Opioid overdose
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
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
without retained drug packages
CPR and advanced life support
If the patient is in cardiac arrest, start CPR immediately according to local advanced life support protocols.[49]Resuscitation Council UK. 2021 resuscitation guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines [58]Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2023 Oct 17;148(16):e149-84. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001161?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org#sec-10 http://www.ncbi.nlm.nih.gov/pubmed/37721023?tool=bestpractice.com
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]Dezfulian C, Orkin AM, Maron BA, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-70. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33682423?tool=bestpractice.com However, if there is uncertainty as to whether there is a pulse, naloxone should be given.[48]Dezfulian C, Orkin AM, Maron BA, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-70. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33682423?tool=bestpractice.com
The endpoint of therapy is the restoration of adequate spontaneous ventilation but not necessarily complete arousal.[2]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com [57]Williams K, Lang ES, Panchal AR, et al. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care. 2019 Nov-Dec;23(6):749-63. https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1597955 http://www.ncbi.nlm.nih.gov/pubmed/30924736?tool=bestpractice.com
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]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com [57]Williams K, Lang ES, Panchal AR, et al. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care. 2019 Nov-Dec;23(6):749-63. https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1597955 http://www.ncbi.nlm.nih.gov/pubmed/30924736?tool=bestpractice.com
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]Kerr D, Kelly AM, Dietze P, et al. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009 Dec;104(12):2067-74. http://www.ncbi.nlm.nih.gov/pubmed/19922572?tool=bestpractice.com [65]Chou R, Korthuis PT, McCarty D, et al. Management of suspected opioid overdose with naloxone in out-of-hospital settings: a systematic review. Ann Intern Med. 2017 Dec 19;167(12):867-75. https://www.acpjournals.org/doi/full/10.7326/M17-2224?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/29181532?tool=bestpractice.com [66]Dietze P, Jauncey M, Salmon A, et al. Effect of intranasal vs intramuscular naloxone on opioid overdose: a randomized clinical trial. JAMA Netw Open. 2019 Nov 1;2(11):e1914977. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755306 http://www.ncbi.nlm.nih.gov/pubmed/31722024?tool=bestpractice.com 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]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com
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]Centers for Disease Control and Prevention. Rising numbers of deaths involving fentanyl and fentanyl analogs, including carfentanil, and increased usage and mixing with non-opioids. HAN no. 413. July 2018 [internet publication]. https://emergency.cdc.gov/han/han00413.asp [51]Armenian P, Vo KT, Barr-Walker J, et al. Fentanyl, fentanyl analogs and novel synthetic opioids: a comprehensive review. Neuropharmacology. 2018 May 15;134(pt a):121-32. https://escholarship.org/uc/item/8xh0s7nf http://www.ncbi.nlm.nih.gov/pubmed/29042317?tool=bestpractice.com Counterfeit hydrocodone/acetaminophen tablets containing fentanyl have been associated with delayed, recurrent toxicity.[67]Sutter ME, Gerona RR, Davis MT, et al. Fatal fentanyl: one pill can kill. Acad Emerg Med. 2017 Jan;24(1):106-13. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13034 http://www.ncbi.nlm.nih.gov/pubmed/27322591?tool=bestpractice.com
Some patients exposed to long-acting or very potent opioids may require further intravenous bolus doses or an infusion of naloxone.[67]Sutter ME, Gerona RR, Davis MT, et al. Fatal fentanyl: one pill can kill. Acad Emerg Med. 2017 Jan;24(1):106-13. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13034 http://www.ncbi.nlm.nih.gov/pubmed/27322591?tool=bestpractice.com [68]Rogers JS, Rehrer SJ, Hoot NR. Acetylfentanyl: an emerging drug of abuse. J Emerg Med. 2016 Mar;50(3):433-6. http://www.ncbi.nlm.nih.gov/pubmed/26589567?tool=bestpractice.com The dose or infusion rate should be titrated to the smallest effective dose that maintains spontaneous normal respiratory drive.[2]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com
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 naloxoneDose regimens may vary. Consult a specialist or local protocols for further guidance on suitable dose regimens. Lower doses and cautious titration are recommended in opioid-dependent patients.
