Contents:
Background
This guideline was initially produced in response to the National Patient Safety Agency recommendation (May 2006) that naloxone is available in all clinical locations where morphine and diamorphine injections are administered or stored. Subsequent patient safety alerts NHS/PSA/W/2014/016 and NHS/PSA/Re/2015/009 recommended that naloxone must be given with great caution to patients who have received longer-term opioid/opiate treatment for pain control or who are physically dependent on opioids/opiates. It acknowledges that the BNF doses recommended for acute opioid/opiate overdose may not be appropriate for the management of opioid/opiate induced respiratory depression and sedation in those receiving palliative care and in chronic opioid/opiate use.
Guideline statements
Naloxone should only be used in palliative care in those circumstances where a clinician suspects opioid-induced toxicity.
Naloxone is not indicated for:
- Patients on opioids who are dying as a natural result of their disease progression
- Symptoms solely induced by non-opioids (e.g. barbiturates, benzodiazepines), or opioid-induced drowsiness and/or delirium which is not life-threatening
It is important, in the management of patients in pain, that the signs of advanced progressive disease are not confused with those of opioid overdosage, leading to inappropriate use of naloxone.
Patients on regular opioids for pain and symptom control are physically dependent; naloxone given in too large a dose or too quickly can cause an acute withdrawal reaction and an abrupt return of pain that is difficult to control.
Total antagonism of opioids can result in severe pain with hyperalgesia. Physical withdrawal symptoms and marked agitation can also occur. Opioid withdrawal syndrome is characterised by anxiety, irritability, muscle aches, nausea and vomiting. In severe cases, this can include life-threatening tachycardia and hypertension. Cardiac arrhythmias, pulmonary oedema and cardiac arrest have been described.
Patients who are taking opioids and have recently received another intervention (e.g. radiotherapy or nerve block) are at risk of opioid toxicity. Concomitant administration of gabapentinoids can increase the risk of respiratory depression.
- Gabapentin (Neurontin): risk of severe respiratory depression – GOV.UK (www.gov.uk)
- Pregabalin (Lyrica): reports of severe respiratory depression – GOV.UK (www.gov.uk)
Naloxone’s antagonism of buprenorphine is less complete because of the latter’s high receptor affinity and prolonged receptor binding – see Management > Buprenorphine for reversal of buprenorphine-induced respiratory depression. Naloxone has been reported to be only partially effective in reversing the effects of tramadol.
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.