Managing Opioid Overdose: A Practical Guide for Clinicians

Opioid overdoses have become an unavoidable part of our daily shifts in the ED. It is a tragic commonality that transcends social and economic lines. It would be a safe bet that if you are reading this, you likely have a friend, family member, or colleague whose life has been disrupted by opioid abuse. 

With the rise of cheap, widely available fentanyl and fentanyl-adulterated street drugs, many patients don’t even realize they’ve taken an opioid. Naloxone may pull them back from the brink, but as every clinician knows, reversal is the start of treatment, not the end.

First Things First: Assess, Ask, Observe

In the era of fentanyl analogues and polysubstance abuse, remember that patients may have mixed toxidromes or present atypically, especially with an increasing prevalence of xylazine (“tranq”), or benzo co-ingestion. 

The classic triad of opioid overdose:

• Respiratory depression

• Decreased level of consciousness

• Miosis 

If the story given by EMS or a friend/family member is unclear as to the causative agent, remember that there may be some sort of opioid adulterant, especially if the patient became suddenly apneic. 

Focus on Your ABCs

Before reaching for the naloxone, take a moment and protect the basics. Is the patient breathing, and is their airway patent? Do they have a palpable pulse? 

In many opioid overdoses, the root cause of death is hypoxia, not the drug itself. So if you only do one thing, remember to support their breathing.

• Rescue breaths with a BVM often restore oxygenation faster than the onset of naloxone

• Oxygen via mask or cannula is helpful, but positive pressure is often needed

• Consider intubation for patients with prolonged apnea or multi-substance overdose

Naloxone: The Right Dose at the Right Time

Naloxone works by displacing opioids from the mu receptors. It’s fast, but sometimes too fast. Especially with potent opioids like fentanyl, rapid reversal can trigger: agitation, vomiting, severe withdrawal, and dangerous tachycardia or arrhythmias.

At some point in your training, you probably heard the saying, “You can always give more, but you can’t give less.” While this pearl of wisdom applies to all medications, it is critical dogma for anyone who has ever cared for a patient on the receiving end of too much naloxone. Instead of regaining consciousness with a new felt appreciation for life and all its wonders, imagine you were instead immediately thrown into a personal hell of suffering from acute withdrawals. 

 Start low, and go slow:

• The IV route is preferred for titration: Start at 0.4mg, and slowly increase up to 2mg. 

• IM or IN (intranasal) options are great for prehospital settings or if IV access is delayed–typically 2-4mg intranasal per dose. 

• Naloxone’s half-life is shorter than many opioids, so be prepared to redose within 30-90 minutes of treatment. 

• If the patient requires multiple doses, consider starting a naloxone infusion. 

Aftercare: Don’t Let Them Walk Into Another Overdose

You’ve saved a life. Now what?

Discharging someone after naloxone reversal because “they seem fine” isn’t doing anyone favors, especially with long-acting agents or mixed overdoses.

Observe the patient in the ED for at least 2-4 hours, especially if the patient required multiple doses of naloxone, used a long-acting opioid (methadone, ER morphine), arrived in respiratory arrest, or required airway management.

Here are some suggestions on how to engage (without judgment) about next steps:

• “Would you like help getting into treatment?”

• “Have you had naloxone to take home before?”

• “Is there someone we can call to be with you right now?”

Resources to offer:

• Naloxone kits with training and education if available in your ED.

• If possible, engage social services to discuss recovery resources available to the patient.

• Arrange close follow-up care within 72 hours if those resources are available.

And don’t forget: patients who leave AMA after overdose are at high risk of death in the following days. Even a brief, compassionate conversation can plant the seeds of change.

A Note on Stigma: Meet Them Where They Are

Your patient isn’t a “drug seeker.” They’re a human being struggling with a treatable condition. Maybe they were using heroin to escape trauma. Maybe they didn’t know that pill had fentanyl in it. Maybe today’s the day they’re ready to talk. Opioid Use Disorder is not a moral failing — it’s a chronic illness. We don’t kick patients out for DKA because they didn’t take their insulin. Let’s extend that same grace here.

Diving Deeper into Opioid Use Disorder

If you find yourself at the forefront of treating opioid use disorder and overdoses, or want to become more comfortable with treatment options such as buprenorphine, then check out OUD Decoded, A DEA-compliant audio course by Hippo that will give you the confidence you need to manage opioid and substance use disorders.