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

- Rogue Medic

Is ‘Narcan by Everyone’ a Good Idea?


Image credit.
 

My friend Jonathan Blatman asks the following question about naloxone (Narcan) on Facebook –
 

I’ve heard that PA (Pennsylvania) is looking to follow down the “Narcan for everyone” route, in allowing PD and BLS folks to give intranasal naloxone.[1]

 

The problem is not that basic EMTs, or first responders, or police are stupid people.

The problem is that all people are stupid people.

Doctors, nurses, and paramedics do not understand naloxone, so we need to improve the understanding of pharmacology among doctors, nurses, and paramedics, before we increase the ranks of ignorant people inappropriately administering the drug.

Naloxone itself is very safe.

A quack once challenged me to take 1,000 times the dose of any medicine I chose, while he would do the same with some natural product. I accepted and chose naloxone, with the condition that he first take 1,000 time the daily recommended dose of one of something he considered completely safe and natural – water.

The quack had it pointed out to him that this dose of all natural water would be deadly. The quack backed out. Whether naloxone’s standard dose is 0.4 mg (it should not be more than this) or the dose more popular in areas with frequent fentanyl overdoses (2.0 mg) does not matter. Naloxone has been demonstrated to be relatively safe at massive doses.
 

Adult Patients
In one small study, volunteers who received 24 mg/70 kg did not demonstrate toxicity.
In another study, 36 patients with acute stroke received a loading dose of 4 mg/kg (10 mg/m2/min) of naloxone hydrochloride injection followed immediately by 2 mg/kg/hr for 24 hours. Twenty-three patients experienced adverse events associated with naloxone use, and naloxone was discontinued in seven patients because of adverse effects. The most serious adverse events were: seizures (2 patients), severe hypertension (1), and hypotension and/or bradycardia (3).
[2]

 

400 mg (0.4 mg dose x 1,000) or 2,000 mg (2.0 mg x 1,000) would be higher than the doses tested in these patients, but would still be much safer than 1,000 times the recommended daily dose of water, even though water is safe and essential for life. It does not matter if there is fluoride in the water for it to be lethal, but we should fluoridate water, because only conspiracy theorists think that fluoride is dangerous in drinking water.
 


 

We engage in magical thinking about the drugs we give.

The problem is not with the drug. The problem is with the actions of the people giving the drug – us.

We still have a big push for giving fibrinolytics (tPA – tissue Plasminogen Activator) to patients with acute ischemic stroke, even though most of the improvement may be due to the transience of stroke symptoms in some stroke patients (TIS – Transient Ischemic Attack). Fibrinolytics do not appear to be beneficial for acute ischemic stroke and there is no reason to give them for a TIA.

There is weak beneficial evidence in only two out of eleven studies (only 18% of studies) – and increases in death in most studies of fibrinolytics for acute ischemic stroke.[3] The problem is not with the drug. The problem is with the actions of the people giving the drug. Most of the evidence shows death increased, but we ignore that.

Naloxone and tPA are both given based on a rush to treatment and a fear of not giving the standard of care – the Yuppie Nuremberg Defense.
 

Everyone’s got a mortgage to pay. [inner monologue] The Yuppie Nuremberg defense.[4]

 

Will this be a matter of providing naloxone, rather than providing ventilations?
 

An epidemic of naloxone-resistant heroin overdoses due to fentanyl adulteration has led to significant morbidity and mortality throughout the central and eastern United States. According to records of the Philadelphia County Medical Examiner’s office, at least 250 overdose deaths have been associated with fentanyl between April 1, 2006, and March 1, 2007.[5]

 

What about people who take more than one drug?

If the opioid is reversed, will there be problems?
 

All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours.[6]

 

Will we identify the patients who have other medical conditions that may respond after naloxone, but not because of naloxone, such as hypoglycemia, stroke, seizures, clonidine overdose, arrhythmia, head trauma, dehydration, syncope, et cetera?
 

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.[7]

 

The problem is not with the administration of naloxone, but with the faulty assumption that because a patient wakes up after naloxone, the patient woke up because of naloxone.

Doctors, nurses, and paramedics do not do a good job of identifying the difference currently. We need to educate them, rather than encourage others to replicate their mistakes.

Pharmacology is poorly understood by people with medical education.
 

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%).[8]

 

The indication for naloxone is respiratory depression.

The treatment for respiratory depression is to supplement oxygen and/or ventilations. We have decided to give naloxone in stead.

Naloxone was used appropriately in fewer than 1% of patients.

How good bad will our naloxone by everyone education be?

Don’t wait with bated breath – someone my administer naloxone.
 

Also read –

Should Basic EMTs Give Naloxone (Narcan)?

The Myth that Narcan Reverses Cardiac Arrest

To Narcan or not Narcan

What About Nebulized Naloxone (Narcan) – Part I

Footnotes:

[1] I’ve heard that PA is looking to follow down the “Narcan for everyone” route, in allowing PD and BLS folks to give intranasal naloxone. . . .
Facebook
Narcan post

[2] NALOXONE HYDROCHLORIDE injection, solution
[Hospira, Inc.]

