Most patients respond with a return of spontaneous respirations and minimal withdrawal symptoms. Repeat doses of naloxone can be given every 2-3 minutes. The duration of effect of naloxone is 30-90 minutes, and patients should be observed after this time frame for resedation. Higher doses may be required before a response is seen in patients who have taken overdoses of buprenorphine or propoxyphene. Fentanyl and its analogs (e.g., 3-methylfentanyl, carfentanil) are potent opioids; patient response may require the administration of multiple doses of naloxone.[11][51]

Counterfeit hydrocodone/acetaminophen tablets containing fentanyl have been associated with delayed, recurrent toxicity.[67]

Some patients exposed to long-acting or very potent opioids may require further intravenous bolus doses or an infusion of naloxone.[67][68] The dose or infusion rate should be titrated to the smallest effective dose that maintains spontaneous normal respiratory drive.[2]

Patients should be monitored for recurrence of toxicity for at least 4 hours from the last naloxone dose or discontinuation of naloxone infusion. Patients exposed to long-acting or very potent opioids should have more prolonged monitoring.

Primary options

naloxone: (standard syringe) 0.4 to 2 mg intravenously/intramuscularly/subcutaneously initially, repeat dose every 2-3 minutes according to response, maximum 10 mg/total dose; (autoinjector 5 mg/0.5 mL) 5 mg intramuscularly/subcutaneously initially, may repeat every 2-3 minutes according to response

More

OR

naloxone nasal: (3 mg/0.1 mL) 3 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response; (4 mg/0.1 mL) 4 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response; (8 mg/0.1 mL) 8 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response

More

Consider – surgical removal

Back
ACUTE
|
with retained drug packages
|
signs of opioid overdose or toxicity: in cardiac arrest
Consider – 

surgical removal

Treatment recommended for SOME patients in selected patient group

Once the patient is stabilized, immediately consult a surgeon for potential surgical removal of the drug packets. A computed tomography scan prior to surgery is helpful but only if the patient is stable enough to be safely maintained on naloxone.[55][75]

1st line – initial ventilation

Back
ACUTE
|
with retained drug packages
|
signs of opioid overdose or toxicity: not in cardiac arrest but with signs of impending complications
1st line – 

initial ventilation

Ventilatory support is the most important intervention and may be life-saving on its own.[58]

The primary focus should be to support the airway and breathing, particularly for patients with stupor and a respiratory rate of 12 breaths/minute or less.[59] In these patients, maintain the airway through chin-lift, head-tilt, or jaw-thrust maneuvers.[59] Breathing may require additional ventilatory support through the use of a bag-valve mask with supplemental oxygen in order to maintain oxygen saturations within target range.[79] It is important to adequately ventilate the patient prior to administration of naloxone, to decrease the likelihood of precipitating acute respiratory distress syndrome, which may be associated with reversal in the presence of hypercarbia.[59][60][61] Patients who present with acute respiratory distress syndrome may require higher concentrations of supplemental oxygen and should be managed with supportive care, low tidal volume ventilation, and positive end-expiratory pressure.[62][63]

Suspected body packers should be monitored closely as there is a high risk of death.

Consider – naloxone

Back
ACUTE
|
with retained drug packages
|
signs of opioid overdose or toxicity: not in cardiac arrest but with signs of impending complications
Consider – 

naloxone

Treatment recommended for SOME patients in selected patient group

If the patient has signs of opioid-induced respiratory depression but has a pulse, or if there is uncertainty as to whether there is a pulse, naloxone should be given.[48] If the patient has reduced level of consciousness but is breathing normally, naloxone treatment should be considered.[48]

The endpoint of therapy is the restoration of adequate spontaneous ventilation but not necessarily complete arousal.[2][57]​​

If intravenous access can be safely obtained, this administration route is likely to be the safest in terms of patient management due to the ability to titrate the dose.[2][57]​​​ Intranasal administration is often used in the prehospital setting. Intranasal naloxone has been shown to be safe and effective in the prehospital setting in a number of trials.[64][65][66]​​ The intramuscular route provides a slower onset of action and a prolonged duration of effect, which may minimize rapid onset of withdrawal symptoms in patients with suspected opioid dependence. A handheld autoinjector is available in some countries and can be used by lay people in a prehospital setting.[65] The subcutaneous route can be used if intravenous access cannot be safely obtained.

Use in opioid-dependent/tolerant patients may precipitate acute opioid withdrawal, and naloxone should be used with caution in these patients. A lower dose of naloxone with slow titration to response is recommended. Consult a specialist for further guidance.

Most patients respond with return of spontaneous respirations and minimal withdrawal symptoms. Repeat doses of naloxone can be given every 2-3 minutes. The duration of effect of naloxone is 30-90 minutes, and patients should be observed after this time frame for resedation. Higher doses may be required before a response is seen in patients who have taken overdoses of buprenorphine or propoxyphene. Fentanyl and its analogs (e.g., 3-methylfentanyl, carfentanil) are potent opioids; patient response may require the administration of multiple doses of naloxone.[11][51] Counterfeit hydrocodone/acetaminophen tablets containing fentanyl have been associated with delayed, recurrent toxicity.[67]

Some patients exposed to long-acting or very potent opioids may require further intravenous bolus doses or an infusion of naloxone.[67][68] The dose or infusion rate should be titrated to the smallest effective dose that maintains spontaneous normal respiratory drive.[2]

Patients should be monitored for recurrence of toxicity for at least 4 hours from the last naloxone dose or discontinuation of naloxone infusion. Patients exposed to long-acting or very potent opioids should have more prolonged monitoring.

