Question: The Opioid Medical Directive allows for Naloxone to be administered 0.8mg SC/IM/IN and 0.4mg IV. The IV route allows the paramedic to titrate to restore the patient's respiratory status. Can this titration also be applied to the SC/IM/IN?
The dosing and intervals in the ALS PCS Opioid Toxicity Medical Directive for SC/IM and IN Naloxone are based on the pharmacologic properties of the drug and the route it is being given. Given the quick onset of action via the IV route, this property allows for titration of the dose to effect. SC/IM/IN routes have longer times to peak effect and therefore cannot be titrated, in addition to the actual mechanical difficulties of providing a titrated dose through these routes. Providing smaller doses via the SC/IM/IN routes that may be ineffective will lead to prolonged periods of hypoventilation given they cannot be ventilated with a BVM. The balance of prolonged periods of hypoventilation must be weighed against the risk of a large dose that causes acute withdrawal. Paramedics can give a maximum of 3 doses of SC/IM/ IN Naloxone which allows for titration to the clinical response.