# Treatment for Opiate Overdose



## KEVD18 (Dec 19, 2008)

i have a purely hypothetical scenario:

you respond for the possible overdose. you arrive to find a patient(specifics are irrelevant) unconcious and responsive only to deep painful stimuli. you have evidence of narcotics use. needle tracks, bent spoons with soot on one side, empty paper 1x1 envelopes etc etc.

decreased resp rate, cyanosis, the works. im not going to bother to make up numbers(this really is hypothetical), but the bottom line is you need to give narcan.

do you:

a) administer enough of the drug to increase the resp rate(thereby increasing oxygenation) and start to bring the patient back around to the point that there v/s stabalize but hold back from brining them back to full conciousness

-or-

b) administer the maximum amount prescibed by your protocols as fast as you physically can deliver it and wait for the storm.


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## KEVD18 (Dec 19, 2008)

mea culpa. this should really be in scenarios. movement at the cl's discretion.


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## marineman (Dec 19, 2008)

Option A is what we were taught but I honestly haven't dealt with an opioid OD patient yet in the field.


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## remote_medic (Dec 19, 2008)

Option C --> Support resps with BVM if hemodynamically stable and let the ER deal with the narcan.


I know that option C is not right...but would be nice. Our protocols here in Maine guide us to give the minimal amount of Narcan for effect execpt in case of an arrest with suspician of narcotics.


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## gillysaurus (Dec 19, 2008)

I've learned that B leads to projectile vomiting like putting a finger over a loaded garden hose. No thanks.

A all the way. 

(And I am a BLS provider, but basics in my area can push Narcan IN with IV certification.)


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## traumateam1 (Dec 19, 2008)

B! Looks like fun!


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## AlaskaEMT (Dec 19, 2008)

A)  I'd rather not risk a combative patient because we ruined his $40 high.


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## Ridryder911 (Dec 19, 2008)

As more and more research with the use of Narcan becomes available, why one need to give more than enough to increase respiratory effort and rate? 

When one sees that it is "working" then one has determined the cause and can be titrated to effect. In all reality, that is all that needs to be done. 

Why risks sudden withdrawal, combativeness, and dangers to the patient and EMS staff? 

R/r 911


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## Epi-do (Dec 19, 2008)

I have seen to many ODs come up swinging in the past.  (I was still a basic, my medic partner decided to wake them up.)  Giving just enough narcan to improve respirations is the only way to go.


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## tydek07 (Dec 19, 2008)

Kev, I think you know my answer and my opinion on this issue   (A)!!


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## traumateam1 (Dec 19, 2008)

tydek07 said:


> Kev, I think you know my answer and my opinion on this issue   (A)!!



Finally.. someone who agrees with me ^_^ lol


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## KEVD18 (Dec 19, 2008)

fwiw guys, this topic came up in the chat room. everybody present was onboards with a with one dissenter(im guessing the same person who voted for b in this poll). i juts figured this topic could use the light of day. maybe, just maybe, it will help that provider improve their practice......


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## firecoins (Dec 19, 2008)

Just enough to improve the resp rate is fine for me.


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## fma08 (Dec 19, 2008)

Ridryder911 said:


> As more and more research with the use of Narcan becomes available, why one need to give more than enough to increase respiratory effort and rate?
> 
> When one sees that it is "working" then one has determined the cause and can be *titrated to effect*. In all reality, that is all that needs to be done.
> 
> ...



Stole the words right out of my mouth.


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## medicdan (Dec 19, 2008)

ALS in the suburban system I work in have an unofficial protocol to push 0.2mg IM to bring back resps enough, load into the truck. En Route, they get O2, monitor, IV, etc going, then push the other 0.2mg just as they roll into the ER.


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## rescuepoppy (Dec 19, 2008)

Epi-do said:


> I have seen to many ODs come up swinging in the past.  (I was still a basic, my medic partner decided to wake them up.)  Giving just enough narcan to improve respirations is the only way to go.



