Patient safety alert

Transparent EEAST crest

Naloxone is an opioid/opiate antagonist licensed for use in:

• complete or partial reversal of central nervous system depression and especially respiratory depression, caused by natural or synthetic opioids; and

• treatment of suspected acute opioid overdose or intoxication. 

Naloxone must be given with great caution to patients who have received longer-term opioid/opiate treatment for pain control or who are physically dependent on opioids/opiates. Use of naloxone in patients where it is not indicated, or in larger than recommended doses, can cause a rapid reversal of the physiological effects for pain control, leading to intense pain and distress, and an increase in sympathetic nervous stimulation and cytokine release precipitating an acute withdrawal syndrome. 

Hypertension, cardiac arrhythmias, pulmonary oedema and cardiac arrest may result from inappropriate doses of naloxone being used for these types of patients. 

The British National Formulary (BNF) [1] recommends a dose range to reverse acute opioid/opiate overdose in adults by intravenous injection of naloxone of 400 micrograms to 2mg. If there is no response, the dose is to be repeated at intervals of two to three minutes to a maximum of 10mg. 

The BNF highlights that doses used in acute opioid/opiate overdose may NOT be appropriate for the management of opioid/opiate-induced respiratory depression and sedation in those receiving palliative care and in chronic opioid/opiate use. The recommended dose for adults in post-operative respiratory depression and for palliative care and chronic opioid/opiate use by intravenous injection is 100 to 200 micrograms (1.5 to 3 micrograms/kg). 

If the response is inadequate, give subsequent dose of 100 micrograms every two minutes. The naloxone doses in the BNF may differ from those in product literature. Even where doses are given as recommended, there is still a need for careful monitoring of vital observations and maintaining or restoring pain relief. 

NHS England has received details of three patient safety incidents describing failure to follow the BNF guidance, including two incidents that resulted in death. Because this risk appears under-recognised, there may be significant under-reporting. 

Additional safeguards that have been locally implemented include raising awareness of the risk of inappropriate doses of naloxone, the use of lower doses of naloxone in clinical protocols and resuscitation drug trays, teaching correct use of naloxone in annual cardiopulmonary resuscitation training sessions, and providing guidance on clinical monitoring and access to specialist pain relief advice after naloxone administration.

Published 28th November 2014 

0 Comments
Leave a Comment
Name (required)
Email Address (required, never displayed)
Enter a message

(all comments are moderated - your submission will be posted on approval.)