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

- Rogue Medic

Should Basic EMTs Give Naloxone (Narcan)?

 
Should basic EMTs be giving naloxone (Narcan) when paramedics do not really understand the drug?

If a patient wakes up after naloxone, does that mean the patient had a drug overdose?

No – but most paramedics do not understand that.[1]

As of January 1, 2014, there will be even more people giving Narcan with little understanding of what they are doing.
 


Peter Thomson.
 

La Crosse firefighters soon could start carrying a life-saving drug for heroin users. The department is applying to be one of the state’s first groups of emergency medical technicians to administer Narcan, the antidote to an opiate overdose.[2]

 

Does naloxone save lives or just make it less work for first responders?

If the basic EMTs are not good at basic ventilation, will they be any better at drug administration?

Are drugs the cure for ventilation problems?
 

The department has witnessed a 53 percent jump in the number of potential drug overdoses since 2009, Chief Gregg Cleveland said.

In 2012, firefighters responded to 98 potential overdoses and 86 so far this year.[1]

 

A 53% increase?

98 last year.

86 so far this year (as of October).

10 months in, so an average of 8.6 per month = 103.2 for the whole year.

Going from 98 to 103 is not a 53% increase.

It isn’t even a 5.3% increase, but only 5.1%
 

Only 5% – not 53%.
 

Bad math.

Correction (13:00 12/28/2013) – the math is not based on the numbers in the article and I did not read the article correctly. The bad math is mine, not Chief Gregg Cleveland’s. Thank you to Christopher Jennison, Jordan L, and Parastocles for pointing out my error.

I apologize to Chief Gregg Cleveland for misrepresenting his statement as bad math, when it was my mistake.
 

Bad decisions.

What kind of time would be saved by having the fire department give naloxone?

What kind of bad outcomes would be prevented?

What kind of better outcomes would be expected?

What is the added cost of implementing this program?

What other programs would be deprived of this money?

Those are just some of the questions that should be asked.

The main question is –

If your fire department is doing such a bad job of managing BLS skills (BVM, positioning, painful stimulus, . . . ), why should we allow you to harm patients with ALS skills?

If your department is not harming patients, then where is the need?

Naloxone does not appear to be the answer to either problem.

Will naloxone cure the math problems of these drug pushing managers?

Footnotes:

[1] Acute heroin overdose.
Sporer KA.
Ann Intern Med. 1999 Apr 6;130(7):584-90. Review.
PMID: 10189329 [PubMed – indexed for MEDLINE]
 

Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.

[2] Firefighters could be getting medication to save drug users
October 31, 2013 12:00 am
By Anne Jungen
ajungen@lacrossetribune.com
LaCrosse Tribune
Article

.

Comments

  1. Not disagreeing with your underlying sentiment, but the 53% is a jump from 2009, not 2012 as you referenced. The 103 you get is from standardizing the 2013 rate out to the full year, and then you say that that 103/98 is not a 53% increase. Without having checked that source for the 2009 number, this math is incorrect as well.

    Nonetheless, interesting thought. The BLS squad at Syracuse University with whom I ride was just given permission for Naloxone after an in-service in the coming months. Over 5 years of riding during undergrad and grad shool, I don’t think I’ve seen more than 10 true overdoses.

  2. The crash course in patho and pharm that paramedics get usually isn’t enough for many to understand let alone what EMT’s get. There are even area’s handing narcan out to addicts to give to each other now. Sanjay Gupta did a segment on how he thinks this should be more widespread, as if it was some amazing new drug. People claim there is such a minimal risk that the benefit outweighs the harm that could be done and some states are even changing Good Samaritan laws to cover it apparently.

    It’s all ridiculous, medications do have side effects that can occasionally be worse than any good that could have been done. If you don’t have the knowledge and capabilities to handle the side effects, you don’t have any business giving the medications. Seems like a fall back to the coma cocktail times to me.

  3. While you might not like the idea of EMT Basics giving it because they’re untrained/don’t know anything/whatever, the fact remains that in some areas police officers are now giving it. With almost zero medical training whatsoever. It’s IN, but still.

    I was looking for a few departments that are already doing it, and I came across another one.

    http://www.nj.com/news/index.ssf/2013/12/police_get_new_life-saving_tool_in_battle_against_nj_heroin_epidemic.html

    According to comments, EMTs cannot use it, but police officers can.

  4. Here in Minnesota a new law will be fast tracked to passage that will allow police and fire departments to carry Narcan. It is being brought forth by a State Senator whose daughter died of a heroin overdose.

    News reports make it obvious that this is being vastly over-sold by various groups with little idea of what they are talking about. Hopefully the conversation will steer into the issues that Rogue Medic has mentioned.

    Several stories highlight a police officer from a New England state that claims he has “saved” more than 170 lives in two years by administrating Narcan (insert eye-roll here). I have personally averaged about 1200 emergency calls per year for 33 years and I can’t say whether I’ve given Narcan 100 times.
    Assertions like these are actually arguments against allowing Narcan into hands of a non-health care professional.