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 naloxone nasalDose regimens may vary. Consult a specialist or local protocols for further guidance on suitable dose regimens. Lower doses and cautious titration are recommended in opioid-dependent patients.
initial ventilation
Ventilatory support is the most important intervention and may be life-saving on its own.[58]Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2023 Oct 17;148(16):e149-84. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001161?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org#sec-10 http://www.ncbi.nlm.nih.gov/pubmed/37721023?tool=bestpractice.com
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]Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012 Jul 12;367(2):146-55. http://www.nejm.org/doi/full/10.1056/NEJMra1202561 http://www.ncbi.nlm.nih.gov/pubmed/22784117?tool=bestpractice.com In these patients, maintain the airway through chin-lift, head-tilt, or jaw-thrust maneuvers.[59]Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012 Jul 12;367(2):146-55. http://www.nejm.org/doi/full/10.1056/NEJMra1202561 http://www.ncbi.nlm.nih.gov/pubmed/22784117?tool=bestpractice.com 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]O'Driscoll BR, Howard LS, Earis J, et al; British Thoracic Society Emergency Oxygen Guideline Group; BTS Emergency Oxygen Guideline Development Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com 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]Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012 Jul 12;367(2):146-55. http://www.nejm.org/doi/full/10.1056/NEJMra1202561 http://www.ncbi.nlm.nih.gov/pubmed/22784117?tool=bestpractice.com [60]Mills CA, Flacke JW, Flacke WE, et al. Narcotic reversal in hypercapnic dogs: comparison of naloxone and nalbuphine. Can J Anaesth. 1990 Mar;37(2):238-44. http://www.ncbi.nlm.nih.gov/pubmed/2311152?tool=bestpractice.com [61]Mills CA, Flacke JW, Miller JD, et al. Cardiovascular effects of fentanyl reversal by naloxone at varying arterial carbon dioxide tensions in dogs. Anesth Analg. 1988 Aug;67(8):730-6. http://www.ncbi.nlm.nih.gov/pubmed/3134834?tool=bestpractice.com 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]Thadani PV. NIDA conference report on cardiopulmonary complications of "crack" cocaine use. Clinical manifestations and pathophysiology. Chest. 1996 Oct;110(4):1072-6. http://www.ncbi.nlm.nih.gov/pubmed/8874270?tool=bestpractice.com [63]Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1334-49. http://www.ncbi.nlm.nih.gov/pubmed/10793167?tool=bestpractice.com
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]Dezfulian C, Orkin AM, Maron BA, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-70. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33682423?tool=bestpractice.com If the patient has reduced level of consciousness but is breathing normally, naloxone treatment should be considered.[48]Dezfulian C, Orkin AM, Maron BA, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-70. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33682423?tool=bestpractice.com
The endpoint of therapy is the restoration of adequate spontaneous ventilation but not necessarily complete arousal.[2]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com [57]Williams K, Lang ES, Panchal AR, et al. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care. 2019 Nov-Dec;23(6):749-63. https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1597955 http://www.ncbi.nlm.nih.gov/pubmed/30924736?tool=bestpractice.com
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]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com [57]Williams K, Lang ES, Panchal AR, et al. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care. 2019 Nov-Dec;23(6):749-63. https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1597955 http://www.ncbi.nlm.nih.gov/pubmed/30924736?tool=bestpractice.com 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]Kerr D, Kelly AM, Dietze P, et al. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009 Dec;104(12):2067-74. http://www.ncbi.nlm.nih.gov/pubmed/19922572?tool=bestpractice.com [65]Chou R, Korthuis PT, McCarty D, et al. Management of suspected opioid overdose with naloxone in out-of-hospital settings: a systematic review. Ann Intern Med. 2017 Dec 19;167(12):867-75. https://www.acpjournals.org/doi/full/10.7326/M17-2224?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/29181532?tool=bestpractice.com [66]Dietze P, Jauncey M, Salmon A, et al. Effect of intranasal vs intramuscular naloxone on opioid overdose: a randomized clinical trial. JAMA Netw Open. 2019 Nov 1;2(11):e1914977. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755306 http://www.ncbi.nlm.nih.gov/pubmed/31722024?tool=bestpractice.com 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]Chou R, Korthuis PT, McCarty D, et al. Management of suspected opioid overdose with naloxone in out-of-hospital settings: a systematic review. Ann Intern Med. 2017 Dec 19;167(12):867-75. https://www.acpjournals.org/doi/full/10.7326/M17-2224?