Naloxone: What You Need to Know

As the number of opioid overdoses has accelerated according to the CDC in the past year, there is continued need to understand the administration of naloxone in these patients. Naloxone administration appears to be associated with a high rate of adverse effects, particularly precipitated opioid withdrawal, likely due to the greater physiological dependence caused by fentanyl. By understanding the pharmacology, the potential risks and benefits of use can be further delineated, such as the use of naloxone to reverse fentanyl or buprenorphine overdoses and what is the optimal dose, route of administration, and observation time. Is the new high dose (8 mg) formulation (Kloxxado) necessary to reverse patients that overdosed on fentanyl or an analog? What is the reason that naloxone may not appear to reverse an opioid overdose and what other clinical management tools should be considered? Should a partial agonist such as buprenorphine be administered to certain patients to smooth reversal? As the current opioid epidemic continues to expand, the number of patients presenting to acute care and outpatient settings or requiring acute care for the management of their opioid use disorder after reversal of an overdose continues to grow accordingly. As opioid withdrawal can be precipitated by administration of opioid antagonists such as naloxone, the presentation and treatment of naloxone precipitated withdrawal can be leveraged to act as a bridge to treatment. If so, how much buprenorphine should be administered? Does the naloxone component of sublingual buprenorphine-naloxone matter in these situations? What if you don’t have intravenous access and need to administer naloxone via an intranasal or intramuscular route? How does that change the anticipated effect and dosing?Presentation attendees will receive didactic information on the pharmacology of naloxone and observe an expert panel discussion on the safe and effective use of naloxone in opioid overdose and subsequent management to improve connections to care for opioid use disorder. The pharmacology of naloxone in relation to various routes of administration (intranasal, intravenous, sublingual, intramuscular) and dose will be described and efficacy for reversal of overdose of several commonly used opioids including fentanyl and analogs reviewed. Length of time for monitoring patients following administration of naloxone will also be described using pharmacological and clinical data as well as reports of buprenorphine induction following naloxone administration to increase linkage to care. We will discuss case scenarios via an expert panel of emergency medicine, medical toxicology, and addiction medicine physicians. There will be availability of the panelists to answer audience questions.