Death (from all opioids, low and high efficacy; agonist or partial agonist) is due to respiratory failure. Blood pressure is usually well maintained, if the patient is supine, until cerebral anoxia causes circulatory failure. At this stage the (pinpoint) pupils may dilate (also if there is hypothermia). The combination of miosis and bradypnoea gives the diagnosis which is vital, for naloxone, a selective competitive antagonist, is life-saving.32 Naloxone, having none of the agonist effects of morphine (respiratory depression, miosis, coma), is safe to give as a diagnostic test in an unconscious or drowsy patient suspected of opioid overdose. The t'/2 of naloxone (1 h) is shorter than most opioids and repeated doses or infusion will be needed. The guide to therapy is the state of respiration, not of consciousness. Patients with opioid overdose should be monitored for recurrence of ventilatory depression, which is an indication for further naloxone (for details see p. 342). Apart from naloxone the general treatment is the same as for overdose by any cerebral depressant. Addicts often take drug overdoses, whether accidentally or not, and naloxone, as well as reversing the life-endangering respiratory depression, will induce an acute (noradrenergic) withdrawal syndrome. Close cardiovascular monitoring is necessary, with use of peripheral adrenoceptor blocking agents or perhaps lofexidine (see above), according to need.
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