Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

The Joy of Naloxone (Narcan)

Naloxone is an opioid antagonist – it reverses the effects of drugs that are derived from opium – heroin; morphine; fentanyl; the hydrocodone in Vicodin, but does nothing for the acetaminophen (Tylenol); . . . .

We are called for a possible HOD (Heroin OD), we arrive and find a Deborah Peel with pin point pupils, scarred veins with some evidence of recent injections, respirations are less than ten; skin is pale, cool, and dry, . . . .

RM – “How are you doing?”

DP – does not respond.

RM – after applying some painful stimulus, “How are you doing?”

DP – imitates Fred Flintstone cursing, but with worse breath.

RM – might as well start with an easy one “What’s your name?”

DP – “Deborah Peel.”

RM – “It is an honor. Where are you?”

DP – “In my office looking down on all my subjects.”

RM – “That must be some good stuff. What day is it?”

DP – “I forget.” First Monday of the month is not a happy time.

And so it goes with no unusual findings.

Protocols insist that suspected HOD patients receive 2.0 mg naloxone IV.

This patient appears to be protecting his airway and breathing adequately, possibly requiring occasional moderate stimulus to keep up his side of the conversation.

Naloxone would not be in the patient’s best interest – tends to bring on withdrawal, pulmonary edema, hypertension, anxiety, and violence.

Violence is not in my best interest, nor is any deterioration of the patient’s condition.

Time to call OLMC (On Line Medical Command) and request permission to not be complicit in the doctor’s violation of his Hippocratic Oath.

Dr. DP – “Hello, this is Deborah Peel Memorial Hospital, Dr. Peel speaking.”

RM – “Hello, this is RM,” and I proceed to give a colorful description of DP to Dr. DP. Then – “I am requesting permission to withhold naloxone, since this patient does not appear to need it.”

Dr. DP – “Follow your protocol. Give the 2 mg naloxone and transport.”

RM – “We’ll see you in five to ten minutes.”

Well, we were already transporting – no reason to delay on scene with this patient (collected all his belongings and off we went).

I need to set up an IV and am not in a rush – think Reverend Jim getting his license. And I manage to complete the IV and blood draw as we are arriving at the ED. Not wanting to disobey orders, I bring the syringe of naloxone in with me and am getting ready to push it when I see Dr. DP. I point out that things did not happen as quickly as the doctor would have liked and confirm that Dr. DP wants 2 mg naloxone given IV, now.

There is a bed and the nurse directs us to put Deborah Peel in that bed.

Dr. DP – “What is it with you? Just follow orders.”

RM – “OK, but as soon as the drug is in, we are out the door. The patient’s information is all here, with the blood samples, and you have a full report.

Now, I have to point out that this is unfair to the nurses, who will end up doing the majority of the work of dealing with Deborah Peel’s possible withdrawal symptoms and possible violence, but it is tempting to get the nurses to leave the room, call Dr. DP over, give the naloxone, leave, and let the naloxone go to work – it is fast – with nobody to assist the doctor.

I believe that people can learn from their mistakes, some just need things spelled out a bit more clearly than others, but I am an optimist. 🙂

So, we really do not leave.

We stick around to assist with this performance art, but we insist that Dr. DP come and play. As EMS providers, we are cross-trained as rodeo clowns, so we are able deal to with the inner psychiatrist that Deborah Peel is sharing – name calling, kicking, spitting, attempted biting, . . . .

Just what the doctor ordered.

But why would a doctor do this?

Why does this happen regularly, even when the Deborah Peel is not in town?

This is bad for patients.

This is bad for EMS.

And, since it is bad patient care, it is probably also bad for the doctor – legally, ethically, medically, . . . .

You do this one time and word tends to get around. Some see the teaching point, some see a reckless and irresponsible manipulation of orders.

So it goes.



  1. Stealing my thunder now…that was going to be the subject of my next EMS1.com column!

  2. Well, there are a lot of ways to spin the naloxone problem. Just one of my pet peeves brought to the surface by the recent list discussion. I just couldn’t find a way to include the cat inversion. :-)))I thought you would be busy with your ballistics information and teaching Mongo a few more chords. Or did the shiny syndrome get in the way?Use what you like – it isn’t as if I am the first person to think of these things.

  3. Interesting protocol. In MD, we have a maximum dose of 2mg, but to be given at 0.4mg increments to restore respiratory effort. The protocols are pretty clear that we’re not supposed to go past the dose necessary to accomplish that. And actually, I nearly got in trouble once because I didn’t feel like carrying some huge load out to the ambo, so I just woke him up, got a refusal, and went on my merry way.

  4. LOVE the GOOD REVEREND JIM. That is one of my favorite bits!Obviously, you missed the point. The OLMCP was ensuring that you didn’t miss the patient’s transition to the big white feathery ambulance in the sky. I suppose in addition to using DANGEROUS medications like oxygen and morphine you expect to be trusted managing an airway?! 😉

  5. Totally unrelated comment, but oh well: You’re profile picture cracks me up.

  6. F…dude, I swear I know the differnce between “you’re” and “your.”

  7. And I wasn’t even happy for that picture, but it caught my good side.No “Juno” quotes on this post, instead go to my post inspired by a quote from “Juno” – Public Perception of Pain Management

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  9. The preceding message was brought to you by the Courtney Love Foundation. 🙂

  10. Shouldn’t it be signed,Love,Courtney?

  11. It def. caught your good side. You’re a bit yellow though, might want to get your liver function tested…

  12. Having had the unfortunate experience of being administered a double dose of Narcan all @ once for literally, “feeling funny” but otherwise alert, joking, breathing fine, pupils fine, bp fine after my Medtronic pain pump refill by an unprepared overzealous group of pain management nurses (no doctors present), I have no doubt that Narcan should only be administered by competent people who have explored all (most time/symptoms permitting) other options to no avail especially if classic OD indicators are NOT present.

    It was by far the worst experience I have ever had and far exceeded the discomfort of the “funny feelings” I had initially reported.

    72 hours later I am still reeling from the effects of the seizures, convulsions, tremors, ptsd, etc., associated with such a large and unnecessary dosage. I wouldn’t wish that on anyone. And I’m in pain management for chronic pain due to degenerative joint disease.

    PM is a joke. No one talks to each other, tries to find underlying problems/solutions that don’t involve opiates, and yet treat patients like they are criminals, constantly subjecting them to scrutiny, drug testing, distrust along with no information, assistance in understanding the whole picture, and often reacting/over reacting with kneejerk actions, egocentric decision making & total disregard for the patient’s ability to understand, add to the discussion, express concerns, offer suggestions, or at the very least tell the patient what is happening to them. I.E. that you just jacked them full of Narcan and their world is about to become the worst scenes from Jacob’s Ladder!

    Thanks for admitteding that previous Narcan administering procedures need to be reevaluated to protect the patient, not do more harm, yet still be available when there really is no other option – low/zero bp readings, blue lips, unresponsive, etc.

    Obviously, the point is to save lives, but cutting off a limb because of a spider bite that the person may be allergic to is not the first or best option to save that person’s life, not immediately anyway.

    Thank you for being honest. I’m curious as to what you and the other professionals commenting here/reading this think about my experience.