Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Opioid-induced respiratory depression
Difficulty rousing, respiratory rate below 8 per minute, shallow breathing, cyanosis or rising carbon dioxide after opioid exposure requires immediate resuscitation-level care.
Action: Stop opioid administration, call emergency help, open and support the airway, ventilate and give oxygen as indicated and check glucose. Give titrated intravenous naloxone to restore adequate ventilation rather than necessarily full wakefulness, repeat or infuse when required and observe because the opioid may outlast the antagonist.
Synopsis
Recognise opioid sedation, respiratory depression and neurotoxicity early, distinguish them from disease deterioration, provide proportionate emergency reversal, treat precipitating illness and redesign analgesia safely when renal clearance is reduced.
Increasing sedation, impaired attention and slowed breathing are more important toxicity signals than pinpoint pupils alone.
First-line emergency care is airway and ventilation support plus stopping further opioid; naloxone supplements rather than replaces resuscitation.
In opioid-dependent palliative patients, titrate naloxone to adequate breathing when possible because complete abrupt reversal can cause severe pain and withdrawal.
Key red flags
Progressive drowsiness usually precedes major respiratory depression and must not be dismissed as normal sleep after a dose increase.
Respiratory toxicity
Slow shallow ventilation, difficult rousing, cyanosis or hypercapnia with compatible exposure is a life-threatening opioid pattern.
Investigation priorities
01
First-line ABCDE and ventilation assessmentFirst stepFirst line
Measure arousability, respiratory rate and depth, airway, oxygenation, circulation, temperature, pupils and capillary glucose.
Management branches
Respiratory emergencyVentilate, reverse proportionately and observe
The patient is difficult to rouse and has clinically important hypoventilation after possible opioid exposure.
Stop opioid, call emergency help, support airway and ventilation, give oxygen as indicated, check glucose and attach appropriate continuous monitoring.
Give intravenous naloxone under the local emergency protocol, titrating to adequate ventilation when opioid dependence permits and escalating doses for apnoea or severe overdose as directed.
Key medicines
Naloxone for opioid respiratory depressionFollow the local emergency or toxicology protocol. In an opioid-dependent patient with inadequate ventilation but a pulse, experienced clinicians may titrate 100 to 200 micrograms intravenously every 2 to 3 minutes to adequate breathing; severe apnoea or overdose requires the protocol's larger initial regimen and resuscitation support.
Transdermal fentanyl in selected renal impairmentOnly for a patient already opioid tolerant with a stable requirement; choose patch strength through the current renal and palliative conversion table, product information and pharmacy or specialist check rather than a generic starting dose.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE CG140 strong opioidsOpioid adverse effects, renal or hepatic comorbidity and specialist switching advice.