Why not just go ahead and wake them up? We always need a reason to justify the weapons we carry.
  Just kidding push enough to bring respiratory rate up and let it go at that. No point in fighting or cleaning anymore than you have to.


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## Hastings (Dec 19, 2008)

KEVD18 said:


> fwiw guys, this topic came up in the chat room. everybody present was onboards with a with one dissenter(im guessing the same person who voted for b in this poll). i juts figured this topic could use the light of day. maybe, just maybe, it will help that provider improve their practice......



Didn't vote, swear to God.

Someone else is trying to be funny.


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## traumateam1 (Dec 19, 2008)

I also didn't vote. Didn't vote A or B because I don't have Narcan protocols.


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## Hastings (Dec 19, 2008)

traumateam1 said:


> I also didn't vote. Didn't vote A or B because I don't have Narcan protocols.



2mg Narcan IV.


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## traumateam1 (Dec 19, 2008)

Hastings said:


> 2mg Narcan IV.



2 or .2? I say 2.. but everyone else is saying .2. Well good thing I don't have the protocol


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## KEVD18 (Dec 19, 2008)

0.4-2.0 q5min to a max of 10mg. but the minimum reccomended dose is 2mg.

iv/in/im/sc/et.

you can also do it as a taper at 0.4mg/hr but thats not really a pre hospital thing.

0.1mg/kg pedi max 0.8mg


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## KEVD18 (Dec 20, 2008)

the one department in ma thats field testing bls narcan is doing 2mg in(one in each nare) with an atomizer


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## traumateam1 (Dec 20, 2008)

KEVD18 said:


> 0.4-2.0 q5min to a max of 10mg. but the minimum reccomended dose is 2mg.
> 
> iv/in/im/sc/et.
> 
> ...



I have co attended some OD calls with a medic who did administer Narcan. Both times it was 2.0mg, and each case they only did it once. But thanks for cleaing up what the doses were Kev, wasn't to sure what the max was.

Hmm.. wonder what would happen if you shot someone up with ~6mg iv first time. This is the crazy wild pt we are talking about?


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## KEVD18 (Dec 20, 2008)

well the drug has zero effects other than to force off the opiates and bind to the receptors. if you dont do narcotics, the drug will have no effects on you whatsoever. thats argument for giving it all at once.

the problem is that, if you are using opiates,  a detox that rapid causes all sorts of bad juju. nausea, vomiting, diarrhea, fever, chills, tremors, tachycardia, aches and pains, elevated pain sensitivity, htn, suicidal ideation, depression, adrenal exhaustion, adrenal fatigue, delirium, a/v hallucinations, agitation, anxiety, panic disorder, paranoia, delusions are all likely symptoms.


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## KEVD18 (Dec 20, 2008)

oh, did i forget *death, *another possible side affect of rapid detox


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## traumateam1 (Dec 20, 2008)

Well that seriously sucks. Give me a few more months and I will be in EMT-A school and get back to you on that one.


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## Sasha (Dec 20, 2008)

Slamming it all at once can and will send a narc addict into severe withdrawal from it. BAD for them, very bad.

Also, if you can achieve the desired effect with the minimum dosage, you shouldn't have extra stuff circulating.

Cowboy medics give us all a bad name.


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## KEVD18 (Dec 20, 2008)

why arent you out drinking?


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## mycrofft (Dec 20, 2008)

*Six years detox ward in the jail...*

Anyone guess what drugs we used with great effect? (Not Narcan, but I'll tell you most were over the counter).
Nowadays if you blasted them with Narcan someone wuold complete the protocol to have you give them Methadone titrated to effect to revert them back to plan A, sorta.
I always had a hankering to try out two IV's (one with NS for the Narcan, the other for a glucose drip), a bedpan, trache tube, and cooling blanket. From high to dry in three minutes. Watch out, Betty Ford Clinic!


