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Another common and potentially reversible cause of AMS is toxic ingestion or drug overdose. Especially given the current opioid use crisis, in patients who may have an opioid toxidrome, consider administration of an opiate antagonist. Naloxone is the current opiate antagonist of choice in the acute care setting. Naloxone is generally safe, with very few serious side effects, the most common being precipitation of withdrawal. Low‐dose administration (0.4 mg initially, titrated to respiratory improvement) may reverse the life‐threatening respiratory depression of opiate overdose without precipitating a possibly agitated “emergence” from opioid sedation that occasionally accompanies full and rapid reversal. However, failure to give an adequate amount of an opioid antagonist is a potential pitfall. The synthetic and semi‐synthetic opioids, as well as heroin in a naive user, may require very large doses of naloxone for reversal. Thus, frequent titration with repeated small doses of naloxone and close monitoring are recommended.

Given the effectiveness of prehospital naloxone, early advanced airway management is contraindicated in the opioid overdose patient. Naloxone can be given by the IM, IN, IV, and IO routes, all of which have been shown to be similarly effective in the prehospital setting [14–16]. In all cases, the EMS clinician should observe and record any response by the patient to the administered medication, as this will facilitate management by subsequent medical personnel.