What is the method for giving naloxone in very small doses to avoid acute opiate withdrawal?

Naloxone is often considered in hospitalized patients with altered mental status or respiratory depression who are on opiates. Many hospital order sets call for doses of 0.1 to 0.4 mg for these purposes. However, such doses may precipitate acute opiate withdrawal (in narcotic tolerant patients) or acute exacerbation of pain. What might be an alternative means of dosing that would be safer in such patients? 

This concern was addressed in the following review:

Reducing the harm of opioid overdose with the safe use of naloxone: a pharmacologic review  Expert Opinion on Drug Safety   Volume 14, 2015 - Issue 7

From the abstract of that review:

Introduction: Opioid overdose fatality has increased threefold since 1999. As a result, prescription drug overdose surpassed motor vehicle collision as the leading cause of unintentional injury-related death in the USA. Naloxone, an opioid antagonist that has been available for decades, can safely reverse opioid overdose if used promptly and correctly. However, clinicians often overestimate the dose of naloxone needed to achieve the desired clinical outcome, precipitating acute opioid withdrawal syndrome (OWS).

Areas covered: This article provides a comprehensive review of naloxone’s pharmacologic properties and its clinical application to promote the safe use of naloxone in acute management of opioid intoxication and to mitigate the risk of precipitated OWS. Available clinical data on opioid-receptor kinetics that influence the reversal of opioid agonism by naloxone are discussed. Additionally, the legal and social barriers to take home naloxone programs are addressed.

Expert opinion: Naloxone is an intrinsically safe drug, and may be administered in large doses with minimal clinical effect in non-opioid-dependent patients. However, when administered to opioid-dependent patients, naloxone can result in acute opioid withdrawal. Therefore, it is prudent to use low-dose naloxone (0.04 mg) with appropriate titration to reverse ventilatory depression in this population.

As is pointed out in the review, caveats include the need to provide ventilatory support in some cases and special considerations regarding the reversal of buprenorphine. These include limited effectiveness of naloxone, slower onset of action and larger dose requirements.