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/29181532?tool=bestpractice.com 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]Centers for Disease Control and Prevention. Rising numbers of deaths involving fentanyl and fentanyl analogs, including carfentanil, and increased usage and mixing with non-opioids. HAN no. 413. July 2018 [internet publication]. https://emergency.cdc.gov/han/han00413.asp [51]Armenian P, Vo KT, Barr-Walker J, et al. Fentanyl, fentanyl analogs and novel synthetic opioids: a comprehensive review. Neuropharmacology. 2018 May 15;134(pt a):121-32. https://escholarship.org/uc/item/8xh0s7nf http://www.ncbi.nlm.nih.gov/pubmed/29042317?tool=bestpractice.com Counterfeit hydrocodone/acetaminophen tablets containing fentanyl have been associated with delayed, recurrent toxicity.[67]Sutter ME, Gerona RR, Davis MT, et al. Fatal fentanyl: one pill can kill. Acad Emerg Med. 2017 Jan;24(1):106-13. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13034 http://www.ncbi.nlm.nih.gov/pubmed/27322591?tool=bestpractice.com
Some patients exposed to long-acting or very potent opioids may require further intravenous bolus doses or an infusion of naloxone.[67]Sutter ME, Gerona RR, Davis MT, et al. Fatal fentanyl: one pill can kill. Acad Emerg Med. 2017 Jan;24(1):106-13. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13034 http://www.ncbi.nlm.nih.gov/pubmed/27322591?tool=bestpractice.com [68]Rogers JS, Rehrer SJ, Hoot NR. Acetylfentanyl: an emerging drug of abuse. J Emerg Med. 2016 Mar;50(3):433-6. http://www.ncbi.nlm.nih.gov/pubmed/26589567?tool=bestpractice.com The dose or infusion rate should be titrated to the smallest effective dose that maintains spontaneous normal respiratory drive.[2]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com
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 naloxoneDose regimens may vary. Consult a specialist or local protocols for further guidance on suitable dose regimens. Lower doses and cautious titration are recommended in opioid-dependent patients.
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 naloxone nasalDose regimens may vary. Consult a specialist or local protocols for further guidance on suitable dose regimens. Lower doses and cautious titration are recommended in opioid-dependent patients.
with retained drug packages
CPR and advanced life support
If the patient is in cardiac arrest, start CPR immediately according to local advanced life support protocols.[49]Resuscitation Council UK. 2021 resuscitation guidelines. 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines [58]Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2023 Oct 17;148(16):e149-84. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001161?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org#sec-10 http://www.ncbi.nlm.nih.gov/pubmed/37721023?tool=bestpractice.com
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]Royal College of Emergency Medicine. Best pratice guidelines: management of suspected internal drug trafficker (SIDT). Dec 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/Management_of_Suspected_Internal_Drug_Trafficker_December_2020.pdf
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]Dezfulian C, Orkin AM, Maron BA, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-70. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33682423?tool=bestpractice.com However, if there is uncertainty as to whether there is a pulse, naloxone should be given.[48]Dezfulian C, Orkin AM, Maron BA, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-70. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33682423?tool=bestpractice.com
The endpoint of therapy is the restoration of adequate spontaneous ventilation but not necessarily complete arousal.[2]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com [57]Williams K, Lang ES, Panchal AR, et al. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care. 2019 Nov-Dec;23(6):749-63. https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1597955 http://www.ncbi.nlm.nih.gov/pubmed/30924736?tool=bestpractice.com
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]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com [57]Williams K, Lang ES, Panchal AR, et al. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care. 2019 Nov-Dec;23(6):749-63. https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1597955 http://www.ncbi.nlm.nih.gov/pubmed/30924736?tool=bestpractice.com
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]Kerr D, Kelly AM, Dietze P, et al. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009 Dec;104(12):2067-74. http://www.ncbi.nlm.nih.gov/pubmed/19922572?tool=bestpractice.com [65]Chou R, Korthuis PT, McCarty D, et al. Management of suspected opioid overdose with naloxone in out-of-hospital settings: a systematic review. Ann Intern Med. 2017 Dec 19;167(12):867-75. https://www.acpjournals.org/doi/full/10.7326/M17-2224?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/29181532?tool=bestpractice.com [66]Dietze P, Jauncey M, Salmon A, et al. Effect of intranasal vs intramuscular naloxone on opioid overdose: a randomized clinical trial. JAMA Netw Open. 2019 Nov 1;2(11):e1914977. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755306 http://www.ncbi.nlm.nih.gov/pubmed/31722024?tool=bestpractice.com 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]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com
