Intravenous vs Subcutaneous Naloxone for Out‐of‐hospital Management of Presumed Opioid Overdose

Abstract

Objective: To determine whether naloxone administered IV to out-of-hospital patients with suspected opioid overdose would have a more rapid therapeutic onset than naloxone given subcutaneously (SQ). Methods: A prospective, sequential, observational cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an urban out-of-hospital setting, comparing time intervals from arrival at the patient's side to development of a respiratory rate 2 1 0 breathdmin, and durations of bag-valve-mask ventilation. Subjects received either naloxone 0.4 mg IV (n = 74) or naloxone 0.8 mg SQ (n = 122). for respiratory depression of < l o breathdmin. Results: Mean interval from crew arrival to respiratory rate 2 1 0 breathdmin was 9.3 2 4.2 min for the IV group vs 9.6 & 4.58 min for the SQ group (95% CI of the difference -1.55. 1.00). Mean duration of bagvalve-mask ventilation was 8.1 & 6.0 min for the IV group vs 9.1 _+ 4.8 min for the SQ group. Cost of materials for administering naloxone 0.4 mg IV was $12.30/patient, compared with $10.7O/patient for naloxone 0.8 mg SQ. Conclusion: There was no clinical difference in the time interval to respiratory rate 2 10 breathdmin between naloxone 0.8 mg SQ and naloxone 0.4 mg IV for the out-of-hospital management of patients with suspected opioid overdose. The slower rate of absorption via the SQ route was offset by the delay in establishing an IV.

Use of naloxone for the management of opioid overdose

“…Wanger et al compared 0.8mg given SC and 0.4mg given IV. The results showed no difference in time interval from arrival at patient's side until respiratory rate rose above 10 breaths per minute [19]. However, the authors may have incorrectly concluded that there was no difference when one may have existed as the study did not meet power.…”

“…However, the authors may have incorrectly concluded that there was no difference when one may have existed as the study did not meet power. Both studies pointed out that the IM and SC routes provide erratic absorption and delayed elimination [18,19]. However, these routes are acceptable alternatives when the IV route is not readily accessible [11,14,16].…”

“…The duration of action for naloxone is 30-60 minutes, and the terminal half-life is 30-90 minutes. It is primarily metabolized by the liver and excreted as inactive metabolites in the urine [13,14,16,19].…”

Emergency medical services controversies in British Columbia

“…The study showed that subcutaneous naloxone is safer, easier to use, and just as effective as intravenous naloxone. 5 Despite being a non-traditional design, its results have been accepted by the prehospital community as valid, and its recommendations have been adopted by other EMS systems. In similar fashion, the results of a 1997 modified randomized crossover study on airway intervention were instrumental in designing protocols for airway management within the BCAS.…”

Prescription Naloxone: A Novel Approach to Heroin Overdose Prevention

“…72,73 The subcutaneous route has been demonstrated to be comparable to the intravenous route but poses some problems in education. 74 The intranasal route of naloxone administration was compared to the intramuscular route in one open-label prehospital randomized trial. The intranasal group took slightly longer to achieve the end point of an adequate respiratory rate and had a higher need for rescue intramuscular naloxone but the complication rate (agitation, vomiting, signs of withdrawal) was much lower in this group.…”