Narcan Question

[82-Alpha599]

Narcan also has a shorter 1/2 life than most opioids, sometimes depending on the opioid type/dose, a narcan infusion must be set up in order to keep them from reverting.

im not saying you're wrong, but do you have any resources to prove that. I looked before and could not find any that agreed on half life of heroin.

I don't think anyone knows the actual half life of street heroin, every batch is different.

 

[Veneficus]

im not saying you're wrong, but do you have any resources to prove that. I looked before and could not find any that agreed on half life of heroin.

I don't think anyone knows the actual half life of street heroin, every batch is different.

Not only have I seen it myself on multiple occasions, I offer:

Lippincott's Illustrated review of pharmacology 4th edition
ISBN 13: 978-0-7817-7155-9. Page 168

It lists the 1/2 life of naxalone between 60-100 minutes and also goes on to say that an infusion or multiple doses may be required to prevent relapse.

 

[82-Alpha599]

i agree.
i was just wondering if anyone has a solid source for heroin half-life.

 

[Veneficus]

i agree.
i was just wondering if anyone has a solid source for heroin half-life.

Because of the variability of the constituants of street "heroin" as well as the phram kinetics and dynamics in the user, I don't think you will find any reliable source as to the halflife of it.

Additionally synthetic opioids are designed to attach to receptors with high affinity which means they will also potentiate their action over a longer duration.

A street user may have subtheraputic levels and when shooting up increases the bioavailability considerably. Additionally they may also have some synergistic substances on board, substances that compete for conjugation enzymes or a decreased clearance from impaired hepatic or renal function.

Based on all of this it would seem that measuring halflife of street drugs would have little benefit in determining treatment modalities in the EMS environment.

 

[Aidey]

Methadone is another one that may require multiple doses of narcan or an infusion.

For some reason the doctors around here continue to expect narcan to be administered in any ALOC patient, regardless of background.

I understand that children could get into medication, or a person in a nursing home could be given someone elses medication so it should be considered in unlikely cases. But at the same time I would like some clinic judgment to be applied in ruling out opiates without having to give narcan.

 

[MrBrown]

Somebody I know takes 120-250mg of methadone daily as well as 6-10 15mg benzos (clonazopam and oxazapam) and has done for thirty years.

Do you really think a little naloxone (or morphine or fentanyl for that matter) is going to work on him?

 

[Jay]

A couple interesting points to go around...

The half life of nalaxone is roughly an hour to an hour and a half where most common analgesics such as oxycodone and hydrocodone are indicated every four to six hours, again there are variables but this shows the basic curves working against each other. The half life of methadone is AT LEAST 24 hours hence dosing >24 hours. That would suggest an IV/Narcan-drip would be necessary for such an OD.

As for additional uses it is an adjunct in Subaxone (along with Buprenorphine) in order to ensure that the person it is Rx'd to wont "shoot it up". Think about it, Nalaxone has almost NO oral-bioavailability and taken orally as part of subaxone wont work against the opioid as part of a replacement therapy. Subaxone is quickly becoming the drug of choice as an alternative to Methadone for addiction treatment or in some cases off label pain management in chronic cases.

Finally, the use of "slamming" nalaxone in the field may in my opinion be deemed cruel and unusual. There has at times been the debate of a nalaxone challenge in an ER/ED setting to simply see if someone is on opioids when there is suspicion that they are a drug seeker. If they have taken opioids you get the puking, headaches, y'all know the drill. In the field it can be the same results by "slamming". It can be a powerful drug to reverse OD when you have adequate proof one exists, e.g. the opioid triad, otherwise it would be a fine second-line method (when given humanely) after determining that other issues are not present, e.g. blood sugar or ETOH which can bear some but not all signs of similarity.

Just my $0.02 on the above comments.

 

[Veneficus]

Somebody I know takes 120-250mg of methadone daily as well as 6-10 15mg benzos (clonazopam and oxazapam) and has done for thirty years.

Do you really think a little naloxone (or morphine or fentanyl for that matter) is going to work on him?

If he is prescribed that, I would not use a reversal agent on him, it might put him into irretractable pain and limit my ability to control pain from there without a barbiturate.

If he ODs we'll just ventilate him for a bit. If it requires long term we'll tube him and put him on a vent.

 

[Melclin]

Because of the variability of the constituants of street "heroin" as well as the phram kinetics and dynamics in the user, I don't think you will find any reliable source as to the halflife of it.

