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  5. Pain medicines / analgesics
  6. Naloxone
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Naloxone

Green – For medicines routinely initiated and used by generalists

Introduction

Description: Antagonist for use in severe opioid induced respiratory depression.

400 micrograms/ml injection (1ml ampoule)

 

  • Reversal of life-threatening respiratory depression due to opioid analgesics, indicated by:
    • a low respiratory rate, less then 8 respirations/minute
    • oxygen saturation below 85%, patient cyanosed.
  • If less severe opioid toxicity:
    • omit next regular dose of opioid; review analgesia.
    • monitor the patient closely; maintain hydration, oxygenation.

 

  • Naloxone is not indicated for opioid-induced drowsiness and/or delirium that are not life threatening.
  • Naloxone is not indicated for patients on opioids who are dying.
  • Patients on regular opioids for pain and symptom control are physically dependent; naloxone given in too large a dose or too quickly can cause an acute withdrawal reaction and an abrupt return of pain that is difficult to control.
  • Patients with pre-existing cardiovascular disease are at more risk of side effects.

 

Side effects

Total antagonism will result in severe pain with hyperalgesia and, if physically dependent, severe physical withdrawal symptoms and marked agitation. Opioid withdrawal syndrome: anxiety, irritability, muscle aches; nausea and vomiting; can include life-threatening tachycardia and hypertension. Cardiac arrhythmias, pulmonary oedema and cardiac arrest have been described.

 

Where intravenous administration possible:

Small doses of naloxone by slow intravenous (IV) injection improve respiratory status without completely blocking the opioid analgesia. Onset of action of intravenous naloxone is 1 to 2 minutes.

  • Stop the opioid.
  • High flow oxygen, if hypoxic.
  • Dilute 400 micrograms naloxone (1 ampoule) to 10ml with sodium chloride 0.9% injection in a 10ml syringe. Refer to prolonged, or recurrent, opioid-induced respiratory depression section below.
  • Administer a small dose of 80 micrograms (2ml of diluted naloxone) as a slow IV bolus every 2 minutes until the patient’s respiratory status is satisfactory (>8 respirations/minute).
  • Flush the cannula with sodium chloride 0.9% between the naloxone doses.
  • Patients usually respond after 2ml to 4ml of diluted naloxone (=80 micrograms to 160 micrograms) with deeper breathing and an improved conscious level.
  • A few patients need 1mg to 2mg of naloxone (this requires between 3 and 5 ampoules). If there is little or no response, consider other causes (for example other sedatives, an intracranial event, acute sepsis, acute renal failure causing opioid accumulation).

Closely monitor respiratory rate and oxygen saturation. Further doses may be needed. The duration of action of many opioids exceeds that of naloxone (15 to 90 minutes) and impaired liver or renal function will slow clearance of the opioid. Opioid depressant effects may return as the effects of naloxone diminish, and additional naloxone doses (or a continuous IV infusion) may be required.

Note: There is wide variation in the recommended initial bolus dose of naloxone reported in the literature from 20 micrograms (American Pain Scociety 2008) to 100 micrograms (PCF-4).

 

Prolonged, or recurrent, opioid-induced respiratory depression:

  • If repeated naloxone doses are required, start a continuous IV infusion of naloxone via an adjustable infusion pump.
    • Add 1mg of naloxone (= 2.5ml of 400 micrograms/ml naloxone injection) to 100ml of sodium chloride 0.9% to give a concentration of 10 micrograms/ml.
    • Calculate the dose requirement per hour by totalling the naloxone bolus doses and dividing by the time period over which all the doses have been given.
    • Start the IV infusion of naloxone at half this calculated hourly rate.
    • Adjust the naloxone infusion rate to keep the respiratory rate above 8 (do not titrate to the level of consciousness).
    • Continue to monitor the patient closely.
    • Continue the infusion until the patient’s condition has stabilised.
  • Additional IV boluses may need to be given using naloxone diluted in sodium chloride 0.9%. Refer to dose & administration section above.
  • Administration should be accompanied by other resuscitative measures such as administration of oxygen, mechanical ventilation, or artificial respiration.

If in doubt, seek advice.

  • Seek and treat the precipitating cause(s) of the opioid toxicity.
  • Review the regular analgesic prescriptions.

 

Care settings where there is no immediate access to the IV route, for example community:

  • Naloxone may be administered intramuscular (IM) when IV access is not immediately available.
  • Onset of naloxone IM is 2 to 5 minutes.
  • 100 micrograms (0.25ml) naloxone IM should be given and repeated after five minutes if there is no improvement with the first dose.
  • An IV line should be sited as soon as possible.

 

  • Naloxone should be available in all clinical areas where opioids are used (National Patient Safety Agency).
  • Naloxone is also available in disposable, pre-filled syringes. These doses may be too high for patients on regular opioid analgesics.
  • Reversal of buprenorphine-induced respiratory depression may be incomplete. Larger naloxone doses may be needed. 

 

Palliative care drug information online

 

Twycross R, Wilcock A. Palliative Care Formulary PCF4+ (4th edition) 2011.

National Patient Safety Agency. Safer practice notice 2006/12.

Adult Emergencies Handbook. NHS Lothian: University Hospitals Division.

Electronic Medicines Compendium. www.medicines.org.uk/naloxone accessed at http://www.medicines.org.uk/emc/medicine/21095/SPC/Naloxone+400+micrograms+ml+solution+for+Injection+(hameln)/

Miaskowski C et al. (2008) Principles of analgesic use in the treatment of acute pain and cancer pain (6e). American Pain Society, Skokie, Illinois, p. 31.

The American Heart Association. Guidelines 2005 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005; 112(Suppl I).

Mercadante.(2003)  Naloxone in treating central adverse effects during opioid titration for cancer pain. Journal of pain and symptom management:vol:26 iss:2 691 -693.

Manfredi P, Ribeiro S, Chandler S, et al. Inappropriate use of naloxone in cancer patients with pain. J Pain Symptom Manage 1996;11:131–134.