Advertisement

Use and efficacy of nebulized naloxone in patients with suspected opioid intoxication

Published:January 23, 2013DOI:https://doi.org/10.1016/j.ajem.2012.10.004

      Abstract

      Objective

      To describe the use and efficacy of nebulized naloxone in patients with suspected opioid intoxication.

      Methods

      This was an observational study conducted at an inner city emergency department. Patients were eligible if they had self-reported or suspected opioid intoxication and a spontaneous respiratory rate ≥6 breaths/minute. Nebulized naloxone (2 mg in 3 mL normal saline) was administered through a standard face mask at the discretion of the treating physician. Structured data collection included demographics, vital signs pre and post naloxone administration and adverse events. The primary outcome was level of consciousness, which was recorded pre and 15 minutes postnaloxone administration using the Glasgow Coma Scale (GCS) and the Richmond Agitation Sedation Scale (RASS).

      Results

      Of the 73 patients who presented with suspected opioid intoxication and were given naloxone over the study period, 26 were initially treated with nebulized naloxone. After nebulized naloxone administration, median GCS improved from 11 [interquartile range (IQR) 3.5] to 13 (IQR, 2.5), P = .001. Median RASS improved from −3.0 (IQR, −1.0) to −2.0 (IQR, −1.5), P < .0001. Need for supplemental oxygen decreased from 81% to 50%, P = .03. Vital signs did not differ pre/post therapy. There were few adverse effects from nebulized naloxone administration: 12% experienced moderate-severe agitation, 8% were diaphoretic and none vomited. Eleven required subsequent administrations of naloxone, nine of whom self-reported using either heroin, methadone or both. Of these, 5 underwent urine drug screening and all 5 tested positive for either opiates or methadone.

      Conclusions

      Nebulized naloxone was well-tolerated and led to a reduction in the need for supplemental oxygen as well as improved median GCS and RASS scores in patients with suspected opioid intoxication.
      To read this article in full you will need to make a payment
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Drug Abuse Warning Network, 2006: National Estimates of Drug-Related Emergency Department Visits, U.S. Department Of Health And Human Services. Substance Abuse and Mental Health Services Administration. Available at http://DAWNinfo.samhsa.gov. Accessed May 3, 2012.

        • Popova S.
        • Patra J.
        • Mohapatra S.
        • et al.
        How many people in Canada use prescription opioids non-medically in general and street drug using populations?.
        Can J Public Health. 2009; 100: 104-108
        • Barton E.D.
        • Colwell C.B.
        • Wolfe T.
        • et al.
        Efficacy of intranasal naloxone as a needleless alternative for treatment of opioid overdose in the prehospital setting.
        J Emerg Med. 2005; 29: 265-271
        • Kelly A.M.
        • Koutsogiannis Z.
        Intranasal naloxone for life threatening opioid toxicity.
        Emerg Med J. 2002; 19: 375
        • Kelly A.M.
        • Kerr D.
        • Dietze P.
        • et al.
        Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose.
        Med J Aust. 2005; 182: 24-27
      2. Occupational exposure to bloodborne pathogens—OSHA. Final Rule.
        Fed Regist. 2001; 66 (Accessed November 5, 2012): 5317-5325
        • Kerr D.
        • Kelly A.M.
        • 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; 104: 2067-2074
        • Robertson T.M.
        • Hendey G.W.
        • Stroh G.
        • et al.
        Intranasal versus intravenous naloxone for prehospital narcotic overdose.
        Acad Emerg Med. 2005; 12: 166-167
        • Dowling J.
        • Isbister G.K.
        • Kirkpatrick C.M.
        • et al.
        Population pharmacokinetics of intravenous, intramuscular, and intranasal naloxone in human volunteers.
        Ther Drug Monit. 2008; 30: 490-496
        • Loimer N.
        • Hofmann P.
        • Chaudhry H.R.
        Nasal administration of naloxone is as effective as the intravenous route in opiate addicts.
        Int J Addict. 1994; 29: 819-827
        • Weinstein S.H.
        • Pfeffer M.
        • Schor J.M.
        • et al.
        Absorption and distribution of naloxone in rats after oral and intravenous administration.
        J Pharm Sci. 1973; 62: 1416-1419
        • Howland M.A.
        Opioid antagonists.
        in: Goldfrank L.R. Flomenbaum N.E. Lewin N.A. Howland M.A. Hoffman R. Weisman R. Goldfrank's Toxicologic Emergencies. Appleton and Lange, Stamford, CT2002: 614-619
        • Mycyk M.B.
        • Szyszko A.L.
        • Aks S.E.
        Nebulized naloxone gently and effectively reverses methadone intoxication.
        J Emerg Med. 2003; 24: 185-187
        • Weber J.M.
        • Tataris K.L.
        • Hoffman J.D.
        • et al.
        Can nebulized naloxone be used safely and effectively by emergency medical services for suspected opioid overdose?.
        Prehosp Emerg Care. 2012; 16: 289-292
        • Karras D.
        • Levy D.
        • Domingo L.
        • et al.
        Nebulized naloxone for reversal of narcotic intoxication: results of a pilot trial.
        Ann Emerg Med. 1998; 32: S56
      3. Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991;20(3):246–52.15.

        • Merlin M.A.
        • Saybolt M.
        • Kapitanyan R.
        • Alter S.M.
        • Jeges J.
        • Liu J.
        • et al.
        Intranasal naloxone delivery is an alternative to intravenous naloxone for opioid overdoses.
        Am J Emerg Med. 2010; 28: 296-303
        • Sporer K.A.
        • Firestone J.
        • Isaacs S.M.
        Out-of-hospital treatment of opioid overdoses in an urban setting.
        Acad Emerg Med. 1996; 3: 660-667
        • Mégarbane B.
        • Buisine A.
        • Jacobs F.
        • Résière D.
        • Chevillard L.
        • Vicaut E.
        • et al.
        Prospective comparative assessment of buprenorphine overdose with heroin and methadone: clinical characteristics and response to antidotal treatment.
        J Subst Abuse Treat. 2010; 38: 403-407
        • Kelly A.M.
        • Kerr D.
        • Dietze P.
        • Patrick I.
        • Walker T.
        • Koutsogiannis Z.
        Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose.
        Med J Aust. 2005; 182: 24-27
        • Burnett A.M.
        • Salzman J.G.
        • Griffith K.R.
        • Kroeger B.
        • Frascone R.J.
        The emergency department experience with prehospital ketamine: a case series of 13 patients.
        Prehosp Emerg Care. 2012; 16: 553-559
        • Nisbet A.T.
        • Mooney-Cotter F.
        Comparison of selected sedation scales for reporting opioid-induced sedation assessment.
        Pain Manag Nurs. 2009; 10: 154-164
        • Ely E.W.
        • Truman B.
        • Shintani A.
        • Thomason J.W.
        • Wheeler A.P.
        • Gordon S.
        • et al.
        Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).
        JAMA. 2003; 289: 2983-2991
        • Sessler C.N.
        • Gosnell M.
        • Grap M.J.
        • Brophy G.T.
        • O'Neal P.V.
        • Keane K.A.
        • et al.
        The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients.
        Am J Respir Crit Care Med. 2002; 166: 1338-1344
        • Baumann B.M.
        • Mazzarelli A.
        • Brunner J.
        • Chansky M.E.
        • Thompson N.
        • Boudreaux E.D.
        Purchase and use patterns of heroin users at an inner city emergency department.
        J Emerg Med. 2012; 42: 93-99