Strength of recommendation: Conditional

This broad recommendation is graded conditional given the variety of settings, skill levels, and access to medical equipment among those likely to witness an overdose. Until recently, intranasal administration of naloxone in the United States was an off-label use, a limitation cited by the guideline authors. However, in November 2015, the FDA approved an intranasal spray formulation of naloxone in an expedited review.⁴

WHO Recommendation #3

In a suspected opioid overdose, first responders should focus on airway management, assisting ventilation, and administering naloxone.

Strength of recommendation: Strong

It always goes back to the ABCs: ventilation is of utmost priority in resuscitation of suspected opioid overdose patients. The authors made the following stepwise recommendations for treating a suspected opioid overdose:

• Apply vigorous stimulation (most commonly sternal rub), check and clear airway, and check respiration—look for chest rising and falling.
• In the presence of vomit, seizures, or irregular breathing, turn the patient on his or her side and, if necessary, clear the airway of vomit.
• In the absence of regular breathing, provide rescue ventilation and administer naloxone.
• If there are no signs of life, commence chest compressions.
• Readminister naloxone after two to three minutes, if necessary.
• In all cases, call for professional assistance.
• Monitor the person until professional help arrives.
• When available, CPR mouth barriers should be used for rescue ventilation.

WHO Recommendation #4

After successful resuscitation following the administration of naloxone, the affected person should have their level of consciousness and breathing closely observed until they have fully recovered.

Strength of recommendation: Strong

“Full recovery” is defined as asymptomatic and at baseline mental status two hours after the last dose of naloxone. Because of the variable half-lives of opioids, the length of observation and determination of recovery should be guided by the specific agent(s) ingested as well as the individual patient’s clinical presentation.

The guideline authors concede that these recommendations do not address the underlying cause of opioid dependence and overdose and that much more work is needed to solve this growing crisis. Although not a permanent fix, naloxone that is widely available to all those likely to witness an opioid overdose can save lives and hopefully stem the tide of opioid overdose deaths.

References

1. Overdose death rates. National Institute on Drug Abuse website. Dec. 2015. Available at: www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed Jan. 5, 2016.
2. Community management of opioid overdose. World Health Organization website. Available at: www.who.int/substance_abuse/publications/management_opioid_overdose/en. Accessed Jan. 5, 2016.
3. GRADE working group. Available at: www.gradeworkinggroup.org. Accessed Jan. 5, 2016.
4. FDA moves quickly to approve easy-to-use nasal spray to treat opioid overdose. US Food and Drug Administration website. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm473505.htm. Accessed Jan. 5, 2016.