Resuscitation care for suspected opioid-associated emergencies (BLS #811): Systematic Review

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This CoSTR is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final COSTR will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none applicable)

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (none applicable)

CoSTR Citation

Castren M, Perkins G, Kudenchuk P, Mancini MB, Avis S, Brooks S, Chung S, Considine J, Hatanaka T, Hung K, Nishiyama C, Ristagno G, Semeraro F, Smith C, Smyth M, Morley P, Olasveengen TM -on behalf of the International Liaison Committee on Resuscitation BLS Life Support Task Force.

Resuscitation care for suspected opioid-associated emergencies Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Basic Life Support Task Force, 2020 Feb 11th. Available from:

Methodological Preamble

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of basic life support conducted by Maaret Castren and Theresa Olasveengen, with involvement of clinical content experts. Evidence for adult literature was sought and considered by the Basic Life Support Adult Task Force. These data were taken into account when formulating the Treatment Recommendations.


The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults and children with suspected opioid-associated cardio / respiratory arrest in the pre-hospital setting

Intervention: Bystander naloxone administration (intramuscular or intranasal), in addition to standard CPR

Comparators: Conventional CPR only

Outcomes: Survival to hospital discharge with good neurological outcome and survival to hospital discharge were ranked as critical outcomes. Return of spontaneous circulation (ROSC) was ranked as an important outcome.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to Oct, 2019.

Consensus on Science

We did not identify any studies reporting any critical or important outcomes of adults or children with suspected opioid-associated cardio / respiratory arrest in any setting, comparing bystander naloxone administration (intramuscular or intranasal) plus conventional CPR, to conventional CPR only.

Treatment Recommendations

We suggest CPR be started without delay in any unconscious person not breathing normally, and that naloxone be used by lay rescuers in suspected opioid related respiratory or circulatory arrest, (Weak recommendation, based on expert consensus)

Justification and Evidence to Decision Framework Highlights

There is no direct evidence comparing outcomes for patients with opioid induced respiratory or cardiac arrest treated with naloxone in addition to standard CPR compared to those treated with CPR alone. In a summary of four case-series including 66 patients, 39/39 patients who received naloxone after a opioid overdose recovered compared to 24/27 who did not receive naloxone.(Giglio 2015) At the population level, there is evidence to demonstrate improved outcomes in communities after implementation of various naloxone distribution schemes. A recent systematic review identified 22 observational studies evaluating the effect of overdose education and naloxone distribution using Bradford Hill criteria, and found causation between implementation of these programs and decreased mortality rates to be likely. (McDonald 2016)

Respiratory or cardiac arrest diagnosis is not always straight forward, and lay rescuers would be expected to have a high suspicion of cardiac or respiratory arrest in any unconscious person with suspected drug overdose. Naloxone administration is likely to have preventive effects if given after a drug overdose which has not yet manifest into respiratory or cardiac arrest, and the potential for desirable effects in a broader population strengthens the suggestion to administer naloxone in this setting. I addition, are very few reports of side-effects from Naloxone.(Wermeling 2015 20) And while it is possible that bystanders might spend valuable time finding and administering Naloxone instead of starting CPR during respiratory or cardiac arrest, lack of reports of harm from large scale implementation of Naloxone distribution schemes indicate this is not likely to be a big problem.

As there is no formal evaluation of naloxone with CPR vs. CPR alone in opioid overdose, it is not possible to formally balance desirable and undesirable effects of naloxone administration by lay persons. As a response to the growing epidemic, naloxone has been widely distributed by health care authorities to lay people in various opioid overdose prevention schemes. Overall these programs report beneficial outcomes at the population level. The BLS task force therefore considers it very likely that the desirable effects outweigh undesirable effects, and that use of naloxone is acceptable by key stakeholders as well as the general population.

Knowledge Gaps

Current knowledge gaps include but are not limited to:

  • There is currently no evidence evaluating the role of naloxone use among bystanders attempting CPR in suspected opioid related respiratory or circulatory arrest.
  • Further research is needed to determine the optimal components of resuscitation and the role of naloxone during bystander CPR.


Evidence-to-Decision Table: BLS-811-Resuscitation-care-for-suspected-opioid-associated-emergencies



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