# What if we gave narcan to everyone?



## DrParasite (Aug 14, 2012)

Question from the uneducated....

what would be the medical consequences to giving every patient we treated  narcan?  Aside from giving an intervention that isn't indicated (hello, every ALS patient gets an IV?), and the obvious cost involved, would there be any negative outcomes to giving narcan to patient's who haven't taken opiates?  Yes, you would kill the highs of people who had taken opiates, and they might not be happy, but are there side effects for the people who haven't taken them?

Lots of older practices of giving for the same of giving (coma cocktail, start a line and give fluids for EVERYONE, etc) were done in the past, and have since stopped.

And I'm not advocating we do this, just asking for information.


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## EpiEMS (Aug 14, 2012)

Disclaimer: I'm not an ALS provider, by any means.

http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300866.pdf

Pretty far down, but they're there, at least, for people who have actually OD'ed on opioids.

Didn't find any specific evidence, but what about the possibility of an allergic reaction?

Generally, though, if used appropriately (i.e. AMS or unconscious/unresponsive with indication of opioid overdose), it's pretty safe, far as I can tell, from a population perspective. Heck, they give it to heroin users to give themselves!

Here's a somewhat silly (and impressive!) story that is very instructive: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3343634/?tool=pubmed


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## EpiEMS (Aug 14, 2012)

Pardon my last post. To be very, very direct:

"Naloxone given to non-opioid-intoxicated or non-dependent patients, even in high doses, produces no clinical effects"

Source: BMJ Best Practice monograph on opioid overdose management
(http://bestpractice.bmj.com/best-practice/monograph/339/treatment/step-by-step.html)

Also, I looked at the MSDS for Naloxone Hydrochloride, and seems like it's pretty safe. After all, the LD50 is >1000 mg/kg.

Please do look at this, too: http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=48015

"Naloxone is an essentially pure opioid antagonist, i.e., it does not possess the “agonistic” or morphine-like properties characteristic of other opioid antagonists. When administered in usual doses and in the absence of opioids or agonistic effects of other opioid antagonists, it exhibits essentially no pharmacologic activity."

So, sounds like it'd be a useless - and possibly expensive - treatment for non-OD'ed patients.


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## Handsome Robb (Aug 14, 2012)

The biggest problem I see is if the patient requires pain management. Yea narcan doesn't hang around that long but if they are altered and require RSI you just knocked out one piece of the RSI puzzle. Will it still work and the procedure still be doable? Absolutely, but even if they are unconscious you still get the physiological pain response.


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## adamjh3 (Aug 14, 2012)

Just curious, is there any reason you picked Narcan specifically? EpiEMS brought up a good point about allergic reactions. Yes, it's rare, maybe even unheard of but there's a possibility. For example, there's a pretty good chance you'd cause a reaction with my girlfriend's daughter as some brands of naloxone have citric acid in them, which she is allergic to. 

Hell, even Benadryl brand diphenhydramine has citric acid in it. Just something to consider when drugs are given empirically.


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## Medic Tim (Aug 14, 2012)

We do not* give narcan to ruin the high. When used correctly it is titrated to restore a pts respiratory drive. The last thing you want is for that pt to wake up. So why would we give this to conscious pts even if we suspect opiate, use let alone every pt. 

*wishful thinking

The thinking that every ALS pt needs an IV is flawed thinking.  Not every pt needs an IV just like not every fall pt needs a board, or every respiratory distress pt needs O2.
 If I am not giving fluid or a med or feel that I will be anytime soon I do not start a Line.


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## usalsfyre (Aug 15, 2012)

There's some documented cases of severe pulmonary edema from naloxone. Hypersensitivity, seizures due to acute withdraws.....not to mention taking away Nana's hydrocodone post-hip surgery is incredibly cruel. 

While I'm not proud of everything I've done in my career, I can honestly say I've never give Narcan to "ruin a high".


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## Merck (Aug 15, 2012)

What a wonderously odd thread....

We could probably give everyone 5mg of metoprolol too without any statistically significant downside, but we don't.  Narcan is a drug like any other.  Saying this is like saying, 'Why don't we just check a blood glucose on everyone?', or 'Why don't they just CT everyone that comes in?'.  The answer is because it's not indicated.   This line of thinking in medicine is interesting but ridiculous.  Narcan is indicated in specifiic circumstances and should be given as such.  Locally our Primary Care Parmedics give 0.8 SC with a repeat 0.4 IV while Advanced Care give the same or increased doses IV.  

I've probably done around 200 narcotic overdoses in my career (not a fish tale) and Narcan works wonderfully.  The problem with titrating it to respiratory rate/effort is the onset time.  A lot of medics don't have 2,3,4,5, minutes of patience for Narcan to take effect.  Also, I've seen it many times where people worry more about giving narcan than say, I don't know, throwing in an OPA and bagging the patient.

The point (granted, 4 beers in at the time of this posting - no wait - 5) is that giving something because you can rather that because you should based on a sound clinical evaluation is foolish, unnecessary, and just plain silly-pants.  

I pity the fool that gets the needle stick giving it (or touches yucky snot going IN).


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## Tigger (Aug 15, 2012)

There are some patients that rely on opiate pain medications to keep their chronic pain at a functioning level. Still others exist that are paralyzed to some degree and suffer without such medications yet cannot orally communicate their need for them. Giving these patients Naloxone would make them suffer for no reason at all. Will they die? I dunno but I don't want to be the person that takes someone from barely functioning to non-functioning.


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## STXmedic (Aug 15, 2012)

Medic Tim said:


> When used correctly it is titrated to restore a pts respiratory drive. The last thing you want is for that pt to wake up. So why would we give this to conscious pts even if we suspect opiate, use let alone every pt.



Why? Why not wake them up? Why not treat and release opiate od patients?


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## Medic Tim (Aug 15, 2012)

PoeticInjustice said:


> Why? Why not wake them up? Why not treat and release opiate od patients?



the first thought that comes to mind is the half life of narcan. Should we leave some more with them once we leave?


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## STXmedic (Aug 15, 2012)

How about an IM dose before leaving?


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## Doczilla (Aug 15, 2012)

I suspect this is rhetorical, but the overdose itself is only one issue. 

I'm pretty sure there will be a doctor ordered psych hold after they "wake up". 

There's also the issue of cocominant ingestion of other meds. Vicodin and Percocet for example. Both come with APAP. 

Just in case that was a serious question.


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## Medic Tim (Aug 15, 2012)

PoeticInjustice said:


> How about an IM dose before leaving?


There are too many variables to this to make it a blanket statement/policy*. What opiate was used, what route it was taken, was anything cut in with it, route of narcan, how much was used, even giving the im or sq could precipitate withdrawal(maybe not now but 10,20,30 min from now) or not be enough and the opiate take over again. It can be difficult at time to find the answers to these questions with this pt demographic.

*  I am guilty in my earlier post of describing how many providers use the drug in certain specific circumstances as the only way it should be used. I apologise for that. A policy should not take the place of a good assessment and sound clinical judgement. I am sure there are pts where waking them up and sending them on their way would work out fine. What I was trying to do (and failed) was hit on the fact that the medication is already used inappropriately and should not be given in the absence of indication especially by providers with little to no education in pharmacology and the like.


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## STXmedic (Aug 15, 2012)

Doczilla said:


> I suspect this is rhetorical, but the overdose itself is only one issue.
> 
> I'm pretty sure there will be a doctor ordered psych hold after they "wake up".
> 
> ...



It is primarily for discussion, but it is also indeed serious. Treating and releasing opiate (usually heroine) abusers is common practice in my system, including being in our protocols by our medical director. Of course, if we suspect further complications beyond the opiate overdose, then we will attempt to transport. If we suspect a polypharmic overdose, we may just titrate to respirations. But for the normal, run of the mill opiate overdoses, why not? If the hospital does put a 72hr hold on them (which they don't), then they'd be back on the street in three days doing the same thing. Abusers absolutely need rehab, but they don't get that in the ED. They might get a "talking to", and then they're released. Before we started regularly treating and releasing, it wasn't uncommon to transport the same person three different times in the same day for the same problem. Taxing on the system, taxing on the hospital, and without benefit to the patient, other than maybe a meal. So yes, it was a serious question.


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## Remeber343 (Aug 15, 2012)

I think the better question is what I we gave everyone Ativan...


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## usalsfyre (Aug 15, 2012)

Remeber343 said:


> I think the better question is what I we gave everyone Ativan...



Only if we got to share...


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## Doczilla (Aug 15, 2012)

I guess this is state dependent, and to a greater extent SOP dependent. 

In Florida, you have very little room to delineate "accidental", and "intentional" overdose. 

The act if overdose itself may suggest a suicidal ideation, and thus fall under the "baker act" law that calls for a psych eval. There are obvious caveats to this, but if youre going to turf someone after reversing their overdose with narcan, what documentation do you have to provide to demonstrate absence of coingestion, absence of intent to harm oneself, and absence of reversal-induced arrythmias, seizures, and further behavioral abnormalities that come with reversal? Is there a run sheet that truly holds this much weight? 

The issue of halflife comes to mind also, which was already brought up. Narcan is titrated, and sometimes preperared as a drip to combat recurrences, as i am sure most of us are aware. How can you truly adjust a dose to cover them in your absence when the exact dose is usually unknown?


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## Aidey (Aug 15, 2012)

Remeber343 said:


> I think the better question is what I we gave everyone Ativan...











usalsfyre said:


> Only if we got to share...



Word.


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## Dwindlin (Aug 15, 2012)

PoeticInjustice said:


> Why? Why not wake them up? Why not treat and release opiate od patients?



We've started to treat and release here. Not sure how I feel about it yet. But I can say I use Narcan frequently and I haven't had to go back and re-dose/code someone yet.


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## STXmedic (Aug 15, 2012)

Doczilla said:


> I guess this is state dependent, and to a greater extent SOP dependent.
> 
> In Florida, you have very little room to delineate "accidental", and "intentional" overdose.
> 
> ...



If they share with us any suicidal ideations, then they will most certainly get an emergency detention.

We have a narrator section in our ePCR where we typically write our reports... We can usually cover our bases on that section, just like with any other transport or refusal.

As for half-life, I've never had to return to a scene to re-dose a patient. Some guys will give an extra IM dose before leaving, but even without them I haven't been called back. Our medical school and associated level 1 hospital did a study a couple years back checking to see if we were leaving people to die. They gathered the names of every patient we treated and released (several a day) for three years; then checked to see if any of those patients had died within 72hrs of release. In three years, they did not find a single one.


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## Doczilla (Aug 15, 2012)

Very, very interesting. Amazing how EMS is progressing over the years. 

Thats one of the great things about medicine, but also one of the more dangerous. If you don't roll with the punches, you become a dinosaur.


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## jwk (Aug 15, 2012)

PoeticInjustice said:


> It is primarily for discussion, but it is also indeed serious. Treating and releasing opiate (usually heroine) abusers is common practice in my system, including being in our protocols by our medical director. Of course, if we suspect further complications beyond the opiate overdose, then we will attempt to transport. If we suspect a polypharmic overdose, we may just titrate to respirations. But for the normal, run of the mill opiate overdoses, why not? If the hospital does put a 72hr hold on them (which they don't), then they'd be back on the street in three days doing the same thing. Abusers absolutely need rehab, but they don't get that in the ED. They might get a "talking to", and then they're released. Before we started regularly treating and releasing, it wasn't uncommon to transport the same person three different times in the same day for the same problem. Taxing on the system, taxing on the hospital, and without benefit to the patient, other than maybe a meal. So yes, it was a serious question.



So playing devil's advocate here - it begs the question - why "treat" them at all?  What have you gained by "treat and release" except to save yourself some work?  You certainly haven't benefited the patient in any way except let them live to get their next fix in a few hours.  That seems absolutely pointless to me.


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## STXmedic (Aug 15, 2012)

We've gained a little less crowding in the EDs, crews being freed up quicker in an already over-taxed system, and a cheaper bill for the patient to not pay. Can most of these patients just "sleep it off", let it run it's course, and never even get narcan? Sure. But we still get the patients that are breathing 4 times a minute with sats in the 60s that can most definitely benefit from our service.

I ask to you, why transport them? If the hospitals don't put them in a rehab facility or offer/push any help for them, what's the point of them being there? If they do get a hold, that just means its 72hrs, possibly of withdrawal symptoms and detox until their next fix.


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## DrParasite (Aug 15, 2012)

Merck said:


> What a wonderously odd thread....
> 
> We could probably give everyone 5mg of metoprolol too without any statistically significant downside, but we don't.  Narcan is a drug like any other.


but what benefit would the metoprolol be?  narcan could be used to "diagnose" an opiate overdose, or a medical condition caused by opiates.  especially if you have an unconscious person for no known reason.


Merck said:


> Saying this is like saying, 'Why don't we just check a blood glucose on everyone?', or 'Why don't they just CT everyone that comes in?'.  The answer is because it's not indicated.   This line of thinking in medicine is interesting but ridiculous.


and yet, every patient that is treated by a paramedic has their BGL check, it's part of the set of vital signs that are part of a paramedic's assessment.  even if the complaint isn't diabetic related.





Medic Tim said:


> We do not* give narcan to ruin the high. When used correctly it is titrated to restore a pts respiratory drive. The last thing you want is for that pt to wake up. So why would we give this to conscious pts even if we suspect opiate, use let alone every pt.


nor did I say we should (although is it really that bad of a thing???).  but a walking & talking person usually has a lower chance of an airway compromise than an unconscious person.

Plus I'd rather have the 300lb former line backer for the Vikings accidental pain med overdose walk out under his own power than have to carry him out in the reeves or have to wait for fire or rescue to show up with a stokes to carry him out.   Yes, it's self preservation, but it made my luck so much easier (and saved my back and the back of my entire crew).

btw, this is only for hypothetical discussion, I would rather wake up an OD to ensure a patent airway or eliminate any potential complications than just to kill a high.  and if it doesn't have a negative side effect when the person hasn't taken any opiates...


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## Smash (Aug 16, 2012)

As some of you probably know, treat and release has been a standard part of ambulance practice in Australia for... well, forever.  Decades.  This is in cities where the service would see literally hundreds of heroin overdoses every day (no, I'm not exaggerating, during the 80s and 90s heroin was rampant).  

IM narcan is given following ventilation and oxygenation and the patient is free to go, unless they want transport or there are extenuating circumstances.  In 14 years I cannot recall any of these overdoses being anything other than accidental.
This system has proved itself safe and effective over many years, with very low rates of re-presentation or harm.

The idea of titrating to respirations and not waking them up is all well and good in a low volume system that runs 60 calls a month.  However, we run 400+ per car, and it would be absurd for those crewa to transport an _extra_ 10 patients requiring close monitoring and intervention to each ER during the day, never mind every other patient who comes in during normal business.  The system, ambulance or hospital, simply would not cope.


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## Doczilla (Aug 16, 2012)

That's interesting. To demonstrate a contrast, almost ALL of the overdoses I have been called to were suicide attempts. And some of these were in Pinellas county Florida, which according the the DEA ranks most populous for opiate abusers. 

Demographically, a majority of these people were working, late-20's---late 30's people,not bums or "addicts." 

But that goes to show you, a system must adapt to the needs of the area it covers, as well as adjust policy to optimise system effectiveness. What works in one area may not fly in another.


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## mycrofft (Aug 16, 2012)

Stray shots.

In my limited experience outside lockdown, most heroin OD patients who roused without significant sequelae (relapsing, ALOC, secondary injury) were not determined to be suicidal but were convinced to stick around at least overnight. On the other hand, a small minority just got up and walked out, literally.

Some addicts in jail told me that Narcan gave them some sort of "high". Go figure.

Many many of our heroin addicts were polypharmacists, notably adding meth, alcohol, Ambien, Ecstasy, and unwittingly whatever else the sellers added (talc, lactose, epsom salt, etc).

If naloxone also competitively inhibits endorphins, what are the effects of that? Quite a few patients were experiencing physical or mental conditions that the heroin was helping them ignore.


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## Merck (Aug 16, 2012)

I didn't say giving metoprolol would be of any benefit.  Neither would indiscriminantly handing out Narcan.  In a situation where one has a pt with a decreased level of consciousness naloxone is indeed part of the treatment but for the most part the fact that the patient is suffering from an opioid overdose is no great mystery, be it on the street or in a nursing home.

As for every patient having a glucose checked as part of vital signs - why?  If there is no diabetic hx or hx of hypo/hyperglycemic episodes and the patient is alert and oriented, why would you poke someone in the finger unncecessarily?

My only point here is that doing something indiscriminantly to all patients to capture that 0.001% pt with some weird presentation is, in my opinion, wrong.  A blanket approach can not replace good judgement and experience in establishing a provisional diagnosis.

And even advanced as we are we don't know everything.  Any long term downside to naloxone - I have yet to see a completely benign drug.  I'm pretty sure thalidomide was a wonder drug in the 50s....


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