    One thing that hasn’t been mentioned is Acetaminophen. About a month ago we had a patient who collapsed in a convenience store. We arrived to find the patient apnic, with a pulse, and SAT’s of 64%. While I “bagged” him/her up to 94%, my partner started a line and gave 1 mg of Narcan. The patient began to ventilate on their own within two minutes and awoke during transport. Denying heroin use, the patient soon admitted to taking 8 Percocet..

    I bring this up because there is also talk in Minnesota to allow Narcan to be sold over the counter. Each dose of Percocet contains 500 mg Acetaminophen. While most ER’s get concerned about ingestion of 10 grams of this drug in healthy people, those with diseased livers (hepatitis and alcoholism, for example) start having trouble with as little as 2.5 grams.

    The patient mentioned above had hepatitis and ingested 4 grams of Acetaminophen.

    Danger Will Robinson.

    There are also consistent reports that a small percentage of patients develop “flash” pulmonary edema after administration of Narcan.

    So, in agreeing with the Rogue Medic, the problem isn’t the absence of Narcan, but the absence of ventilation. What we are looking for are easy answers to the problem of our EMT’s and First Responders not performing their duties.

    There are no easy answers.

  5. Narcan is a generally safe drug; serious complications are rare. Any discussion on this topic needs to start with that fact in mind.

    Layperson administration programs have been done in many states for quite a few years now and have had very good results. I can think of no reason why laypersons would be able to use nalaxone safely, but not EMT’s.

    One could argue that airway management and ventilation is preferable to nalaxone administration, but I’m aware of no evidence that either prehospital RSI or prolonged ventilation of an unprotected airway in a (presumably non-NPO) patient is less risky than nalaxone administration.

    And are airway management and nalaxone administration mutually exclusive anyway?

  6. There’s an enormous amount of international data supporting lay administration of naloxone as a lifesaver— there have been *no* accounts of harm. If wrongly administered, it basically does nothing— but if it’s not there when needed, people die.

    For just a few examples, see:

    http://www.ncbi.nlm.nih.gov/pubmed/23372174
    http://jama.jamanetwork.com/article.aspx?articleid=1391926

    It is so mainstream that the FDA is considering making it over the counter, which is supported by the head of the National Institute on Drug Abuse and the drug czar’s office. There is no data to support your opposition.

    See:

    http://healthland.time.com/2012/08/22/preventing-overdose-obama-administration-drug-czar-calls-for-wider-access-to-overdose-antidote/

  7. The study you linked has several flaws that it points out on its own in the end. It also only contains data from communities involved in the implementing the programs, with no control of any kind.

    “Using an observational approach, this study cannot prove definitively that OEND caused a reduction in opioid related overdose death rates. This study had several other limitations to the data available, which we attempted to address. Firstly, the true population of opioid users in each community was not known. To account for this we adjusted analyses for differences in demographics, use of addiction treatment, and proportion of prescriptions to doctor shoppers. Secondly, opioid overdose fatalities may have been misclassified. However, in Massachusetts the medical examiner’s office is centralized, with each death certificate processed through the same system. Thirdly, visits to emergency departments and admissions to hospitals associated with opioid poisoning were defined based on administrative discharge codes. Although discharge codes are a blunt measure of cause for utilization, systematic directional misclassification has not been found in other studies.39 Fourthly, overdoses may have occurred in clusters, which could result in the assumption that spurious events represent a trend. However, this study was conducted over eight years in 19 communities. Fifthly, we created measures of OEND implementation consistent with our conception of how OEND may impact on rates of fatal overdose and acute care utilization, but they have not been validated in other populations. We tested several levels of OEND implementation and found similar patterns of association with opioid related overdose and acute care utilization rates. Lastly, the description of reported overdose rescue attempts was limited to only those rescues reported back to programs, and thus was likely underreported.”

    There are several very well known potential side effects to naloxone administration and no matter how rare some are, they still exist and will still hurt someone (even more so they occur in the presence of lay persons). Here is a nice list of them with examples of what has occured with them.

    http://www.drugs.com/sfx/naloxone-side-effects.html

    We need to think about what the issue is here. Just as Rogue Medic states, the issue is lack of respiratory effort/drive, not lack of naloxone. Lay persons should be trained to open and maintain airways with basic techniques, and assist respirations or ventilate as needed. They can do this while the 9-1-1 they should be calling is dispatching providers already in existance who carry this medication along with most of the capabilities of an ER to handle most of the likely possible reactions they may have to it if it is given. Not only that, but they can handle most of the alternative issues that this individual may have going on that narcan can not fix. Granted, this would require them to call 9-1-1 and ask for help, which will most likely lead to police involvement which would deter them.

    EMS providers have Naloxone, which is an invasive procedure to administer, you are placing a substance that is normally outside the body inside the bloodstream. It is, or at least should be, kept in a temperature controlled environment with expiration date monitored as well.

