MJ, a 48-year-old male arrives to your emergency room unresponsive. He was found in the park by his sister. Upon examination you observe MJ is unconscious with pinpoint size pupils and his lips are tinted blue. MJ’s vitals from intake are listed below:

Past medical history:

Opioid Use Disorder

Labs/Vitals:

Ht: 5’11 ft

Wt: 200 lbs

BP: 90/60 mmHg

HR: 49 BPM

RR: 10

Temp: 90.5 F

What is the appropriate naloxone dose MJ should receive?

A. 0.4 mg Intranasal

B. 0.4 mg Orally

C. 0.4 mg Rectal

D. 0.4 mg Intramuscularly

Answer with rationale:

Overdose emergencies are intense and require quick decision making. Due to the level of urgency in this situation and the patient’s unknown medical history, it is important to closely monitor the patient. Repeat administration of naloxone is common, especially in large overdoses or overdoses involving long-acting dosage forms, such as a fentanyl patch. Important vitals to look for in opioid toxicity are as follows: bradycardia, hypotension, hypothermia, and a decrease in respiratory rate. These symptoms in addition to pinpoint pupils can indicate an opioid overdose.

The initial dose of naloxone ranges depending on the dosage form and is usually administered every 2-3 minutes based on response.  The maximum dose of naloxone a patient should receive is generally 10-15mg. Naloxone is available in multiple dosage forms, but a patient actively experiencing an overdose especially who is unconscious should receive administration intranasally (IN), intramuscularly (IM), or intravenously (IV).

Answer A is incorrect. While the naloxone dose could be administered intranasally, this dose is not available within a nasal spray. Typically these ready to use dosage forms are given as 3mg or 4mg intranasally. 

Answer B is incorrect. Naloxone is available in many different administration forms. However, PO naloxone is only indicated for opioid induced constipation and not opioid reversal. In addition, patients who are unconscious cannot receive oral therapy due to inability to swallow and potential risk for aspiration. 

Answer C is incorrect. While naloxone is available in many dosage forms, rectal naloxone is not commercially available.

Answer D is correct. This is an appropriate starting dose for naloxone. IM naloxone is a quick and effective route for emergency situations. The patient could receive IV naloxone as well if a peripheral line could be obtained quickly. 

Brand/generics Covered:

Naloxone (Various Brand Names depending on dosage form)

Naplex Competencies Covered:

2.A.2 – Indications, usage, and dosing regimens

2.C.4 – Administration (e.g., techniques, preparation, routes)

3.C.1 – Signs, Symptoms, and findings of medical conditions, etiology of diseases, or pathophysiology

3.C.6 – Toxicologic exposures and overdoses