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

- Rogue Medic

Narcan Solves Riddle – Part IV

OK a double Normal Sinus Rhythm post this week. 🙂

This week, again, there is no theme. Read the rest of the NSR Blog posts at NSR Week 14.

This continues from Part I, Part II, and Part III. One of the problems with people claiming that naloxone is diagnostic, or that there is something to be gained by drawing conclusions from a response to naloxone, is that it is just bad logic.

Nassim Nicholas Taleb wrote about this in his book Fooled by Randomness: The Hidden Role of Chance in Life and in the Markets and in his latest book The Black Swan: The Impact of the Highly Improbable. He paraphrases the conclusion –

How many white swans does one need to observe before inferring that all swans are white and that there are no black swans? Hundreds? Thousands? The problem is that we do not know where to start[1]

While we do not care that much about swans in EMS, the occasional dying swan act is just something we occasionally need to deal with. The problem of drawing inappropriate conclusions may be our biggest problem. Claiming that naloxone is diagnostic is not any different from claiming that all swans are white.

I have seen many swans.

OK.

They were all white.

Still OK.

Therefore all swans are white.

That may be true, but there is no way that we can prove this.

How many swans do we need to see to be able to draw this conclusion?

All of them.

Not 51%.

Not 90%.

Not 99%.

Not 99 and 44/100ths%.

Not 99.999%.

We need to see all of them.

So we round up all of the swans in the world and observe that they are all white. Then we are sure.

No.

Still not OK.

We also have to examine all past swans and all future swans.

There may have been a species of non-white swans that became extinct.

There may be a genetic mutation, or there may be genetic manipulation, that would lead to a non-white swan.

Therefore, how many administrations of naloxone to opioid-free people do you need to observe – without response – to be able to state that naloxone is diagnostic for opioids?

All of them.

All in the past.

All in the future.

We can conclude that it seems that naloxone is a way of identifying opioid consumers, but that we reserve judgment on something that cannot be proven.

So there is no way to prove this?

That’s right.

But there is a way to disprove this.

Why disprove it?

Because bad logic leads us to make mistakes.

In EMS, it is fortunate that we are only playing with patients’ lives. So why worry about making bad decisions? Especially, since this is not a decision likely to kill anyone?

Even though this is not likely to kill anyone, similar logic is not so benign.

So, how do we disprove something like this?

How many non-white swans would it take to prove that not all swans are white?

At least one.

It is such a fragile and useless conclusion, that to disprove it requires one and only one example of failure of the supposed rule.

An exception does not confirm a rule. An exception demonstrates that the rule is faulty.[2]

Farther down in the same paragraph, Dr. Taleb provides the answer –

Note that the Black Swan is not just a metaphor: until the discovery of Australia common belief held that all swans were white; such belief was shattered with the sighting of the first cygnus atratus.[1]


How many ways do I need to demonstrate that it is foolish to conclude what a person may have consumed based on their apparent response to a medication – a medication that has a long history of being wrong?

Well the patients who were postictal (recovering from a seizure) were clearly not patients who should have received naloxone.

Is that because a competent assessment is better at diagnosing the presence of opioids?

That eliminates any reason for using naloxone diagnostically, doesn’t it?

Seizures can occur secondary to opioid use. Stroke/TIA (Transient Ischemic Attack) can also appear to respond to naloxone without any opioid consumption. Alcohol can respond to naloxone. Clonidine can respond to naloxone. These are not opioids.

Squirting naloxone in the veins, muscles, nares, tongue, . . . of every unconscious person does not diagnose the cause of unconsciousness.

This drug abuse (abuse of naloxone by EMS) may mislead us.

If we give naloxone to a person who had a seizure, the patient appears to respond, and we then decide to treat the patient as a drug addict, is there a possibility for harm to the patient? Aren’t we supposed to treat seizure patients for seizure, rather than for an imaginary drug overdose?

If we give naloxone to a person who had a stroke, the patient appears to respond, and we then decide to treat the patient as a drug addict, is there a possibility for harm to the patient?

All this is doing is teaching us, or reinforcing, bad diagnostic skills.

Aren’t we supposed to be doing just the opposite?

Science is only valid if there is a way of disproving the hypothesis. Anything that cannot be disproved is not science. This use of naloxone to diagnose is not science. This use of naloxone to diagnose is pseudoscience and needs to be opposed.

Pseudoscience kills.

Footnotes:

[1] The Roots of Unfairness: the Black Swan in Arts and Literature
Nassim Nicholas Taleb
FooledByRandomness.com
Free PDF

[2] What’s the meaning of the expression, “That’s the exception that proves the rule?”
A Straight Dope Classic from Cecil’s Storehouse of Human Knowledge
Article

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Comments

  1. I loved that book. And you’re right; logical errors like this abound in medicine, which is sometimes more about Ego than Evidence.

  2. Here is a coincidence that would be given too much significance by those who don’t understand the topic – my most recent post is a comment on one of your posts – What?As Dr. Taleb points out, humans are not good at logic.The evidence part of medicine does keep improving. My protocols are improving – and it appears to be purely because of evidence. The traditionalists seem to be losing ground. I hope it continues. 🙂

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