Last reviewed: March 2026
Contents
MDM Templates
Opioid Overdose
Patient presents with altered mental status, miotic pupils, and respiratory depression consistent with opioid toxidrome. Responded to naloxone with improved mental status and respiratory effort.
Presentation consistent with opioid intoxication based on classic toxidrome and naloxone response. Given rapid and sustained improvement after naloxone, presentation not consistent with pontine stroke, clonidine toxicity (no bradycardia and hypotension), organophosphate poisoning (no secretions, no fasciculations), or significant polysubstance ingestion.
Reassessment: Monitored for renarcotization. Reassessed 1 hour after last naloxone dose — patient is wide awake, pupils midrange, breathing comfortably. No evidence of recurrent sedation or respiratory depression.
Plan: Discharge with naloxone prescription, overdose education, and substance use resources. Return for recurrent drowsiness, difficulty breathing, or confusion.
Opioid Overdose — Severe / Post-Arrest
Patient presents in severe opioid toxicity with respiratory arrest or cardiac arrest. Resuscitation initiated with focus on oxygenation and ventilation as the primary intervention.
Opioid overdose death is a respiratory arrest that progresses to hypoxic cardiac arrest. Naloxone alone may be insufficient if significant hypoxia has already occurred. Must consider complications of prolonged down time: aspiration pneumonia, anoxic brain injury, rhabdomyolysis, compartment syndrome from prolonged positioning, and non-cardiogenic pulmonary edema. Fentanyl and its analogues may require higher or repeated naloxone doses.
Plan: Secure airway. Naloxone titrated to respiratory effort. CXR for aspiration or pulmonary edema. CK and renal function for rhabdomyolysis. Compartment checks on dependent extremities. Admit to ICU for post-arrest care or if requiring ongoing airway support.
Opioid Withdrawal
Patient presents with myalgias, diaphoresis, lacrimation, rhinorrhea, piloerection, diarrhea, and restlessness consistent with opioid withdrawal. Vitals notable for mild tachycardia and hypertension. No fever, no altered mental status.
Opioid withdrawal is intensely uncomfortable but not life-threatening in otherwise healthy adults. Not consistent with sepsis (no fever, no localizing source), thyroid storm (no goiter, no tremor), sympathomimetic toxicity (no mydriasis, no agitation beyond restlessness), or serotonin syndrome (no clonus, no hyperreflexia). Clinical picture and timeline consistent with withdrawal from known opioid use.
Plan: Symptom management with ondansetron, NSAIDs, clonidine, and dicyclomine as needed. Consider ED-initiated buprenorphine if patient is interested in medication-assisted treatment and meets criteria. Discharge with substance use resources and follow-up for addiction medicine. Return for fever, intractable vomiting, or inability to tolerate fluids.
Clinical Education
Opioid Toxidrome
Classic triad: miosis, respiratory depression, altered mental status. Miotic (“pinpoint”) pupils are the most reliable physical exam finding. Exceptions: meperidine, tramadol, and propoxyphene can cause mydriasis due to serotonergic or anticholinergic properties. Mixed ingestions may also alter the expected pupil finding.[1]
Respiratory depression is the mechanism of death. Opioids suppress the medullary respiratory center, leading to progressive hypoventilation, apnea, hypoxic cardiac arrest, and death. The entire treatment algorithm centers on restoring ventilation.
Synthetic opioids (fentanyl, carfentanil) dominate the current overdose epidemic. They are more potent, have faster onset, and may require higher or repeated naloxone doses compared to heroin or prescription opioids. Chest wall rigidity (“wooden chest syndrome”) can occur with rapid IV fentanyl and may require neuromuscular blockade to ventilate.
Naloxone Dosing and Pitfalls
Titrate naloxone to respiratory effort, not consciousness. The goal is a respiratory rate >12, not a fully alert patient. In practice, most ED physicians give 0.4-2 mg IV as an initial dose. For apneic or pulseless patients, give 2-4 mg IV without hesitation. The only real downside of higher doses is precipitated withdrawal — agitation, vomiting (aspiration risk), tachycardia — which is uncomfortable but not dangerous. EMS routinely gives 2-4 mg IM/IN in the field for the same reason: underdosing and having to re-access while managing an apneic patient is the greater risk.[1]
Naloxone dosing:
| Route | Dose | Notes |
| IV (ED, breathing) | 0.4-2 mg, repeat q2-3 min | Most attendings start at 0.4-1 mg for hypoventilation |
| IV (apneic/pulseless) | 2-4 mg | No reason to start low in a dying patient |
| IM (EMS) | 2-4 mg | Prehospital standard — higher dose accounts for slower absorption |
| Intranasal | 4 mg (Narcan nasal spray) | Bystander/prehospital use |
| IV infusion | 2/3 of effective bolus dose per hour | For long-acting opioids or recurrent sedation |
Renarcotization is the critical post-naloxone risk — but the observation period itself is the diagnostic test. You don’t need to know what opioid the patient took to decide how long to watch them. Naloxone’s clinical duration varies by route:
| Route | Onset | Duration of Clinical Effect |
| IV | 1-2 min | 20-40 min |
| IM | 2-5 min | 60-90 min |
| Intranasal | 3-5 min | 45-90 min |
| Subcutaneous | 5-10 min | 60-90 min |
The 1-hour reassessment is the clinical decision point. By 60 minutes after an IV dose, the naloxone has worn off. If the patient is wide awake with midrange pupils and normal respirations, the opioid is not outlasting the naloxone — by definition it was short-acting or a small enough burden that the body is clearing it. That patient has declared themselves low-risk. If at 60 minutes the patient is becoming somnolent or miotic again, the opioid is winning — you now know you’re dealing with a longer-acting agent or larger body burden, and you extend observation, redose, or admit accordingly. The observation period tells you what the patient took; you don’t need to know in advance to decide how long to watch.
