What are the alternatives to Narcan when treating opiate overdose?

1.

Elsevier ClinicalKey Drug Monograph

Content last updated: April 4, 2024.

Indications And Dosage **For known or suspected opioid overdose** Intravenous dosage Non-opioid-dependent Adults: 0.5 mg/70 kg IV. If needed, a second dose of 1 mg/70 kg IV may be given 2 to 5 minutes later. If no clinical response is observed, additional doses are unlikely to have an effect. Use the lowest effective dose. Known or suspected opioid-dependent Adults: 0.1 mg/70 kg IV as an initial challenge dose. If there is no evidence of withdrawal after 2 minutes, give 0.5 mg/70 kg IV. If needed, a second dose of 1 mg/70 kg IV may be given 2 to 5 minutes later. If no clinical response is observed, additional doses are unlikely to have an effect. Use the lowest effective dose. Intramuscular or Subcutaneous dosage (only if IV access is lost or not readily obtainable) Adults: 1 mg IM or subcutaneously as a single dose. Intranasal dosage Adults: 2.7 mg (1 spray) intranasally every 2 to 5 minutes in alternating nostrils as needed. Each device contains a single dose. Seek immediate medical assistance after administration of the first dose. Monitor the patient closely until emergency medical personnel arrive. If the patient responds to treatment and subsequently relapses back into respiratory depression before medical assistance arrives, administer an additional dose in the opposite nostril. Children and Adolescents 12 to 17 years: 2.7 mg (1 spray) intranasally every 2 to 5 minutes in alternating nostrils as needed. Each device contains a single dose. Seek immediate medical assistance after administration of the first dose. Monitor the patient closely until emergency medical personnel arrive. If the patient responds to treatment and subsequently relapses back into respiratory depression before medical assistance arrives, administer an additional dose in the opposite nostril.

2.

Infante AF, Elmes AT, Gimbar RP, et al. Stronger, Longer, Better Opioid Antagonists? Nalmefene Is NOT a Naloxone Replacement. The International Journal on Drug Policy. 2024;124:104323. doi:10.1016/j.drugpo.2024.104323.

Publish date: February 4, 2024.

The fatal overdose crisis claims nearly 200 lives daily in the United States (U.S). Evolutions in the illicit drug supply, such as the addition of sedative adulterants and a shift to synthetic opioids such as fentanyl, have driven increasing rates of both fatal and non-fatal overdose. Specifically, synthetic opioid usage of fentanyl was implicated in 68 % of the U.S. drug overdose deaths in 2022 alone. This has placed tremendous burden on communities, emergency medical services, and healthcare systems, and contributed to tragedy and grief both in the U.S. and worldwide. Despite the availability of effective opioid antagonist medications and standards of care, there has been increased interest in research and development of alternative opioid overdose reversal agents by the National Institutes of Health (NIH) in partnership with pharmaceutical manufacturers over the last decade. The U.S. Food and Drug Administration (FDA) recently approved nalmefene (Opvee) a mu-opioid receptor antagonist that boasts an extended half-life and stronger mu-receptor affinity compared to the standard of care use of naloxone for opioid reversal. In this article, we explore the medical need and ramifications of the introduction of longer-acting opioid antagonists in the current opioid overdose landscape. Existing data highlight the effectiveness of already available naloxone products as a safe and effective standard of care. These data support the notion that stronger, longer-acting agents may be unnecessary, and their existence may cause undue harm, such as more severe and/or prolonged withdrawal symptoms, lead to challenging patient interactions, and complicate the initiation of medications for opioid use disorder.

3.

Elsevier ClinicalKey Clinical Overview

Treatment Treatment planning in consultation with a medical toxicologist is recommended Regional poison centers may be contacted at 1-800-222-1222 Treatment of the overdose patient should focus on supportive measures (also known as the Scandinavian method Treat all patients, whether or not they are symptomatic, as having the potential for a life-threatening ingestion Delay in providing supportive care leads to increased morbidity and mortality Primary management "Coma cocktail" (flumazenil, naloxone, dextrose, physostigmine) should not be routinely administered Dextrose can be given, because neuroglycopenia may be present in setting of euglycemic capillary/serum testing Thiamine can be given, especially with concomitant alcohol use history Flumazenil should not be routinely used due to risk of precipitating withdrawal Naloxone reserved for concern of opioid toxicity: altered mental status, miosis, and respiratory depression Physostigmine can be given in consultation with medical toxicologists if concern for anticholinergic toxidrome Respiratory support Provide ventilatory support via bag-valve mask with an oro-/nasopharyngeal airway, or perform endotracheal intubation with ventilator support Intubate early if patient is unable to maintain an airway, there is concern for aspiration, or the patient’s expected clinical course is deterioration Noninvasive positive pressure ventilation is relatively contraindicated in the overdosed or poisoned patient due to increased risk of aspiration Circulatory support Maintain perfusion through use of fluids and targeted medications Note that the poisoned heart may have decreased inotropy and chronotropy, and IV fluid administration may lead to pulmonary edema Vasopressors may best support adequate cardiac output in this setting Treat rhythm and conduction abnormalities identified on ECG as conduction abnormalities are associated with adverse cardiac events Treat prolonged QRS (greater than 100 milliseconds) with sodium bicarbonate Treat prolonged QTc (greater than 500 milliseconds) with magnesium sulfate