DailyMed
Adverse reactions
Overdosage
FDA Label

[3] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman
Smart EM
Article

[4] Thank You for Smoking
Movie, based on the book by Christopher Buckley
Wikiquote
Quote page

[5] Heroin: what’s in the mix?
Muller AA, Osterhoudt KC, Wingert W.
Ann Emerg Med. 2007 Sep;50(3):352-3.
PMID: 17709054 [PubMed – indexed for MEDLINE]

[6] Scopolamine Poisoning among Heroin Users — New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996
MMWR (Morbidity and Mortality Weekly Report).
Vol 45, No 22;457;
Free Full Text from the Centers for Disease Control and prevention.

[7] The empiric use of naloxone in patients with altered mental status: a reappraisal.
Hoffman JR, Schriger DL, Luo JS.
Ann Emerg Med. 1991 Mar;20(3):246-52.
PMID: 1996818 [PubMed – indexed for MEDLINE]

[8] 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. 2012 Apr-Jun;16(2):289-92. doi: 10.3109/10903127.2011.640763. Epub 2011 Dec 22.
PMID: 22191727 [PubMed – indexed for MEDLINE]

.

Comments

  1. As an EMT in western PA, I would much rather add EtCO2 monitoring to my scope of practice so that I can better ensure I’m providing adequate respirations for all of my patients with abnormal respirations rather than to save some work on certain drug overdoses.

    • Garrett,

      I completely agree about the much greater benefit of capnography.

      I hope BLS capnography is coming to Pennsylvania, but the paramedics do not seem to understand capnography, so it may be difficult.

      When waveform capnography became mandatory for all intubated patients in Pennsylvania, the medics would attach the capnography, get a reading (assuming they used it at all), and disconnect the capnography.

      The next set of protocols had to change the rule to require continuous waveform capnography, because the medics were disconnecting one of the most useful pieces of equipment they have.

      We learn very slowly. sometimes, the more letters that follow a name, the slower the person learns, even though all of those degrees are supposed to indicate a greater ability to learn.

      .

      • Garrett,

        I hope you get it too. Used properly, it’s a good tool, and not just when you’re assisting respirations or ventilating your patient. Honestly, I think it should be included as a basic vital sign whenever it’s available. We already treat SpO2 that way (though I still have to constantly kick people for relying on the pulse-ox to check pulse rates).

        We have BLS capnography here in VA, but it’s recent, and I find myself constantly having to encourage and re-educate our EMT’s (and even some of our ALS providers, since we’ve only had the equipment for a bit over two years) to use it.

        • Jake,

          Pulse oximetry can be used to check the pulse, but there are confounders and it does not really tell you about the quality of the pulse, the temperature of the skin, the turgor of the skin, or the moisture of the skin. I also like to compare the left radial pulse to the right radial pulse (and the right dorsal pedal pulse with the left dorsal pedal pulse), which requires simultaneous palpation of the pulses on the right and left sides.

          Making capnography a basic vital sign would be interesting, but the problem is similar to the problem with naloxone. The problem is not in the tool, but in how the tool is used.

          Everything is dangerous without understanding.

          .

  2. You make some good points, that add to the concerns I’ve had when hearing about these programs:

    Not being terribly familiar with these programs, what’s the dosage they’re teaching these responders to give / equipping them with? Is it enough to trigger withdrawal symptoms in a long-term addict (one reason we stopped slamming 2mg for everyone and started titrating to respirations)? What’s the cop going to do then?

    Does the LEO training include what to do if the patient starts vomiting and compromises their airway? Do they get suction along with the medication?

    Narcan is harmless if you’re healthy. It is NOT harmless to someone who is addicted to narcotics, to the point that even the ER docs – with equipment and training far beyond what we have available in the field – are cautious in using it.

    The trend in EMS over the last decade has been to back away from narcan – giving it less often, and being more cautious with the dosage, rather than trying to use it as a diagnostic tool and slamming a patient with high doses. This almost seems to be a reversal of the trend.

    I’d be happier training and equipping the cops to do proper ventilations while waiting for EMS. Because we’re not very likely to give narcan at all.

    • Jake,

      I do not know what is included in the training/education.

      The problem is that we do not currently do a good job of educating doctors, nurses, and paramedics, so we can expect that the education of first responders will be less adequate than that already inadequate education.

      As you stated, while the drug is relatively safe, the way it is used can change that.

      That appears to be the part that people do not want to accept.

      .

  3. AS you’ve said many times, they didn’t call for lack of narcan. They almost always call for lack of breathing. Why not just provide good “customer service” and give them what they called for. Ventilation….

    • Toasted Medic,

      The problem is that we do not provide an adequate pharmacology education for doctors, nurses, and paramedics, but we expect a quick course on naloxone to provide a better understanding to first responders.

      We have discouraged good assessments, so that it is considered more appropriate to give a drug, than to assess and improve oxygenation and/or ventilation by means other than the supposed antidote. Why supposed? Because if the patient’s condition is not due to opioid overdose, the treatment is not naloxone.

      .

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  1. […] lives, but the illusion of safety and condoning of destructive behavior by providing a seemingly benign antidote will cost more lives than it saves. The more coverage that an “antidote” to heroin […]

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