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]Centers for Disease Control and Prevention. Rising numbers of deaths involving fentanyl and fentanyl analogs, including carfentanil, and increased usage and mixing with non-opioids. HAN no. 413. July 2018 [internet publication]. https://emergency.cdc.gov/han/han00413.asp [51]Armenian P, Vo KT, Barr-Walker J, et al. Fentanyl, fentanyl analogs and novel synthetic opioids: a comprehensive review. Neuropharmacology. 2018 May 15;134(pt a):121-32. https://escholarship.org/uc/item/8xh0s7nf http://www.ncbi.nlm.nih.gov/pubmed/29042317?tool=bestpractice.com
Counterfeit hydrocodone/acetaminophen tablets containing fentanyl have been associated with delayed, recurrent toxicity.[67]Sutter ME, Gerona RR, Davis MT, et al. Fatal fentanyl: one pill can kill. Acad Emerg Med. 2017 Jan;24(1):106-13. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13034 http://www.ncbi.nlm.nih.gov/pubmed/27322591?tool=bestpractice.com
Some patients exposed to long-acting or very potent opioids may require further intravenous bolus doses or an infusion of naloxone.[67]Sutter ME, Gerona RR, Davis MT, et al. Fatal fentanyl: one pill can kill. Acad Emerg Med. 2017 Jan;24(1):106-13. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13034 http://www.ncbi.nlm.nih.gov/pubmed/27322591?tool=bestpractice.com [68]Rogers JS, Rehrer SJ, Hoot NR. Acetylfentanyl: an emerging drug of abuse. J Emerg Med. 2016 Mar;50(3):433-6. http://www.ncbi.nlm.nih.gov/pubmed/26589567?tool=bestpractice.com The dose or infusion rate should be titrated to the smallest effective dose that maintains spontaneous normal respiratory drive.[2]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com
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 naloxoneDose regimens may vary. Consult a specialist or local protocols for further guidance on suitable dose regimens. Lower doses and cautious titration are recommended in opioid-dependent patients.
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 naloxone nasalDose regimens may vary. Consult a specialist or local protocols for further guidance on suitable dose regimens. Lower doses and cautious titration are recommended in opioid-dependent patients.
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]Baril L. Body packers, stuffers, and pushers: time bombs in our EDs. FOAMTOX. 2022 Jun 13. https://www.emdocs.net/body-packers-stuffers-and-pushers-time-bombs-in-our-eds [75]Taming the SRU. Packers, stuffers, and pushers. Sep 2022 [internet publication]. https://www.tamingthesru.com/blog/2022/9/12/packers-stuffers-and-pushers
initial ventilation
Ventilatory support is the most important intervention and may be life-saving on its own.[58]Lavonas EJ, Akpunonu PD, Arens AM, et al. 2023 American Heart Association focused update on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning: an update to the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2023 Oct 17;148(16):e149-84. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001161?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org#sec-10 http://www.ncbi.nlm.nih.gov/pubmed/37721023?tool=bestpractice.com
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]Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012 Jul 12;367(2):146-55. http://www.nejm.org/doi/full/10.1056/NEJMra1202561 http://www.ncbi.nlm.nih.gov/pubmed/22784117?tool=bestpractice.com In these patients, maintain the airway through chin-lift, head-tilt, or jaw-thrust maneuvers.[59]Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012 Jul 12;367(2):146-55. http://www.nejm.org/doi/full/10.1056/NEJMra1202561 http://www.ncbi.nlm.nih.gov/pubmed/22784117?tool=bestpractice.com 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]O'Driscoll BR, Howard LS, Earis J, et al; British Thoracic Society Emergency Oxygen Guideline Group; BTS Emergency Oxygen Guideline Development Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72(suppl 1):ii1-90. https://thorax.bmj.com/content/72/Suppl_1/ii1.long http://www.ncbi.nlm.nih.gov/pubmed/28507176?tool=bestpractice.com 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]Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012 Jul 12;367(2):146-55. http://www.nejm.org/doi/full/10.1056/NEJMra1202561 http://www.ncbi.nlm.nih.gov/pubmed/22784117?tool=bestpractice.com [60]Mills CA, Flacke JW, Flacke WE, et al. Narcotic reversal in hypercapnic dogs: comparison of naloxone and nalbuphine. Can J Anaesth. 1990 Mar;37(2):238-44. http://www.ncbi.nlm.nih.gov/pubmed/2311152?tool=bestpractice.com [61]Mills CA, Flacke JW, Miller JD, et al. Cardiovascular effects of fentanyl reversal by naloxone at varying arterial carbon dioxide tensions in dogs. Anesth Analg. 1988 Aug;67(8):730-6. http://www.ncbi.nlm.nih.gov/pubmed/3134834?tool=bestpractice.com 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]Thadani PV. NIDA conference report on cardiopulmonary complications of "crack" cocaine use. Clinical manifestations and pathophysiology. Chest. 1996 Oct;110(4):1072-6. http://www.ncbi.nlm.nih.gov/pubmed/8874270?tool=bestpractice.com [63]Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1334-49. http://www.ncbi.nlm.nih.gov/pubmed/10793167?tool=bestpractice.com
Suspected body packers should be monitored closely as there is a high risk of death.
