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Opioid Toxicity

Question Type:
Intervention
Full Question:
Among adults who are in cardiac arrest or respiratory arrest due to opioid toxicity in any setting  (P), does  any specific therapy (eg, naloxone, bicarbonate, or other drugs) (I), compared with  usual ALS  (C), change  (O)?
Consensus on Science:
For the important outcome of survival with favorable neurologic outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year, survival only at discharge, 30 days, 60 days, 180 days, and/or 1 year, ROSC, after opioid-induced cardiac arrest, we found no study with comparative data beyond standard ALS care. For the important outcome of survival with favorable neurologic outcome at discharge, 30 days, 60 days, 180 days, and/or 1 year, survival only at discharge, 30 days, 60 days, 180 days, and/or 1 year, ROSC, after opioid-induced respiratory arrest, we found no comparative studies. There were 12 studies of which 5 compared intramuscular and intranasal routes of naloxone administration (2 RCT,(Kelly 2005, 24; Kerr 2009, 2067) 3 non-RCT,(Wanger 1998, 293; Barton 2005, 265; Robertson 2009, 512) and 7 assessed the safety of naloxone use or were observational studies of naloxone use).(Cetrullo 1983, 199; Osterwalder 1996, 409; Sporer 1996, 660; Stokland 1998, 3144; Buajordet 2004, 19; Cantwell 2005, 315; Boyd 2006, 1266; Nielsen 2011, 1410; Wampler 2011, 320), These studies report that naloxone is safe and effective in treatment of opioid-induced respiratory depression, that complications are rare and dose related, and that mortality is rare when patients refuse transfer after initial naloxone administration.
Treatment Recommendation:
We recommend the use of naloxone by IV, intramuscular, subcutaneous, IO, or intranasal routes in respiratory arrest associated with opioid toxicity (strong recommendation, very-low-quality evidence). The dose of naloxone required will depend on the route. We can make no recommendation regarding the modification of standard ALS in opioid-induced cardiac arrest. Values, Preferences, and Task Force Insights In making these recommendations, we place a high value on the potential of the opioid antagonist naloxone to reverse opioid-induced respiratory depression.

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