There is a recent paper looking at the use of nebulized naloxone (Narcan) to treat possible opioid OD (OverDose), or something like that. It is not exactly clear what is being treated. First, we probably want to minimize the use of IV/IM needles when dealing with a population that is not expected to be good at preventing transmission of bloodborne pathogens, even where needle exchange programs decrease that risk.
Needleless naloxone may be easier when intravenous (IV) access is difficult and may decrease occupational blood-borne exposure in this high-risk population. Several studies have examined intranasal naloxone, but nebulized naloxone as an alternative needleless route has not been examined in the prehospital setting.[1]
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It is a good idea to compare the two treatments and to include placebo versions of both. If only one route/treatment is being used, to at least compare that route/treatment with placebo. This is the way that we learn what works, but that is not the way this study was run.
The second reason this makes for a poor outcome measure is that the medics are not “blinded” to the treatment the patient got – they all knew they were giving an active agent.[2]
Without anything to compare the treatment with, we are only determining if the result is acceptable.
What does acceptable mean in this study?
Did the naloxone improve the any patient’s respiratory rate?
Did the naloxone improve the any patient’s pulse oximetry?
Did the naloxone improve the any patient’s heart rate (bradycardia is a common side effect of opioid-induced respiratory depression)?
Or did the naloxone just appear to improve the level of consciousness of some patients?
Why should we be giving naloxone?
The documented indication for nebulized naloxone administration was suspected opioid overdose in 70 patients (66.7%), altered mental status in 34 patients (32.3%), and respiratory depression in one patient (0.9%).[1]
Why?
Suspected opioid OD (not just any OD and it depends on what else is on board) with respiratory depression.
Without respiratory depression, there is no need for naloxone, unless it is to get the patient to walk to the ambulance. If that is the reason, does the patient really need to be transported to the hospital?
Is that really better than giving the Goldolocks amount of naloxone to allow the patient to safely refuse further treatment? The concern is the respiratory depression/inability to protect the airway.
Aren’t we checking for a gag reflex?
Not me. Where is the benefit in that?
If the patient is not breathing adequately, is there any expectation that giving a nebulized reversal agent will effectively treat the respiratory depression? That is the question that should have been asked. I think that there is a good reason to expect nebulized naloxone to work with significant respiratory depression and that it may be safe and effective, but I think that we definitely need to demonstrate this in a study that documents the changes in vital signs, so that we can identify potential problems early.
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To be continued in Part II and Part III.
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Footnotes:
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[1] Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose?
Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2011 Dec 22. [Epub ahead of print]
PMID: 22191727 [PubMed – as supplied by publisher]
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[2] Narcan Nebs – Why? New research doesn’t say..
Sunday, January 22, 2012
Mill Hill Ave Command
Article
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But, but, doesn’t this allow for the EMT’s and firefighters, and what the heck, even the cops to be able to punish those people that have people that care about them enough to call for medical help when they overdose on their recreational drug of choice? Why should only paramedics be allowed to punish these people on so many levels?
Really not sure the goal here. Nasal works real well and works on the unresponsive. Is bagging in a neb easier than this?
Thank You. It makes me sick to see the thick skulled dinosaurs out there that believe that just becasue someone is high, it warrants Narcan. People get high everyday and don’t require a grand slam dose of Narcan to get them through to the next day. It is for respiritory depression due to a narcotic overdose. Not as a punishment for reliving the ’60’s.
We’ve been doing nebulized narcan in our system for a couple of years now. I assume it hasn’t killed anyone since they still let all of us ambulance monkeys and the rest of the chicago fire guys do it. I’m sure other people have used it to “make people act right” with much success. I’ve never used it. If they’re breathing enough to make a nebulizer work they dont need the narcan. I imagine I’ll never use it now that the powers that be decided nasal atomizers won’t kill people. I’ll let some ER doctor or nurse punish them for being high.
Why do we even touch the OD patient to begin with? They didn’t call for an ambulance. If they’re breathing, let them stay. They paid for their fix, let them enjoy it. They obviously cannot be helped by any sort of treament program and would never benefit from medical care. Why should feel some sort of responsibility to help these patients? Because they might have families and children? Screw that. They obviously want to die, or at least get high, so what business is it of ours? It’s just like those damn suicidal patients. Pulling us away from reading studies and saving real people by figuring out the exact process to get those cardiac saves. Those are the ones we need to focus on. Sure they’re one out of a million, but at least the 76 year old woman we save will get another few years in the nursing home. It’s not like a heroin user has ever been rehabilitated and done something useful with their life.
I can’t wait to be as jaded as you guys.
I’m not trying to start any thing but I’m just curious what medical condition you think a breathing person who is altered from doing heroin has? I don’t see anyone advocating letting people die in the street. If you have a valid medical reason for reversing an obvious narcotic overdose who has an intact airway and adequate respirations I’d love to hear it. Otherwise my jaded self will continue to not see the point in it. It seems like all you create is a pissed off drug user enclosed in a small space with lots of sharp objects.
“I’m just curious what medical condition you think a breathing person who is altered from doing heroin has”
How do you plan on assessing them appropriately when they are unresponsive?
Is drug dependency no longer a medical condition?
Is a heroin overdose an automatic exclusion from any comorbidity?
Or, are they just not treated because it is felt that they are not worth the time?
I understand that these can be difficult patients, but sometimes you just need to suck it up and be a damn professional.
The bottom line is, Narcan doesn’t fix drug dependency. Drug dependency is not an indication for use of Narcan … respiratory depression due to narcotic OD is.
We aren’t saying drug abusers don’t need or deserve treatment … just that as long as they are breathing and maintaining their airway, they don’t need Narcan.
I still don’t think you answered my question. And I’m pretty sure you just called me unprofessional.
Like I asked before; Explain to me why I need to wake up an obvious drug overdose with an intact airway and adequate breathing.
I never implied doing anything less than a full assessment. I never said they weren’t worth my precious time or however you worded it.
I’m just asking how waking them up in the back of the ambulance just for the sake of waking them up does anyone any good?
My response is Comments on What About Nebulized Naloxone (Narcan).
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Giving nebulized Narcan is like giving oral Zofran to someone who is actively projectile vomiting.