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## remote_medic (Dec 20, 2008)

mycrofft said:


> Anyone guess what drugs we used with great effect? (Not Narcan, but I'll tell you most were over the counter).
> Nowadays if you blasted them with Narcan someone wuold complete the protocol to have you give them Methadone titrated to effect to revert them back to plan A, sorta.
> I always had a hankering to try out two IV's (one with NS for the Narcan, the other for a glucose drip), a bedpan, trache tube, and cooling blanket. From high to dry in three minutes. Watch out, Betty Ford Clinic!



anyone else confused?


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## Kendall (Dec 20, 2008)

Yeah, a little bit....

Narcan should be titrated to effect. Thats in the ALS protocols here... Why put yourself, your partner, and your patient at risk by pushing it all at once?


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## Jon (Dec 20, 2008)

traumateam1 said:


> 2 or .2? I say 2.. but everyone else is saying .2. Well good thing I don't have the protocol


Thats why we should be using leading zeros...

.2 looks like 2.
0.2 looks like 0.2... 02 don't make sense!


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## Jon (Dec 20, 2008)

As for the initial question - if we JUST give enough to give them enough respritory drive that we don't tube them... it makes the ALS provider's life easy. We don't need to worry about an advanced airway... and we don't need to deal with a high drug addict that wants to refuse and/or fight us.

If you choose option B or C (tube them)... you are making your life difficult for no good reason... unless you haven't gotten a tube in a while


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## Ridryder911 (Dec 20, 2008)

Look how Narcan is packaged. It comes for adults as 0.4mg (vials) or 2mg vials (preload). Most use 0.4 mg IV; if effect noted then repeat to desired effect of increased respiratory rate and oxygenation effect. 

R/r911


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## Melbourne MICA (Dec 21, 2008)

*Narcan for effect*

We use 1.6-2.0mg IMI with concurrent BVM/100% O2. Extra 08.mg IM/IV if needed. BVM corrects the hypoxia, slow onset from IMI and correction of hypoxia means less chance of withdrawl type side effects ie pt wakes up nauseated, sweaty, tachy, agitated, feeling like crap and wants to take a swing at you. Takes a little longer but worth the wait.

It was one of the best changes to our guidelines ever. Old days BLS couldn't give Narcan (everybody can now) - MICA guys (who nearly always arrived after the BLS crews) didn't like pts waking before they set up a line and gave pushes of Narcan - result  - lots of agitated pts.

Provided arrival time is short and pt hasn't been down too long (with maybe some EAR at scene with 911 phone assist) we get excellent results without incident. Pts wake up, sit and go - whoa, what happened? Beside 99% of the time pts don't want to go to hospital. Win win situation. You should rarely have to intubate unless it's a polypharmacy overdose.

MM


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## vquintessence (Dec 22, 2008)

*Ooops!*

This is going on a tangent but figured it fits the conversation...

Everyone in here is talking about giving Narcan in doses titrated solely to increasing respiratory drive.  Kudos and glad there weren't any sadists who want to give our frequent fliers withdrawals galore.

Anyway here's a scary story:

I have a coworker over here who is gung-ho when it comes to "doing things because he can".  Well this guy went on a call where it was an obvious heroine OD.  Everybody knows this pt and sure enough the fella shot himself too hot once again.  Anyways so the pt has a little puke and whatnot and he's getting bagged s any problems.

Well it's Medic X's turn to lead for pt care... and the treatment option of choice?  *To give the pt a freakin IO to push 2mg*.  :glare:  Yeah.  Enough said.  This guy has 10 plus years of "ALS experience" which makes it even the more scary.  The ED flipped when they saw what happened.  Medic X also got a slap on the wrist for the matter.


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## Ridryder911 (Dec 22, 2008)

Just to prove some systems never remove idiots. 

R/r 911


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## Outbac1 (Dec 22, 2008)

If we need to bring them back for airway control we give 0.4mg IV. If they need more we give another 0.4mg. After that they're SOL as we only carry two amps. Usually we just manage their airway for them. If they're out of it they are no threat to me.


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## medic258 (Dec 22, 2008)

2mg IM. If that doesn't do it I will start a line and give 2mg more.


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## boingo (Dec 24, 2008)

Skip the needle altogether and give it nasally.  IO?  Damn, thats just evil.


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## bonedog (Dec 25, 2008)

WE use 0.8 mg SC which takes about 7 minutes to raise LOC to the point they can walk to the rig. LEO attend most and convince the patients to accept transport.

I would caution anyone on T&R these patients because as unusual as it may seem some times they lie. Especially be sure to carry the methadone OD.



I had the pleasure of treating an addict for anaphylaxis, once she could breath she accused me of giving her that narcan stuff....^_^


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## el Murpharino (Dec 25, 2008)

vquintessence said:


> Well it's Medic X's turn to lead for pt care... and the treatment option of choice?  *To give the pt a freakin IO to push 2mg*.  :glare:  Yeah.  Enough said.  This guy has 10 plus years of "ALS experience" which makes it even the more scary.  The ED flipped when they saw what happened.  Medic X also got a slap on the wrist for the matter.



Did your agency's CQI have a look at that report and question why this was done?  Did it get kicked up to a regional council?


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## chocchipsmom (Dec 25, 2008)

Sasha said:


> Slamming it all at once can and will send a narc addict into severe withdrawal from it. BAD for them, very bad.
> 
> Also, if you can achieve the desired effect with the minimum dosage, you shouldn't have extra stuff circulating.
> 
> Cowboy medics give us all a bad name.



One of my former partners was one pf those "Cowboys".  I got slammed around the back of the truck til we were able to restrain him.  
Our protocols state 0.4 - 2.0 mg titrate to effect.  Keep 'em breathing, but don't wake 'em up!


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## vquintessence (Dec 25, 2008)

el Murpharino said:


> Did your agency's CQI have a look at that report and question why this was done?  Did it get kicked up to a regional council?



Yes and his reasoning was that he couldn't obtain IV access after 2 attempts so IO was acceptable because pt was in imminent respiratory failure.  It was behind closed doors and I wasn't his partner that day so I don't know how he explained why IM/SC/IN weren't treatment options (let alone why his partner didn't speak up).  MA OEMS doesn't state any specific requirements for an acceptable use of IO, so Medic X technically didn't violate any protocols.  The company never reported him to the state.  The hospital and pt never spoke up either and it's been well over half a year.


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## Flight-LP (Dec 25, 2008)

I'm surprised that no one has mentioned option "D", just intubate them! Ventilatory support is the issue, if you secure the airway, you then have total control over their respiratory effort. Problem solved without risk of violence, concern for pt. or responder safety, and without concern that your Narcan administration hasn't over stimulated the pts. heart to where the increased myocardial workload and oxygen demand causes them to have an MI.....

I've had a LOT of narcotic OD's over the last decade, not once have I given Narcan. If they are down, keep them down. As long as you can control the airway, you are golden. Let the ER, and a more controlled environment be the one to bring them back down. Doing it in the field is only asking for trouble................................

And I am really dying to know who's great idea it was to teach new Paramedic's to give Narcan after the pt. has been intubated with no sedative or paralyti options. I was seeing that more and more before I left the States, never could understand the f'd up logic to it.....


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## Melbourne MICA (Dec 26, 2008)

*Confused*

I'm rather confused having read some of these posts. Our protocol in Melbourne is certainly not geared towards partial management of the narcotic overdose. We ventilate and administer the narcotic antagonist to correct the bulk of the side effects of the overdose - IE the neurological narcosis effects and the respiratory depression/suppression.

As I said in my last post, the pt regains consciousness and reacquires spontaneous ventilation's all things being equal. Where poly-pharmacy OD is suspected/confirmed or unknown aetiology is at work we will then manage further and transport to hospital as needed. 

On rare occasions a pt will ask to go to hospital or we will suggest this is a good course of action if the pt is not 100% clinically.

Otherwise we fix the problem, inform the pt then discuss options. 99% of the time they refuse transport and are offered some practical advise.

Perhaps our clientele is more predictable and there are less issues revolving around weapons than in the US.

During drug glut periods at my branch alone I could do 2 or 3 heroin OD's in one shift. (I am aware of the other types of Od's of course and we get our fair share of these as well).

Could someone help me out as to why most posters in this thread are talking about deliberately keeping your Pt's unconscious and nearly always transporting.

MM


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## boingo (Dec 26, 2008)

I think intubating them is a bit overkill.  Sure, they aren't protecting their airway, but when you have an identifiable and readily treatable etiology of their respiratory depression, we should try to reverse it.  There are several systems that treat and release heroin OD's, and some cities even give narcan to their known drug users for self/buddy administration, i.e Boston, San Fransisco.  To date there have been no reported bad outcomes, and the majority of those treated by non-EMS personell do not seek further medical attention.  I guess if you see heroin OD rarely then intubating may make sense, but as our Aussie friend and others see them daily, intubating them all would be a burden on the system.


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## bonedog (Dec 26, 2008)

In Vancouver I had to, on several occasions treat multiple patients.We would have the FR ventillating while my partner and I would  go and innoculate the victims.

I say victims as when ever there was a "corporate take over" the first thing done was release high grade junk to kill off the competitors dealers, along with any of their compadres.

Triage dictated that anyone in cardiac arrest was skipped and move on. I personally treated 8 patient's in one rooming house, while my partner treated 6 more in the alley. There were around 900 deaths that year due to herion OD.

Tubing with these numbers would have been folley, and why would you pack  them when you can walk them? My philosophy is lift only when absolutely neccesary.


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## Melbourne MICA (Dec 26, 2008)

*Overkill*



boingo said:


> I think intubating them is a bit overkill.  Sure, they aren't protecting their airway, but when you have an identifiable and readily treatable etiology of their respiratory depression, we should try to reverse it.  There are several systems that treat and release heroin OD's, and some cities even give narcan to their known drug users for self/buddy administration, i.e Boston, San Fransisco.  To date there have been no reported bad outcomes, and the majority of those treated by non-EMS personell do not seek further medical attention.  I guess if you see heroin OD rarely then intubating may make sense, but as our Aussie friend and others see them daily, intubating them all would be a burden on the system.



I agree. Without labouring the point, I can't see where there is a pressing need to be overly agressive in Mx of heroin Od's unless they are showing clincial S&S of hypoxic brain injury, credible evidence of poly pharmacy overdose or remain unresponsive to a second Narcan administration. Provided the pt is well ventilated on his/her side with an OP/NP in an IM/IN Narcan dose will do the job every time. Why tie up the ED with streams of readily treatable pts who are just as likey to abscond anyway and certainly don't warrant an ETT probably requiring induction with more side effects to manage for your trouble.

Your situation in the US may be different relative to the "class" of your drug pts and risks therein but here a heroin OD is bread and butter ambo stuff, quick, easy and cost effective with no ED beds tied up and a life saved for your effort.

I'm not trying to tell anybody to suck eggs.

MM

PS I hope all you guys and gals are having a great holiday season.


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## reaper (Dec 27, 2008)

How do you justify leaving them on scene?

Depending on the amount of heroin they have in them, they will need multiple doses of narcan. Yes, you can bring them around on scene, but they may go unresponsive again as soon as the narcan wears off. So do send a unit back out to them again?


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## Melbourne MICA (Dec 27, 2008)

*A clash of realities*



reaper said:


> How do you justify leaving them on scene?
> 
> Depending on the amount of heroin they have in them, they will need multiple doses of narcan. Yes, you can bring them around on scene, but they may go unresponsive again as soon as the narcan wears off. So do send a unit back out to them again?



I guess this is where reality and medicine clash. There are always plenty of what if's including heroin OD's and the standard approach is to recommend and offer transport to hospital for all revived and cogniscent (GCS 15) Heroin OD's.

However the ritual reply from my experience and that of others over many years is refusal. Advice is offered for their protection from further drug related harm including the liklihood of further narcosis. But we have no legal grounds to force attendence at hospital.

