The role of naloxone in the opioid crisis

Figures & data

Figure 1. Drug overdose deaths in the United States, 1999–2016, by opioid category. Deaths involving more than one drug may be counted in more than one category. Data taken from the NCHS Data Brief, December 2017 [1].

Table 1. Case studies involving higher than usual doses of naloxone in patients with synthetic opioid intoxication.

Ref.	Patient	Drug	Naloxone dose	Outcome
[12]	23-year-old female, unresponsive, 4 breaths/min	U-47700 insufflated and IV	2 mg IN – no response; 2 mg IV - response (4 mg total)	Discharged next day; LC-MS drug confirmation
[13]	36-year-old male, altered mental status, pinpoint pupils, GCS = 6	Vaping “synthetic opium” shown to contain acetylfentanyl	2 mg IV – awoke but eventually mental status declined; 2 mg IV – again roused but mental status declined; 2 mg IV followed by 1.5mg/hour infusion (>7.5 mg total)	Admitted to ICU; Identity of drug determined through website of sale
[14]	24-year-old male, hypotension, hypoxic respiratory failure	Street purchased hydrocodone/acetaminophen tablets shown to contain fentanyl	2 mg IN + 1 mg IV – no significant response (3 mg total)	Eighteen further patients over eight days, one death, 3/18 received ≥5 mg naloxone total bolus dose, 4/18 received a naloxone infusion

Table 2. Retrospective case series involving higher than usual doses of naloxone to treat patients with suspected synthetic opioid intoxication.

Ref.	Study description	Naloxone administered	Summary of findings
[15]	Observational case series; Chicago, IL; ED data; Opioid overdoses 5 April–6 Dec	Twenty-six cases; 0.4–12 mg IV naloxone; average 3.36 mg	6/26 patients required >6 mg IV naloxone; 0.4 mg effectively reversed patient toxicity in only 15% of ED cases; even with some initial doses of 2 mg IV no patients experienced significant withdrawal
[10]	Data analysis of NEMSIS 2012–2015; naloxone use only; comparison of single vs. multiple naloxone administration (MNA)	2012: 95,012 patients received naloxone; 14.49% MNA 2015: 173,016 patients received naloxone; 18.24% MNA	MNA increased 25.8% from 2012 to 2015; odds of MNA were the highest in north-eastern US, which is consistent with increased use of fentanyl; no data on administration route
[16]	Survey study; April 2016 MA; adults who had used opioids (<2 months) and witnessed or survived an opioid overdose (<6 months)	83% of survey respondents reported that ≥2 naloxone doses (likely 2 mg/2ml) were required in cases of suspected fentanyl overdose	∼2/3 of opioid overdose deaths in south-eastern MA (Oct 2014–Mar 2015) involved fentanyl [44% in Oct 2014 to 76% in Mar 2015]

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