The dose of naloxone is the same, regardless of the route of administration: 0.4-2 mg. This can be repeated at 2-3-minute intervals up to a maximum dose of 10 mg, as clinically indicated. The end-point is reached when the adverse effects of the narcotic are reversed. As pain returns, it may be necessary to transition to a non-narcotic pain control approach, like ketamine.

Naloxone can be administered through several different routes, to include intranasal, intramuscular, or intravenous. In cases of OTFC (transmucosal fentanyl) overdose without an established IV or IO access, intranasal, or intramuscular administration is recommended, as the time to establish an IV would unnecessarily delay the delivery of the medication. However, if IV or IO access is present, they should be used if the parenteral formulation is available, as that will provide the fastest distribution of the antagonist in this time-sensitive procedure.

Titration of opioids in pain relief is very difficult under the best circumstances. In the tactical environment, there are several additional factors that complicate the process. For example, even though a casualty may not be hypotensive or show signs that suggest hypotension is pending, they may be dehydrated and have very little reserve so that a small change in their blood pressure or dilation of their vasculature leads to symptomatic hypotension. Or their respiratory drive may be adequate, but tenuous, and is only uncovered with the administration of an opiate. As a result, it is not uncommon to have narcotic side-effects manifest themselves prior to achieving adequate pain management.

Fortunately, naloxone is a rapid-acting opioid antagonist that can quickly counteract the effects of the narcotic, if administered in a timely fashion. As time is of the essence, it is very important to have naloxone readily available prior to administering an opioid medication. During this time (of narcotic overdose symptoms) it is essential to continuously reassess and support the casualty’s respiratory and circulatory status.