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]Dezfulian C, Orkin AM, Maron BA, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-70. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33682423?tool=bestpractice.com If the patient has reduced level of consciousness but is breathing normally, naloxone treatment should be considered.[48]Dezfulian C, Orkin AM, Maron BA, et al. Opioid-associated out-of-hospital cardiac arrest: distinctive clinical features and implications for health care and public responses: a scientific statement from the American Heart Association. Circulation. 2021 Apr 20;143(16):e836-70. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000958?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/33682423?tool=bestpractice.com
The endpoint of therapy is the restoration of adequate spontaneous ventilation but not necessarily complete arousal.[2]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com [57]Williams K, Lang ES, Panchal AR, et al. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care. 2019 Nov-Dec;23(6):749-63. https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1597955 http://www.ncbi.nlm.nih.gov/pubmed/30924736?tool=bestpractice.com
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]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com [57]Williams K, Lang ES, Panchal AR, et al. Evidence-based guidelines for EMS administration of naloxone. Prehosp Emerg Care. 2019 Nov-Dec;23(6):749-63. https://www.tandfonline.com/doi/full/10.1080/10903127.2019.1597955 http://www.ncbi.nlm.nih.gov/pubmed/30924736?tool=bestpractice.com 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]Kerr D, Kelly AM, Dietze P, et al. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009 Dec;104(12):2067-74. http://www.ncbi.nlm.nih.gov/pubmed/19922572?tool=bestpractice.com [65]Chou R, Korthuis PT, McCarty D, et al. Management of suspected opioid overdose with naloxone in out-of-hospital settings: a systematic review. Ann Intern Med. 2017 Dec 19;167(12):867-75. https://www.acpjournals.org/doi/full/10.7326/M17-2224?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/29181532?tool=bestpractice.com [66]Dietze P, Jauncey M, Salmon A, et al. Effect of intranasal vs intramuscular naloxone on opioid overdose: a randomized clinical trial. JAMA Netw Open. 2019 Nov 1;2(11):e1914977. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755306 http://www.ncbi.nlm.nih.gov/pubmed/31722024?tool=bestpractice.com 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]Chou R, Korthuis PT, McCarty D, et al. Management of suspected opioid overdose with naloxone in out-of-hospital settings: a systematic review. Ann Intern Med. 2017 Dec 19;167(12):867-75. https://www.acpjournals.org/doi/full/10.7326/M17-2224?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org http://www.ncbi.nlm.nih.gov/pubmed/29181532?tool=bestpractice.com 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]Centers for Disease Control and Prevention. Rising numbers of deaths involving fentanyl and fentanyl analogs, including carfentanil, and increased usage and mixing with non-opioids. HAN no. 413. July 2018 [internet publication]. https://emergency.cdc.gov/han/han00413.asp [51]Armenian P, Vo KT, Barr-Walker J, et al. Fentanyl, fentanyl analogs and novel synthetic opioids: a comprehensive review. Neuropharmacology. 2018 May 15;134(pt a):121-32. https://escholarship.org/uc/item/8xh0s7nf http://www.ncbi.nlm.nih.gov/pubmed/29042317?tool=bestpractice.com Counterfeit hydrocodone/acetaminophen tablets containing fentanyl have been associated with delayed, recurrent toxicity.[67]Sutter ME, Gerona RR, Davis MT, et al. Fatal fentanyl: one pill can kill. Acad Emerg Med. 2017 Jan;24(1):106-13. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13034 http://www.ncbi.nlm.nih.gov/pubmed/27322591?tool=bestpractice.com
Some patients exposed to long-acting or very potent opioids may require further intravenous bolus doses or an infusion of naloxone.[67]Sutter ME, Gerona RR, Davis MT, et al. Fatal fentanyl: one pill can kill. Acad Emerg Med. 2017 Jan;24(1):106-13. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13034 http://www.ncbi.nlm.nih.gov/pubmed/27322591?tool=bestpractice.com [68]Rogers JS, Rehrer SJ, Hoot NR. Acetylfentanyl: an emerging drug of abuse. J Emerg Med. 2016 Mar;50(3):433-6. http://www.ncbi.nlm.nih.gov/pubmed/26589567?tool=bestpractice.com The dose or infusion rate should be titrated to the smallest effective dose that maintains spontaneous normal respiratory drive.[2]Blundell M, Gill R, Thanacoody R, et al. Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department. Emerg Med J. 2024 Jun 20;41(7):440-5. http://www.ncbi.nlm.nih.gov/pubmed/38763520?tool=bestpractice.com
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 naloxoneDose regimens may vary. Consult a specialist or local protocols for further guidance on suitable dose regimens. Lower doses and cautious titration are recommended in opioid-dependent patients.