Additionally synthetic opioids are designed to attach to receptors with high affinity which means they will also potentiate their action over a longer duration.

A street user may have subtheraputic levels and when shooting up increases the bioavailability considerably. Additionally they may also have some synergistic substances on board, substances that compete for conjugation enzymes or a decreased clearance from impaired hepatic or renal function.

Based on all of this it would seem that measuring halflife of street drugs would have little benefit in determining treatment modalities in the EMS environment.

im not saying you're wrong, but do you have any resources to prove that. I looked before and could not find any that agreed on half life of heroin.

I don't think anyone knows the actual half life of street heroin, every batch is different.

The serum half-life of heroin is generally said to be ~10 minutes. It moves across the blood brain barrier quickly where is then metabolized to a few things, namely morphine, which in turn has a longer half-life than naloxone. This is what our uni paramedic pain guru told me a while back, and this is the closest piece of literature I could find supporting it that I could link to: http://www.ncbi.nlm.nih.gov/pubmed/2420426

But "Kendall, J.M. and Latter, V.S.: Intranasal diamorphine as an alternative to intramuscular morphine: pharmacokinetic and pharmacodynamic aspects. Clin. Pharmacokinet. 42(6): 501-513, 2003." has a much better round up of its pharmacology.

 

[82-Alpha599]

Finally, the use of "slamming" nalaxone in the field may in my opinion be deemed cruel and unusual. There has at times been the debate of a nalaxone challenge in an ER/ED setting to simply see if someone is on opioids when there is suspicion that they are a drug seeker. If they have taken opioids you get the puking, headaches, y'all know the drill. In the field it can be the same results by "slamming". It can be a powerful drug to reverse OD when you have adequate proof one exists, e.g. the opioid triad, otherwise it would be a fine second-line method (when given humanely) after determining that other issues are not present, e.g. blood sugar or ETOH which can bear some but not all signs of similarity.

That sounds pretty dumb. Just do a blood tox or urine test.

 

[Aidey]

I think part of that is a patience thing. It takes 2 minutes to push narcan, it can take 20 to 2 hours to get lab results back.

 

[Jay]

I was thinking that there are "instant" tests for opioids that are available commercially. Via urinalysis you will have the results within 5 minutes, I believe that Calloway Labs manufactures one for Pain Management (verification) use that will give both instant results plus allow an MRO to confirm the results with an "independent" study later on. This of course is a requirement in physical medicine where opioid administration is both necessary and strictly controlled. The problem at hand is that there are certain physicians that would rather simply perform a narcan challenge may it be they are a lazy burnout of 25 years on the job or perhaps they are a resident who thinks that it will get a quick rise of s--ts and giggles to get him/her past their first __ (fill in the blank) hours that shift; either way there are easier and better ways of doing the job without jeopardizing the health and dignity of the patient.

 

[82-Alpha599]

it isnt only unethical but dangerous. You could send someone into withdrawals, may it be a junkie, or a cancer pt who accidentally took and extra vicodin today. Plus now they may be in pain until the narcan wheres off and some narcotic can take effect again.

 

[Veneficus]

if I could just ask?

In both pain management and palliative care, there is considerable use of opioids.

Narcan is usually deemed as an emergent reversal agent, and as already pointed out on several posts, there are times when you wouldn't want to use it. (most of the time)

If the patient is in an uncontrolled setting (out of hospital) and suffering from a life threatening respiratory depression or hypotension perhaps, but why else.

Both of these conditions are quite well controlable with both ventilation and an airway adjunct, if need be intubation, and some fluids. Before pushing the narcan (just enough to potentially get away from a life threatening depression)

In a healthcare facilty, in an emergent patient, the same situation applies. There is absolutely no reason to "wake somebody up." Even if you have to maintain them via drip in a depressed state. If the ICU is full they can be sent somewhere else that isn't.

In a clinic, administering PO opioids, they should be capable of controlling an airway until EMS can arrive and cart the pt off to a more capable facilty if longer term care is required.

Same day surgery should have some type of post anesthesia care available and really shouldn't raise any issues.

What then is the point of acute reversal?

So you have to wait a few minutes to a few hours for a tox? Who cares?

What is the point of "strict regulation" of opioids? If the patient is an addict, they'll get them somewhere. As well patients respond differently to different substances and doses for various reasons.

You detect opioids in a patient complaining of pain so you plan to give them no more? "Sorry you already had some opioids so we are going with an NSAID?"

This thread is starting to make no sense to me.