Definitions

Opioid Overdose

A clinical syndrome of respiratory depression, altered mental status, and miotic pupils following opioid use. Death is caused by respiratory failure.

Naloxone (Narcan)

An opioid antagonist that reverses respiratory depression by displacing opioids from the mu receptor. Effective for opioids only — does not reverse benzodiazepines, alcohol, or stimulants.

Precipitated Withdrawal

Acute opioid withdrawal triggered by naloxone administration. Includes vomiting, agitation, diaphoresis, body aches. Uncomfortable but rarely life-threatening.

Purpose

To define recognition, treatment, and disposition of suspected opioid overdose — including coordination with law enforcement, refusal handling, and post-overdose support referral.

Scope

Applies to all suspected opioid overdoses and to overdoses where the agent is unclear and respiratory depression is present.

Recognition

• Respiratory depression — rate < 12, shallow breathing, periods of apnea.
• Altered mental status — unresponsive or responsive only to pain.
• Miotic (small) pupils — though sympathomimetic co-ingestion may obscure this.
• Cyanosis around lips and fingertips.
• Drug paraphernalia at scene.
• Recent history of opioid use from bystanders.
• Resuscitation in suspected opioid overdose follows standard BLS / ALS until reversed.

Initial Management

1. Open the airway and support ventilation with bag-valve-mask. This is the most important early step.
2. Apply pulse oximetry, oxygen, cardiac monitor, capnography when available.
3. Establish IV / IO access when feasible.
4. Glucose check.
5. Naloxone per dosing below.

Naloxone Dosing (Adjust to Your Standing Orders)

Titration & Recurrence

• Titrate naloxone to respiratory rate and oxygenation, not to alertness. Full alertness may trigger combative behavior or precipitated withdrawal.
• Long-acting opioids and high-dose fentanyl may require repeat doses or naloxone infusion. Monitor for re-sedation.
• Patients who initially respond and then re-sedate during transport are common — anticipate and prepare additional doses.

Post-Reversal Care

• Reassure the patient; their last awareness may be hours ago.
• Expect agitation, nausea, vomiting — protect the airway, prepare for emesis.
• Many patients refuse transport once awake. See the Refusal section below.
• Re-assess vitals every 5 minutes minimum.
• Continuous monitoring for re-sedation throughout transport.

Refusal After Reversal

Naloxone-reversed patients commonly refuse transport. This is one of the highest-liability refusal situations in EMS.

1. Conduct a thorough capacity assessment per the Patient Refusal SOP.
2. Specifically explain: 'Naloxone wears off in 30–90 minutes. Your fentanyl / heroin may last longer. You can stop breathing again. You can die.'
3. Document risks explained verbatim.
4. Consult online medical control for any reversal refusal.
5. Encourage the patient to allow another adult to stay with them.
6. Leave naloxone (intranasal kit) and overdose education materials.
7. Document the refusal completely.

Family / Bystander Naloxone

• If a bystander administered naloxone before EMS arrival, document this in the PCR — agent, dose, time, effect.
• Continue medical evaluation regardless of bystander dose.
• Recognize bystander efforts; consider this an opportunity for harm-reduction education.

Pediatric Overdose

Pediatric opioid overdose is increasingly common — often unintentional exposure (fentanyl analogs in the home). Treat aggressively; pediatric airway compromise occurs faster than adult. Mandatory reporting per the Mandatory Reporting SOP.

Linkage to Care

• Many regions have peer recovery navigators, EMS Leave-Behind programs, or MAT (medication-assisted treatment) bridge programs.
• Whenever the patient consents, refer to the regional opioid response program.
• Provide overdose education materials and naloxone kit where authorized by state law.
• Document the referral in the PCR.

Provider Safety

• Standard PPE — gloves and eye protection.
• Concern about fentanyl absorption through skin is not supported by toxicology evidence; standard PPE is sufficient.
• Do not lick fingers, wear gloves when handling unknown substances, follow PPE for the actual exposure pathway.
• Provider exposed to suspected powdered fentanyl: wash skin with soap and water, monitor for symptoms, treat symptomatic exposure with naloxone.

Documentation

• Chief complaint, history, scene findings.
• Initial vitals, oxygenation, respiratory rate.
• Bystander or prior naloxone administration.
• Naloxone administration — dose, route, time, response.
• Subsequent dosing.
• Reassessment vitals.
• Behavioral response and any restraint per the Behavioral SOG.
• Refusal documentation if applicable.
• Referral provided.

Training

• Initial training in opioid overdose response and naloxone titration.
• Annual refresher with case-based scenarios including high-dose fentanyl and pediatric cases.
• Joint training with regional peer recovery and MAT bridge programs.
• Trauma-informed approach and stigma reduction training annually.

References

• SAMHSA Opioid Overdose Toolkitsamhsa.gov
• NAEMSP Position Statement on Naloxonenaemsp.org
• Naloxone Standing Order[INSERT STATE / MEDICAL DIRECTOR]
• Regional Bridge Program[INSERT PROGRAM]

Adapt this template

Before this template becomes your department's policy, review the following items and adjust accordingly. Anything else that does not match your operation should be updated as well.

• Adjust naloxone dosing to your standing orders. Many systems now start with lower titrated doses to avoid precipitated withdrawal.
• Identify your regional peer recovery or MAT bridge program.
• Confirm state law on naloxone leave-behind authority.
• Cross-reference Patient Refusal, Behavioral / Mental Health Response, and Controlled Substance Handling SOPs.