Palliative Care
in Dumfries and Galloway
Staff Area
Managing Opiate Toxicity in Patients Established on Opiate Treatment for Symptom Relief in Palliative Care
If a person is on opiates for symptom control in palliative care, and they develop early signs of opiate toxicity, then omit or reduce the next regular dose of opioid and / or consider an opiate switch or use of adjuvant medications. It is advised that you seek specialist help (on call senior doctor in Palliative Medicine available 24/7 via switchboard 01387 246246 or dial 100 in DGRI) for ongoing pain management. Check calcium and renal function.
If a person is on opiates for symptom control in palliative care, and they develop life-threatening opiate toxicity, naloxone (opiate antagonist) may be required, following the guidance below. Naloxone can precipitate withdrawal, which in itself can be dangerous, particularly if a patient has cardiac problems. If unsure, seek specialist / senior advice.
Naloxone is indicated when:
there is a low respiratory rate < 8
respirations/minute
or oxygen saturation <85%
or if the patient is cyanosed.
Dose and Administration of naloxone
The aim is to gradually improve respiratory effort without causing withdrawal symptoms. This is achieved through administration of small opiate doses and titrating to effect. It can take up to 2 minutes for IV naloxone to work.
1. Stop the opioid.
2. High flow oxygen, if hypoxic.
3. Dilute 400 micrograms naloxone (1 ampoule) to 10ml with sodium chloride 0.9% injection in a 10 ml syringe.
4. Administer a small dose of 80 micrograms (2ml of diluted naloxone) as a slow IV bolus every 2 minutes until the patient’s respiratory status is satisfactory (>8 respirations /minute).
5. Flush the cannula with sodium chloride 0.9% between the naloxone doses.
6. Patients usually respond after 2ml to 4ml of diluted naloxone (=80 micrograms to 160 micrograms) with deeper breathing and an improved conscious level.
7. A few patients need 1mg to 2mg of naloxone (This requires between 3 and 5 ampoules).
If there is little or no response, consider other causes (e.g. other sedatives, an intracranial event, acute sepsis, acute renal failure causing opioid accumulation). Patients on buprenorphine may need higher doses.
Naloxone is short acting and, therefore, the patient will need continued monitoring – the duration of action of most opiates is longer than that of naloxone, so an infusion may be required. This is even more likely with renal or hepatic impairment.
Closely monitor respiratory rate and oxygen saturation.
Further doses may be needed.
Seek anaesthetic / palliative medicine specialist advice as appropriate.
Care settings where there is no immediate access to the IV route (eg) Community
• Naloxone may be administered IM when IV access is not immediately available
• Onset of intramuscular naloxone is 2-5 minutes
• 100 micrograms (0.25ml) naloxone IM should be given and repeated after five minutes if there is no improvement with the first dose