We've learned from experience and frequent interaction with locals that the compromise position is the best alternative available. As we all know, the potential for violence is always but a missplaced word away.

Clinically from my experiences, the recidivist rate of heroin OD on the same day from the same patient is almost non-existant. At the standard dose we give, 1.6-2.0mg IM there is a low probability of repeat stuporous collapse requiring reattendence.

Ethical/clincial idealism is a mark worth striving for but in such cases reality does bite. We have not had a single attack against officers by opiate OD pt's across the board in years because of this approach. Alternately I cannot remember the last time I went back to the same patient in the same shift. I can only assume the heroin user has survived one more day.

 - Now psychostimulants is another matter altogether.

MM


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## ccfems540 (Dec 27, 2008)

I am limited by my protocol to give 1mg IV followed by and additional 1mg in 5 minutes if the first dose has no effect.  I can also give 2mg IN(1mg per nostril) if no IV access is available.


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## Ridryder911 (Dec 28, 2008)

reaper said:


> How do you justify leaving them on scene?
> 
> Depending on the amount of heroin they have in them, they will need multiple doses of Narcan. Yes, you can bring them around on scene, but they may go unresponsive again as soon as the Narcan wears off. So do send a unit back out to them again?



You can't and hence the troubles. I cannot remember specific to the studies as the main point was attempting to paint a picture wanting more funding  to justify "administering Narcan" and or supplying clean needles" for the junkies. In some cities there was also a place to crash and have someone be able to administer Narcan if needed in the first few moments. 

From what I recall (after being appalled, that tax monies is being wasted on this b.s.) is most have built a tolerant level, and what usually would kill the "normal" person, barely phases the junkies. 

Yup, Liberalism at its finest. 

R/r 911


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## eric2068 (Jan 4, 2009)

*Opiate*

I like option c. Option a if absolutely necessary, and option b only if patient is four pointed, suction is ready, and cop armed with a taser. When I was a baby-medic I tried option b. Never make that mistake again.


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## bonedog (Jan 4, 2009)

I see that Switzerland is supplying free heroin and cocaine to addicts to cut out the organized crime. 

Great idea as obviously the "war on drugs" is an abysmal failure. 

Now they will only have to concentrate on easier crimes like prostitution and gambling, although with free dope the hookers won't have to turn tricks to support thier habits, win win....


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## knxemt1983 (Jan 10, 2009)

depends on if I like the er staff we're going to see. if I like em 0.4 titrated, if not then I titrate it until we hit the ed hall then give it all to em and let the ed deal with it....


no seriously, I'm kidding, I have seen it done like that but I don't, titrate to effect to reverse resp depression. The ones I have had thats basically what the edoc has done too brought them out slowly.


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## Sasha (Jan 10, 2009)

bonedog said:


> I see that Switzerland is supplying free heroin and cocaine to addicts to cut out the organized crime.
> 
> Great idea as obviously the "war on drugs" is an abysmal failure.
> 
> Now they will only have to concentrate on easier crimes like prostitution and gambling, although with free dope the hookers won't have to turn tricks to support thier habits, win win....



And when they OD and die, their family can sue the government.


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## JPINFV (Jan 10, 2009)

bonedog said:


> Now they will only have to concentrate on easier crimes like prostitution and gambling, although with free dope the hookers won't have to turn tricks to support thier habits, win win....



You mean not everyone works for hookers and blow?
/sarcasm (MAJOR SARCASM)


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## bonedog (Jan 10, 2009)

One end of the scale or the other, just throw em' in jail with that Tommy Chong....


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## eric2068 (Jan 10, 2009)

Don't ya love it. Ya ask the question "Do they use drugs?" You get the shocked response, "No, never!!!" Then the narcan works.
 Life is tough, it's tougher when you are stupid.-John Wayne :wacko:


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## DrankTheKoolaid (Jan 11, 2009)

*re*

Option A for sure, last thing i want is a pissed off junky swinging at me in the back of the truck because i just pissed off the last of his dope.

Corky


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