No response to 10 mg total naloxone strongly suggests a non-opioid cause of AMS. Reassess the differential. Consider benzodiazepines, GHB, clonidine, or structural CNS pathology.[1]
Complications of Opioid Overdose
Aspiration pneumonia/pneumonitis is common after prolonged obtundation. Obtain CXR in any patient who required intubation or had a prolonged down time. Treat with antibiotics only if clinical infection develops — aspiration pneumonitis is an inflammatory process.
Non-cardiogenic pulmonary edema (NCPE) can occur after naloxone reversal or opioid overdose itself. Presents as acute hypoxia and bilateral infiltrates. Mechanism is likely acute catecholamine surge and negative-pressure pulmonary edema. Treatment is supportive with oxygen and NIPPV or intubation if severe.[1]
Rhabdomyolysis from prolonged immobilization in a single position. Check CK in any patient found down for a prolonged period. Examine dependent extremities for compartment syndrome — a swollen, tense limb after prolonged down time needs emergent pressure measurement.
Wound botulism should be considered in injection drug users presenting with cranial nerve palsies, descending weakness, or bulbar symptoms. This is a rare but life-threatening complication of skin-popping or wound injection.
Withdrawal Management
Opioid withdrawal is miserable but not fatal in otherwise healthy adults. Exceptions: neonates (neonatal abstinence syndrome) and patients with severe comorbidities (heart failure, COPD) where the physiologic stress of withdrawal can decompensate the underlying disease.[2]
Timeline varies by opioid:
| Opioid | Onset of Withdrawal | Peak | Duration |
| Heroin / fentanyl | 8-24 hours | 36-72 hours | 5-7 days |
| Methadone | 24-36 hours | 72-96 hours | 14-21 days |
Symptom-directed treatment: Clonidine 0.1-0.2 mg PO q6-8h (for autonomic symptoms), ondansetron 4 mg IV/PO (nausea), dicyclomine 20 mg PO (abdominal cramping), loperamide (diarrhea), NSAIDs (myalgias), hydroxyzine (anxiety/insomnia). IV fluids for dehydration from vomiting and diarrhea.
ED-Initiated Buprenorphine
ED-initiated buprenorphine reduces opioid use, increases treatment engagement, and reduces mortality. The landmark D’Onofrio 2015 trial demonstrated that ED-initiated buprenorphine with referral was superior to referral alone. This is now considered standard of care and is endorsed by ACEP.[3]
Initiation criteria: Patient with opioid use disorder, in moderate withdrawal (COWS ≥8), interested in treatment, and not pregnant (pregnancy requires specialized dosing). Must be in withdrawal — administering buprenorphine to a patient with opioid on board precipitates severe withdrawal.
Protocol: Buprenorphine/naloxone 4 mg SL, reassess in 1 hour. If still in withdrawal, give additional 4 mg SL (max 8 mg on day 1 in ED). Prescribe home supply to bridge to outpatient follow-up (typically 8-16 mg/day). Arrange follow-up with addiction medicine or buprenorphine-waivered provider within 72 hours.
Common concern — precipitated withdrawal: Occurs when buprenorphine (partial agonist) displaces a full agonist from receptors. Avoid by ensuring the patient is already in withdrawal (COWS ≥8) before the first dose. If precipitated withdrawal occurs, it is self-limited (1-3 hours) and treated symptomatically.
Disposition
Discharge (overdose): Reassess at 1 hour after last naloxone dose. If patient is wide awake, pupils midrange, breathing comfortably — the naloxone has worn off and the opioid is not coming back. Safe for discharge. No need for a blanket 4-hour observation if the 1-hour reassessment is normal. If at 1 hour the patient is becoming somnolent or miotic, extend observation, redose, or admit — the opioid is outlasting the naloxone. Naloxone prescription provided. Overdose education and substance use resources given. Return for drowsiness, difficulty breathing, or confusion.
Discharge (withdrawal): Tolerating oral intake. Symptoms controlled. If buprenorphine initiated, bridge prescription and follow-up arranged. Return for intractable vomiting, inability to keep fluids down, or fever.
Admit: Recurrent somnolence or respiratory depression at 1-hour reassessment requiring repeat naloxone or infusion. Aspiration pneumonia or non-cardiogenic pulmonary edema. Rhabdomyolysis. Post-cardiac arrest. Suspected body packing.
References
- Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367(2):146-155. PubMed
- Kosten TR, Baxter LE. Effective management of opioid withdrawal symptoms: a gateway to opioid dependence treatment. Am J Addict. 2019;28(2):55-62. PubMed
- D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. PubMed
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