Primary options

naloxone: (standard syringe) 0.4 to 2 mg intravenously/intramuscularly/subcutaneously initially, repeat dose every 2-3 minutes according to response, maximum 10 mg/total dose; (autoinjector 5 mg/0.5 mL) 5 mg intramuscularly/subcutaneously initially, may repeat every 2-3 minutes according to response

More

OR

naloxone nasal: (3 mg/0.1 mL) 3 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response; (4 mg/0.1 mL) 4 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response; (8 mg/0.1 mL) 8 mg (1 spray) into one nostril initially, may repeat every 2-3 minutes in alternating nostrils according to response

More

Consider – surgical removal

Back
ACUTE
|
with retained drug packages
|
signs of opioid overdose or toxicity: not in cardiac arrest but with signs of impending complications
Consider – 

surgical removal

Treatment recommended for SOME patients in selected patient group

If a suspected packer presents with signs of opioid overdose, they require an urgent surgical consult. Indications for surgical removal of packages include abdominal pain (possible obstruction or ileus), radiologic evidence of remaining package(s) which are too large to pass through the gastrointestinal tract, and/or evidence of significant or worsening toxicity. An abdominal CT prior to surgery is helpful but only if the patient is stable enough to be safely maintained on naloxone. The patient should be monitored closely as there is a high risk of death.[53]

1st line – observation

Back
ACUTE
|
with retained drug packages
|
asymptomatic or mild signs of opioid toxicity
1st line – 

observation

Patients who ingest opioids for transport may present in various ways and varying levels of toxicity, including asymptomatic or mild signs.[55]

Body packers ingest large quantities of carefully wrapped packages. The packages generally are more resistant to leakage and breaking as they pass through the digestive tract, but if they do, the excessive amount of the drug may quickly lead to a fatal overdose. Body packers should be monitored closely as there is a high risk of death. Body stuffers usually ingest fewer, more loosely wrapped packages, but as the packets are more prone to breaking they may also induce significant toxicity. Body pushers are patients who hide smaller quantities of the drug in various orifices.

The risk of leakage for body stuffers and subsequent opioid overdose is high. These patients should initially be managed with close observation in the emergency department (i.e., intravenous access, cardiac monitor, frequent physical exams and appropriate laboratory tests). They may take several hours for symptoms to develop. Signs of impending complication and overdose include abdominal pain, vomiting, bradycardia, hypotension, central nervous system depression, respiratory compromise, and pulmonary edema.[53][55]​​

In body packers, patients should be observed for at least 24 hours and until all packets have been passed (2-3 normal stools or negative repeated radiologic study). In body stuffers or pushers, patients generally should be observed for at least 8-12 hours and until all packets have passed, although overnight monitoring may also be reasonable for patients stuffing opioid agonists.[55]

Consider – whole bowel irrigation

Back
ACUTE
|
with retained drug packages
|
asymptomatic or mild signs of opioid toxicity
Consider – 

whole bowel irrigation

Treatment recommended for SOME patients in selected patient group

Whole bowel irrigation can speed up the passage of drug packages in body packers where there is radiologic evidence of retained packages and no clinical features of opioid toxicity suggestive of package leakage. A computed tomography scan can help determine the location and estimated number of objects, along with potential complications.

An osmotically balanced polyethylene glycol electrolyte solution may be given orally or via a nasogastric tube until the rectal effluent is clear and all packages have been passed.

Contraindications to whole bowel irrigation include loss of protective airway reflexes, ileus, bowel obstruction, bowel perforation, hemodynamic instability, or clinical evidence of packet leakage.[53]

Whole bowel irrigation is not recommended for body pushers or body stuffers as it can cause package disruption and leakage.

Consider – activated charcoal

Back
ACUTE
|
with retained drug packages
|
asymptomatic or mild signs of opioid toxicity
Consider – 

activated charcoal

Treatment recommended for SOME patients in selected patient group

Some experts recommend a single dose of activated charcoal 1 hour prior to bowel irrigation in body packers. Activated charcoal is more clearly recommended for the management of body stuffers or pushers whose packets are at high risk of breaking, but remains controversial in the management of body packers.[53][55][77]​​

If whole bowel irrigation is not available or not feasible in body packers, activated charcoal in combination with oral laxatives can be considered.[78]

In asymptomatic body stuffers and pushers, it is reasonable to consider an initial dose of activated charcoal in these patients if they are compliant.

Primary options

charcoal, activated: consult local protocol for dose guidelines

Consider – surgical removal

Back
ACUTE
|
with retained drug packages
|
asymptomatic or mild signs of opioid toxicity
Consider – 

surgical removal

Treatment recommended for SOME patients in selected patient group

In the case of surgical complication (e.g., obstruction, perforation), immediate surgical removal is required.[53][55]​​

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer