# Narcan can now be administered by everyone in Ca.



## exodus (Feb 4, 2014)

http://www.kcra.com/heroin-antidote.../-/rxw8r6z/-/index.html#.UvCJ7-VNAl4.facebook

Makes me wonder if basics will be allowed to administer it while working.


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## chaz90 (Feb 4, 2014)

Based on the rest of what I read about the plight of many EMTs in CA, I'd guess not. Perhaps you can follow AHA recommendations to the letter and immediately "call for help" (to a bystander in this case) when you get on scene of an opiate OD.

I kid. Mostly


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## CentralCalEMT (Feb 4, 2014)

Ah, yes California, the state that would not let EMTs use AEDs, won't give paramedics RSI even with additional training and home to such "progressive" EMS systems such as Orange County wants to give laypeople an emergency drug. 

Considering basics just got permission to use AEDs while on duty, I am gonna guess that it will take about a decade for narcan to appear on BLS ambulances. 

That being said, I have serious reservations about this law. I highly doubt the friends/family administering narcan will also notify EMS. IV drug users seem to be scared of any vehicle with flashing lights and not just cop cars. Therefore, you will have a lot of OD patients thinking they are OK and then, when the narcan wears off, go into respiratory arrest and die. Naturally, the article fails to mention what we all know, that the effects of opiates far outlast the effects of narcan. 

Also with the random crap most heroin is cut with, you never know exactly what the patient took. Compounding this issue, many drug users use multiple drugs, and have other chronic health problems from years of drug use such as diabetes, seizures or any other conditions that can cause ALOC and/or respiratory depression. Whats not to say that they are in respiratory arrest from some other cause? I can imagine the delay calling EMS when the heroin user stops breathing because of airway obstruction from a seizure who does not get the help he needs because his friends are messing around with giving him narcan and 20 min later when he is still unresponsive they finally decide to call EMS.


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## SandpitMedic (Feb 4, 2014)

CentralCalEMT said:


> ....
> Considering basics just got permission to use AEDs while on duty, I am gonna guess that it will *take about a decade* for narcan *to appear on BLS ambulances. *



I was a basic in CA back in 2008-2011.... And we were trained and allowed (in fact mandated) to use the AED if needed.

That was both in Central NorCal and San Berdo Counties.

Also, narcan doesn't take 20 minutes to work.

As for the stuff I bolded- that's just EMS. We're slow to evolve, that's part of our problem gaining speed.


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## mycrofft (Feb 5, 2014)

Yes you can use it on the job….if you're a heroin addict.:rofl:

AED"s are tricker because you can't use them in a moving vehicle unless you stop every two minutes for "Analyzing"...


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## TheLocalMedic (Feb 5, 2014)

Is Narcan a lifesaving drug?  Absolutely.  

Should EMTs be allowed to carry and administer it?  Heck yeah.  

Is there any good argument against EMTs having it?  Nope.  

…

So will we let them have it then?  Probably not.  That would be just too logical.


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## Carlos Danger (Feb 5, 2014)

Good stuff.

I have long thought nalaxone should be an OTC drug.


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## mycrofft (Feb 5, 2014)

http://reference.medscape.com/drug/narcan-naloxone-343741#4
"Adverse Effects
Frequency Not Defined
Withdrawal reaction precipitated

Abrupt reversal of narcotic depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure and tremulousness

Cardiac arrest

Ventricular fibrillation

Dyspnea

Pulmonary edema"

MEDSCAPE attributes these to opioid withdrawl syndrome. In my experience,:censored:but without nalozone, very rare. Otherwise , they basically call it mother's milk, and in fact states it's not known if it affects lactation. 

Slippery slope giving drugs to techs otherwise not trained in them and then expecting them to titrate it to effect.


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## Carlos Danger (Feb 5, 2014)

mycrofft said:


> http://reference.medscape.com/drug/narcan-naloxone-343741#4
> "Adverse Effects
> Frequency Not Defined
> Withdrawal reaction precipitated
> ...



Does it really make sense to not administer an antidote to a dying person because the antidote may have some negative side effects?


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## NomadicMedic (Feb 5, 2014)

Here in Delaware, a trial program to allow EMT basics to administer Narcan is ongoing. The only problem is I foresee are; EMTs giving a CVA or other altered patient 2 mg of Narcan and then waiting around to see what happens, or administering 2 mg of Narcan up a heroin addicts nose and then getting their butts kicked. both of those will be good learning experiences, and I bet they'll only happen once or twice.


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## CentralCalEMT (Feb 5, 2014)

SandpitMedic said:


> I was a basic in CA back in 2008-2011.... And we were trained and allowed (in fact mandated) to use the AED if needed.
> 
> That was both in Central NorCal and San Berdo Counties.
> 
> ...



Yeah I was referring to good old LA county which still has BLS ambulances without AED. I'm happy most counties aren't quite so far behind the times.


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## SandpitMedic (Feb 6, 2014)

Lol the county with "advanced scope" doesn't allow the use of AEDs?!
What a joke. Wowza!


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## SandpitMedic (Feb 6, 2014)

Perfect timing for this though- considering the Phillip Seymour Hoffman thing.


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## mycrofft (Feb 6, 2014)

*Good question.*



Halothane said:


> Does it really make sense to not administer an antidote to a dying person because the antidote may have some negative side effects?



Asking the question supplies the answer. "Do no (further) harm".

They will not allow laypersons to legally get and administer enough narcan to help in many cases. (So, often futile).

Some places already and illicitly slip narcan to their addicted clients, but one news article I head said they don't know if it is doing any good. (Suggests it is futile).

If you are convinced what you are going to do pharmaceutically (no matter how thin the chance of it working and no matter how thin your absolute knowledge of the drug) ought to be done because "I gotta do SOMETHING!"  (to do nothing is distressing to you), then you are one foot in the Malpractice Hole and sliding towards killing or harming someone. 

There are three questions here:

1. _Is it ethical and safe_ (forget legal for the moment) to do this?

2. _Is it realistic_ to expect it to help, based in scientific evidence and experience? Or will we see gross misdosaging, calls for 911 delayed because "We gave him the narcan, dude!", and incorporation of narcan into abuse patterns rather than as curative (such as medical O2 getting highjacked for hangovers enabling alcohol abuse).

3. Historically "antidotes" and "harmless drugs" (look up the history of the medicinal uses of thalidomide, radium salts, and strychnine) aren't.  Should people without depth in background in assessment, care and pharmacodynamics be given antidote drugs to administer on the basis that a "panacea dose" (not tailored to pt weight and dose of poison) will save lives? IS there a "panacea dose", or do we just blast everyone with a high (pun untintended) dose? And remember, this is medicine being held and given by junkies, maybe often by people under the influence at the time.


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## mycrofft (Feb 6, 2014)

*Just found this*

http://www.drugs.com/pro/narcan.html *


AND I QUOTE:

"Overdosage

There is limited clinical experience with Narcan overdosage in humans.

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 Narcan 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).

At doses of 2 mg/kg in normal subjects, cognitive impairment and behavioral symptoms, including irritability, anxiety, tension, suspiciousness, sadness, difficulty concentrating, and lack of appetite have been reported. In addition, somatic symptoms, including dizziness, heaviness, sweating, nausea, and stomachaches were also reported. Although complete information is not available, behavioral symptoms were reported to often persist for 2-3 days."

So, crappy science or no science of ill effects, but some _are_ suggested by a very small study (why on CVA patients?). 

* This article was headed by an ad asking "Want to detox at home?". Kid   you  NOT!


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## SandpitMedic (Feb 6, 2014)

mycrofft said:


> Asking the question supplies the answer. "Do no (further) harm".
> 
> They will not allow laypersons to legally get and administer enough narcan to help in many cases. (So, often futile).
> 
> ...



These are the right questions. And very well stated.


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## TheLocalMedic (Feb 6, 2014)




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## mycrofft (Feb 6, 2014)




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## SandpitMedic (Feb 6, 2014)

Exactly.- the pictures!

And that's the truth. Satire aside.

You're looking at what will happen. People (generally our clientele) can't even handle NyQuil, yet were sitting here debating giving them Narcan.

Jeeze. Rogue media circus.


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## TheLocalMedic (Feb 6, 2014)

DEAR LORD, HERE I AM AGAIN, ASKIN' ONE MORE CHANCE FOR A SINNER!






[EXPLICIT]

http://www.youtube.com/watch?v=CXJ8c0rWJsk


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## Carlos Danger (Feb 6, 2014)

mycrofft said:


> Asking the question supplies the answer. "Do no (further) harm".



Well, considering there is nothing more "harmful" than severe respiratory depression, and also considering that narcan is a relatively safe drug (especially when compared to the risks associated with not breathing) I'd say giving narcan to someone who needs it is never going to be "doing more harm". Rare complications aside, of course.

For some reason, people in the EMS community love to drone on about how ridiculously dangerous narcan is. I think part of the bad attitude towards narcan comes from a machismo that would rather intubate than simply push a med that instantly fixes the problem (if I had a buck for every time I heard a paramedic say something to the effect of "Narcan? Pfft. I just tube 'em all", I'd be rich), part of it comes from ED doctors and medical directors who don't like it because they give too much of it and then have to deal with the violence and hypertensive crises that sometimes follow, and part of it comes from simply not being experienced with the drug. 

"But what about people who give it and don't call 911 and then the patient re-sedates!?!" So what? Would that patient have been better off if the narcan had never been given? Don't forget that these people often don't call 911 anyway....

I'm no authority on heroin and I'm sure the effects vary considerably depending on purity, what it's cut with, etc. But I have read that it's duration is generally shorter than that of morphine. Morphine's respiratory depressant effects from a single bolus generally peak at about 30-40 minutes and then begin to taper off at 60-75 minutes....compare that to the duration of action of narcan, which is 1-4 hours. Even at the low end (1 hour), it is unlikely that a dose of narcan given at the onset of respiratory depression will lose effect sooner than the resp depressant effects of morphine. And heroin doesn't even last as long as morphine. An OD of one of the oral opioids? Yeah, that is different. But does the fact that some people might not be helped by narcan mean that no one should have it? 

If there is some compelling evidence that narcan does more harm than good, then yeah, it probably shouldn't be out there. But I don't think that is the case. The few trials involving layperson/police/EMT narcan administration that I've heard about were all considered successful.

I remember hearing the same doom-and-gloom when epi autoinjectors and even AED's were introduced. "The lay-public will never get this right. They'll kill each other left and right".


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## mycrofft (Feb 6, 2014)

*Good points,Halothane*

Well, considering there is nothing more "harmful" than severe respiratory depression, and also considering that narcan is a relatively safe drug (especially when compared to the risks associated with not breathing) I'd say giving narcan to someone who needs it is never going to be "doing more harm". Rare complications aside, of course.
There's the money shot.

For some reason, people in the EMS community love to drone on about how ridiculously dangerous narcan is. I think part of the bad attitude towards narcan comes from a machismo that would rather intubate than simply push a med that instantly fixes the problem (if I had a buck for every time I heard a paramedic say something to the effect of "Narcan? Pfft. I just tube 'em all", I'd be rich), part of it comes from ED doctors and medical directors who don't like it because they give too much of it and then have to deal with the violence and hypertensive crises that sometimes follow, and part of it comes from simply not being experienced with the drug. 

I've not heard droning about the _*dangerous *_Naloxone, and oddly we used to see a BP DROP during heroin detox done with benedryl, antispasmodics, and acetaminophen. My concern about Naloxone is when it is given in a wrong dose, and when it is given in lieu of definitive treatment. Or for home detox as the ad asked, which is abuse. Bad precedent. 

"But what about people who give it and don't call 911 and then the patient re-sedates!?!" So what? Would that patient have been better off if the narcan had never been given? Don't forget that these people often don't call 911 anyway….

This patient is dying primarily due to overdose, but  secondarily to inadequate treatment as mandated by the person who sent out the Naloxone. A protocol is implied, a "panacea dose" is distributed, and then they walk off with their hands in their pockets claiming victory. 

I'm no authority on heroin and I'm sure the effects vary considerably depending on purity, what it's cut with, etc. But I have read that it's duration is generally shorter than that of morphine. Morphine's respiratory depressant effects from a single bolus generally peak at about 30-40 minutes and then begin to taper off at 60-75 minutes....compare that to the duration of action of narcan, which is 1-4 hours. Even at the low end (1 hour), it is unlikely that a dose of narcan given at the onset of respiratory depression will lose effect sooner than the resp depressant effects of morphine. And heroin doesn't even last as long as morphine. An OD of one of the oral opioids? Yeah, that is different.* But does the fact that some people might not be helped by narcan mean that no one should have it? * (emphasis by mycrofft).
The most telling argument in favor. As to length of the drug's activity, every systemic drug except when given via IV has a bell curved onset and fade. But it seems Narcan could outlast the acute respiratory impairment stage of an overdose.

If there is some compelling evidence that narcan does more harm than good, then yeah, it probably shouldn't be out there. But I don't think that is the case. The few trials involving layperson/police/EMT narcan administration that I've heard about were all considered successful. The graphic in the Connecticut study supporting their legislation implies that distribution of narcan didn't really affect the curve of drug od's.

I remember hearing the same doom-and-gloom when epi autoinjectors and even AED's were introduced. "The lay-public will never get this right. They'll kill each other left and right". I remember that too…when AED's had override buttons. And who knows how many iatrogenic cases have been triggered by epipen use? I DO know of at least one case where definitive care was delayed after epi was given…by the pt's MD father!

OK than. Let's do it but have a mandatory scientific study of the results after three to five years later.

I am still opposed generically to setting up drug administration by persons without the background to do it responsibly, though, and this is a step that way and yes that includes EMT-B's.

See next reply. It is pro-narcan program.


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## mycrofft (Feb 6, 2014)

*Here's Connecticut's program.*

Connecticut State Mental Health and Addiction Services p[rogram's Naloxone rescue kit plan in PDF (like a power point)

http://www.ct.gov/dmhas/lib/dmhas/presentations/Naloxone.pdf

Connecticut loses more adults to opiate overdose than MVA, fire and firearms combined.


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## unleashedfury (Feb 7, 2014)

Whilst I agree that having narcan on hand for Layperson(s) may save lives. It may just prolong the OD till they die later. 

You have to think like a user to rationalize the point. 
If were all at a drug house shooting heroin into our veins one person OD's. So bust out the Narcan Kit and hit them with it. If we call 911 that means cops Fire or EMS is going to come. Now were marked... They know we use, and now they know where we live, and so on such forth. 

I actually had a girl once dump her boyfriend off at a street corner because he OD'd in her car. She called his parents and said oh he Overdosed on Heroin while I was taking him home, so I dropped him on a street corner and left. I don't want to get caught into a mess with the cops cause they'll know I'm a user then. 

What a girlfriend, leaves her man on the street corner to die, since her drug habit was more important..


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## Jmo371 (Feb 7, 2014)

ironically NYS actually does allow us to use it at the basic level.....maybe they got one thing right lol ;(


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## Carlos Danger (Feb 7, 2014)

mycrofft said:


> Connecticut loses more adults to opiate overdose than MVA, fire and firearms combined.



Now that is mind blowing.....


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## Carlos Danger (Feb 7, 2014)

unleashedfury said:


> I actually had a girl once dump her boyfriend off at a street corner because he OD'd in her car. She called his parents and said oh he Overdosed on Heroin while I was taking him home, so I dropped him on a street corner and left. I don't want to get caught into a mess with the cops cause they'll know I'm a user then.
> 
> What a girlfriend, leaves her man on the street corner to die, since her drug habit was more important..



The fact that junkies don't like to call 911 is all the more reason why they should have narcan.....maybe if she had it she could have given him an IM injection and he would have been fine.

If I'm not mistaken, most opioid OD's are actually from the time-release oral analgesics, (Oxycontin, MS-Contin, etc.). Narcan likely won't help much in these cases, but it might still help in a few. 

Is narcan going to save the day every time? Of course not. Does that mean it should never be used?


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## dixie_flatline (Feb 7, 2014)

unleashedfury said:


> What a girlfriend, leaves her man on the street corner to die, since her drug habit was more important..



For a real junkie, there is the need to fix, and then way down below there is everything else.  Boyfriends aren't even close most of the time.


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## mycrofft (Feb 17, 2014)

dixie_flatline said:


> For a real junkie, there is the need to fix, and then way down below there is everything else.  Boyfriends aren't even close most of the time.



Sometimes,_ in heroin veritas_. But usually just self-serving bull shirt.

1. Most ODs don't occur in an archetypical "shooting gallery", they occur where the user won't be disturbed and maybe with a cohort or two. If polypharmacy is involved (speedballing for example), maybe a party. But the same dynamic ensues. One way to clean a party out of junkies (and honor students) it to spread the word someone OD's and that 911's been called. Rats off a ship…..

2. Methadone, prescriptions for detox drugs to be used by a patient at home (kid you not!!!), clean syringes, all are found in the hands of people they weren't given to because the recipients sold them for drugs. I see Naloxone being used the same way.

BIG question: since cold turkey heroin detox in utero is frequently fatal to the fetus, what happens when the addicted mom gets a slam of Naloxone? Any references or citations? Experiences?


A small question: how many people on this forum are or have been addicted at some time? Statistically, the answer is "yes".:mellow:


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## mycrofft (Feb 17, 2014)

*Naloxone and pregnancy…AND I QUOTE...*

http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health_Care_for_Underserved_Women/Opioid_Abuse_Dependence_and_Addiction_in_Pregnancy

GOOD article about addiction and pregnancy.

" The use of an antagonist, such as naloxone, to diagnose opioid dependence in pregnant women is contraindicated because induced withdrawal may precipitate preterm labor or fetal distress (13). *Naloxone should be used only in the case of maternal overdose to save the woman’s life.*"  (accents by Mycrofft).

So it is a balancing act. If you are _sure_ the mother is dying, then save the mother, but the fetus _*may*_ abort or die. 
How many addicted women may try this as an abortificant? (Don't smirk. I've seen insulin overdose tried, with methamphetamine administration as their correction for insulin coma. Didn't work out so well).


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