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 naloxone nasalDose regimens may vary. Consult a specialist or local protocols for further guidance on suitable dose regimens. Lower doses and cautious titration are recommended in opioid-dependent patients.
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]Royal College of Emergency Medicine. Best pratice guidelines: management of suspected internal drug trafficker (SIDT). Dec 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/Management_of_Suspected_Internal_Drug_Trafficker_December_2020.pdf
observation
Patients who ingest opioids for transport may present in various ways and varying levels of toxicity, including asymptomatic or mild signs.[55]Baril L. Body packers, stuffers, and pushers: time bombs in our EDs. FOAMTOX. 2022 Jun 13. https://www.emdocs.net/body-packers-stuffers-and-pushers-time-bombs-in-our-eds
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]Royal College of Emergency Medicine. Best pratice guidelines: management of suspected internal drug trafficker (SIDT). Dec 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/Management_of_Suspected_Internal_Drug_Trafficker_December_2020.pdf [55]Baril L. Body packers, stuffers, and pushers: time bombs in our EDs. FOAMTOX. 2022 Jun 13. https://www.emdocs.net/body-packers-stuffers-and-pushers-time-bombs-in-our-eds
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]Baril L. Body packers, stuffers, and pushers: time bombs in our EDs. FOAMTOX. 2022 Jun 13. https://www.emdocs.net/body-packers-stuffers-and-pushers-time-bombs-in-our-eds
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]Royal College of Emergency Medicine. Best pratice guidelines: management of suspected internal drug trafficker (SIDT). Dec 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/Management_of_Suspected_Internal_Drug_Trafficker_December_2020.pdf
Whole bowel irrigation is not recommended for body pushers or body stuffers as it can cause package disruption and leakage.
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]Royal College of Emergency Medicine. Best pratice guidelines: management of suspected internal drug trafficker (SIDT). Dec 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/Management_of_Suspected_Internal_Drug_Trafficker_December_2020.pdf [55]Baril L. Body packers, stuffers, and pushers: time bombs in our EDs. FOAMTOX. 2022 Jun 13. https://www.emdocs.net/body-packers-stuffers-and-pushers-time-bombs-in-our-eds [77]CorePendium. Body packers, body stuffers. Aug 2024 [internet publication]. https://www.emrap.org/corependium/chapter/recz0he8IPlduUXNR/Body-Packers-Body-Stuffers
If whole bowel irrigation is not available or not feasible in body packers, activated charcoal in combination with oral laxatives can be considered.[78]Juurlink DN. Activated charcoal for acute overdose: a reappraisal. Br J Clin Pharmacol. 2016 Mar;81(3):482-7. https://bpspubs.onlinelibrary.wiley.com/doi/10.1111/bcp.12793 http://www.ncbi.nlm.nih.gov/pubmed/26409027?tool=bestpractice.com
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
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]Royal College of Emergency Medicine. Best pratice guidelines: management of suspected internal drug trafficker (SIDT). Dec 2020 [internet publication]. https://rcem.ac.uk/wp-content/uploads/2021/10/Management_of_Suspected_Internal_Drug_Trafficker_December_2020.pdf [55]Baril L. Body packers, stuffers, and pushers: time bombs in our EDs. FOAMTOX. 2022 Jun 13. https://www.emdocs.net/body-packers-stuffers-and-pushers-time-bombs-in-our-eds
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