Opioid Overdose Medical Slides

Present the titrated approach: start with naloxone 0.04-0.4 mg IV (goal is adequate ventilation, NOT full arousal — aggressive dosing causes acute withdrawal with vomiting/aspiration and combative patients). For suspected fentanyl: may need higher total doses (up to 10-12 mg reported) due to potency and receptor binding affinity. IM: 0.4-2 mg (absorption slower, suitable for field). Intranasal: 4 mg (Narcan nasal spray, standard community distribution). Key teaching point: ventilate with BVM FIRST — naloxone has a 2-3 minute onset IV, and the patient needs oxygenation now. Repeat every 2-3 minutes as needed.

Present the observation challenge: naloxone duration (30-90 min) is shorter than most opioids, creating renarcotization risk. Heroin: 1-hour post-naloxone observation generally sufficient if asymptomatic and ambulatory (Boyer 2005 criteria: can walk, normal vitals, GCS 15, no concern for coingestants). Fentanyl: extended observation warranted — transdermal patches and body-stuffing/packing can cause delayed/prolonged toxicity. Consider naloxone infusion (2/3 of effective bolus dose per hour) for patients requiring repeated doses. All patients who used alone, used IV, or whose substance is unknown should be observed for minimum 2-4 hours.

Present the paradigm shift to ED-initiated medications for opioid use disorder: the D'Onofrio 2015 JAMA trial showed buprenorphine initiation in the ED doubled engagement in addiction treatment at 30 days versus referral alone. Protocol: once opioid withdrawal confirmed (COWS ≥8-12), administer buprenorphine 4 mg SL, observe 1 hour, give additional 4 mg if tolerated, prescribe bridge supply with warm handoff to outpatient treatment within 72 hours. California bridge model and ACEP policy statement support this approach. Emphasize: every overdose is a reachable moment for OUD treatment engagement.