42-year-old man • altered mental status • vomiting • agitation • Dx?

This additional history suggested the patient’s true diagnosis was acute opioid withdrawal precipitated by his accidental self-administration of naloxone.

DISCUSSION

Naloxone is a pure mu-opioid receptor antagonist that is used for opioid overdose.¹ In the past decade, in response to the opioid epidemic, naloxone has become increasingly available in the community as a way of decreasing opioid-related deaths.^1,2 The US Food and Drug Administration recommends that all patients who are prescribed opioids for pain or opioid use disorder, as well as those who are at increased risk for opioid overdose, should be prescribed naloxone and educated on its use. Patients who received a naloxone prescription from their primary care provider have been found to have 47% fewer opioid-related ED visits.³

Quick effects, potential for complications. Use of naloxone can rapidly induce opioid withdrawal symptoms, including gastrointestinal effects, tachycardia, and agitation, as well as diaphoresis, shivering, lacrimation, tremor, anxiety, mydriasis, and hypertension. Naloxone use can also lead to severe complications, such as violent behaviors, ventricular tachycardia or fibrillation, asystole, or pulmonary edema, in the period immediately following administration.⁴ These effects most often subside within 20 to 60 minutes after administration of naloxone, as the antagonist effect wears off.

The treatment of naloxone toxicity is supportive, with particular attention paid to the patient’s mental and respiratory status.

Our patient was advised by his primary care physician on the proper use of all of his medications, including nasal sprays. The clinic pharmacist also met with him for an additional educational session on the proper use of naloxone.

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