    Just because the FDA is considering making something over the counter, does not immediately qualify it as the solution. There have been medications and procedures before that the FDA and very well respected medical associations have recommended and approved that did plenty of harm and had to be recanted. More than likely without good eveidence, which is near impossible to get on this subject, the only way that it will be approved for widespread use as you indicate is if it is strongarmed with political pressure and misinformation.

    You say there isn’t any data to support opposition, but there really isn’t enough data to support the approval either. The movement in medicine is for evidence based practices, which this is not an example of.

  8. If you found your child unconscious and blue after taking an opioid, would you want naloxone on hand?

    If yes, why would you deny it to anyone else? It has *already* been distributed to thousands of people without the side effects you are so worried about— and with the positive effects of actually saving lives. The side effect of overdose— death— is far more problematic than any of the side effects you mention.

    Just because evidence isn’t perfect doesn’t mean it’s not evidence. I am a huge supporter of evidence based medicine and everyone in the addiction field who has looked at the evidence— including the National Institute on Drug Abuse— favors naloxone distribution.

    NIDA is funding the development of a nasal spray form which the FDA has asked to be developed— given this, approval for lay use is extremely likely. You have no data, just hypothetical concerns about side effects that aren’t actually occurring.

    • We are the improper community to use the hypothetical situation you used. I can call 9-1-1 while I or someone else rescue breathes for my child knowing that if needed, the responding EMS providers will be able to administer naloxone in a safer environment than if I took the time going through the house trying to find the naloxone while my child is not breathing. One person can ventilate a person and call 9-1-1 at the same time. One person can not ventilate a person appropriately, pull up a medication, and administer it at same time. Even if it is an intranasal dosing, which by the way does exist and is currently a widely used means of administration.

      The shear fact that there is no easily found data into the known side effects posted by the FDA on naloxone is enough reason to wait before it is just handed out. No data literally means nothing, it does not mean that there is nothing wrong. And, the side effects do happen, just because you haven’t heard of any does not mean they do not.

      Here is yet another link to the drugs information including labels and official FDA information. Please be sure to read the FDA’s own precautions. Then explain to me how introducing another medication that has known side effects that are worse than what is currently occurring and would require more medications and interventions (that are not on hand of course because all you have is naloxone and you still haven’t called 9-1-1 because you were hoping they would just wake up) makes more sense than giving a CPR or Basic Life Support course to addicts and interested public.

      http://www.drugs.com/pro/naloxone-injection.html
      It’s even the “pro” version if it means anything to you.

      I do not doubt that handing naloxone out to addicts, their friends, and their families will save people at all. I have not seen any evidence that it will do a better job than proper use of existing measures and teaching CPR and basic first aid to the general public as well as extra time teaching it to this target group. Not only that but if more people have some form of training be it a video or formal class have a better chance of attempting resuscitative measures, which would help more than just overdose patients. It’s my opinion and I am entitled to it just as you are yours.

      http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/CPRFactsandStats/CPR-Statistics_UCM_307542_Article.jsp

      • One person can ventilate a person and call 9-1-1 at the same time.

        I think you vastly,/b> over-estimate the airway management capabilities of a panic-stricken parent. In these situations I think an Epi-Pen style Nalaxone device would be a (relatively) idiot-proof life saver.

        Every parent of a school-age child knows a child who carries an Epi-Pen or has such a child themselves. You tell Mom and/or Dad during patient education that this device is like an Epi-Pen for overdoses and they WILL know exactly where that device is at all times.

        • I absolutely agree I may be expecting quite a bit from another parent, and I haven’t been placed in that situation with my own so I can only hope. An auto-injector sounds like a good direction to go in and is absolutely an easily taught concept. I’m not so sure it would work well in the realm of illegal/recreational drug use though since there would obviously be a limit to how many doses are available and how much a single dose is. Also, epipens are given with a prescription and the training in their use, or are used by medical personnel with training and specific orders for their use. Thanks

  9. Live human study http://journal.cpha.ca/index.php/cjph/article/view/3788
    teaching 10’s of thousands of laypersons to give chest compression’s only for opioid OD. A 30 minute long training with no mention of respiratory assist and told specifically no rescue breathing if you ask the trainer.

    Read moderated comments AHA & ILCOR Opioid overdose response education https://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=891

  10. Re: Above live human study http://journal.cpha.ca/index.php/cjph/article/view/3788

    “You would think it brutal to withhold from the less capable the air they need. The moment you begin discriminating against the less capable, you establish conditions that breed dissatisfaction and resentment: you invite envy, discord and strife.” Alexander Berkman “Life of an Anarchist” p. 282

    Don’t Forget the Magic

Trackbacks

  1. […] [2] Should Basic EMTs Give Naloxone (Narcan)? Fri, 27 Dec 2013 14:00:22 Rogue Medic Article […]

Speak Your Mind