You find him unresponsive in the bathroom stall. Pinpoint pupils, respiratory rate of 4, SpO2 in the 70s. Classic opioid overdose. Your partner is already drawing up the Narcan.
What happens next depends entirely on how you give it.
The Goal Is Breathing, Not Awake
Here is what we sometimes forget in the adrenaline of the moment: naloxone reverses respiratory depression, not unconsciousness. A patient breathing adequately at 12-14 times per minute does not need to be wide awake and answering questions.
The problems with over-aggressive reversal:
- Acute withdrawal — Vomiting, agitation, and combativeness
- Aspiration risk — Vomiting while still too sedated to protect their airway
- Patient leaves AMA — Now in withdrawal and convinced they do not need help
- Provider safety — A patient who was dying is now swinging at you
- Pulmonary edema — Rare but reported with rapid, high-dose reversal
What Your Protocols Say (Follow Them)
This is critical: your local protocols dictate your naloxone dosing. Different services have different approved routes, doses, and titration guidelines based on medical director oversight and local needs.
What this pearl offers is context for understanding why those protocols exist—not permission to deviate from them.
Understanding Titration (Where Protocols Allow)
Many modern protocols now support titrated naloxone administration. The principle is simple:
- Support ventilations first — BVM with good seal and OPA/NPA as needed
- Give naloxone incrementally — Following your protocol’s specified doses and intervals
- Watch for response — Increased respiratory rate and effort, improving SpO2
- Stop when breathing is adequate — Not when they are fully awake
A patient breathing 14 times per minute with an SpO2 of 96% does not need more naloxone just because they are not talking to you.
The Fentanyl Factor
Fentanyl and its analogues have changed the game. These patients may:
- Require higher total doses to reverse (follow your protocol’s guidance)
- Re-sedate more quickly as naloxone wears off
- Have unpredictable responses depending on what else was in the supply
This makes ongoing monitoring even more critical. A patient who “woke up” after naloxone can stop breathing again 30-60 minutes later when the naloxone wears off but the opioid is still on board.
Documentation Matters
Whatever your protocol, document clearly:
- Initial presentation and vitals
- Doses given, routes, and times
- Response to each intervention
- Ongoing monitoring findings
- Patient’s mental status and respiratory status at transfer of care
The Pearl
The goal is breathing, not awake. Follow your local protocols for dosing—they exist for good reasons. Support ventilations, give naloxone as your protocols direct, monitor for re-sedation, and remember that a patient breathing adequately is a successful resuscitation even if they are not having a conversation with you.
This clinical pearl is for educational discussion only and does not replace your local protocols or medical direction. Naloxone dosing varies by jurisdiction, route, and clinical situation. Always follow your service’s approved guidelines and consult medical control when appropriate.