How to distinguish opioid toxicity from natural dying in patients with advanced illness and how to manage opioid toxicity?

Patients with advanced, life-limiting illness might develop pain or breathlessness, requiring opioids. Opioid neurotoxicities, like sedation and delirium, overlap with signs of natural dying. Understanding natural dying is a core clinical skill for all healthcare professionals. It is important that clinicians accurately assess patients to distinguish opioid toxicity from natural dying. This is vital to ensure appropriate use of opioids and ensure patient comfort. Patients with opioid toxicity and no pain can usually be managed by reducing the opioid dose. In patients with opioid toxicity and pain, a change in opioid is often needed. In patients on regular opioids for symptom management, life-threatening opioid-induced respiratory depression (causing both a decrease in respiratory rate and oxygen saturations) is rare. Initial management is with stimulation and oxygenation. Low-dose intravenous naloxone (20-100 μg every 1-2 min) is rarely needed in this patient cohort. Specialist palliative care input should be sought.