Naloxone-associated pulmonary edema following recreational opioid overdose

Abstract

Objective: Describe a series of patients who developed naloxone-associated pulmonary edema after recreational opioid use.

Design: Single center retrospective case series of patients who developed pulmonary edema following the prehospital administration of naloxone.

Setting: Academic, urban safety-net hospital.

Patients: Adults with recreational opioid overdose who developed naloxone-associated pulmonary edema, defined as the acute onset of respiratory distress, hypoxemia, and radiographic pulmonary edema after naloxone administration for opioid intoxication, provided that gas exchange and chest imaging rapidly improved and pulmonary aspiration of gastric contents was not clinically suspected.

Measurements and main results: Ten adults (median age 23 years, 90% male) met our case definition for naloxone-associated pulmonary edema. Implicated opioids were heroin in 8 patients and methadone and oxycodone in 1 patient each. The median total dose of naloxone was 4.25 mg (interquartile range [IQR] 3.3-9.8) prior to the onset of clinically-apparent pulmonary edema. Seven patients received invasive mechanical ventilation for a median of two days (IQR 0.8-5), one of whom received veno-venous extracorporeal membrane oxygenation support, and all survived to hospital discharge.

Conclusions: Severe acute pulmonary edema may follow naloxone administration after recreational opioid overdose. Acute care clinicians should be aware of this potentially life-threatening adverse effect of naloxone.

Keywords: Hypoxemic respiratory failure; Mechanical ventilation; Naloxone; Opioid overdose; Pulmonary edema.