Narcan Rx

[Nova1300]

I'm curious how often you folks are seeing these narcan nasal antidote kits used, specifically by family members or friends of overdose patients? If the patient gets reversal before you arrive, is it presenting any particular issues for you in the field?

My hospital is the ICU referral center for a large swath of Appalachian coal country. We routinely get several ventilated overdose patients on any given night.

The problem with these patients is that they burn off their drugs, frequently self-extubate and then usually sign out AMA. It's very rare that an overdose patient actually stays in house long enough to get out of the unit. So we really have very little to offer them.

I have recently started writing narcan Rx for family members of these patients as soon as they are admitted to the unit, because often I'm the only provider they will see before they disappear. However, none of my colleagues write them and most are completely unaware of the existence of nasal reversal.

I'm thinking about initiating a protocol here in the unit in which the family members of these patients are offered a narcan Rx as part of a standing protocol at admission.

But before I jumped into that project, I was curious if it was presenting any issues for you folks in the field. Or are you even seeing them used at all?

 

[hometownmedic5]

Between bystander narcan(available without a prescription in Massachusetts) and first responder narcan, I almost never give it anymore. By the time I get to the scene, the patient is awake, breathing, usually belligerent, and ready for their mandatory ride to the hospital.

Yes, you read that right. If you od in mass and narcan is used, you have to go to the hospital and stay there for four hours. That law causes so many more problems than bystander narcan.

 

[StCEMT]

I don't see bystanders using it, but I used to work in a city where BLS fire had it. Now it's just me that gives Narcan. I personally dont care if it's me or not that does it. If they are awake, thats less I have to worry about.

 

[NomadicMedic]

We have it here, but I've not seen it. Most of the ODs that I go on are synthetic drugs or a polypharm mess.

 

[Ensihoitaja]

It's pretty widely available in Colorado, including several large pharmacy chains that will give it out on request. I've never responded on anyone that's gotten family/friend Narcan. Maybe they just don't call.

 

[Nova1300]

Thank you. Good info.

 

[Tigger]

It's pretty widely available in Colorado, including several large pharmacy chains that will give it out on request. I've never responded on anyone that's gotten family/friend Narcan. Maybe they just don't call.

My Colorado experience has been similar. We are seeing law enforcement using it more, but not families. But I would not say we have an opioid crisis in my area.

 

[Ensihoitaja]

We had an initial surge of fire and police Narcan (mostly fire), but that's dropped back nearly to what it was before they rolled it out. We still see quite a bit of opioid ODs, though.

 

[NPO]

I've had a first responder use it once in a hypoglycemic diabetic.

It didn't work.

 

[Never2Old]

In my part of PA we see a lot of Law Enforcement use of Narcan, usually multiple doses before we even get on scene. If I give Narcan it is usually because I beat PD to the scene, or the officer is dealing with something else on scene. Regardless of administration, if the patient is AAOx4 prior to transport, they can refuse further assessment, treatment and transport. We hear that a majority of the transported patients usually AMA once they get to the hospital. Narcan is available here in PA from a pharmacy for users and family members, and I have run into a few situations where the family or the patient either has Narcan, or have used it prior to PD or EMS arriving. Problem is that if the user has it, they certainly can't use it when needed, and often the family is unaware the user is unresponsive until too late. We are also seeing a lot of carfentanil, which means usually IV narcan or multiple doses to be effective.

 

[babymedic842]

There is a public access program in my area that started about 4 years ago. You had to take a course, and in the end you were written a prescription for 2 doses of narcan. From what I understand now it’s available pretty much over the counter. We have seen some unintended effects such as dealers having and giving it before dropping the patient off elsewhere in no condition to take care of themselves, or family members administering it then not calling 911. It’s undoubtedly saved lives, but EMS in the area is pretty much in agreement that it’s not addressing the problem as a whole.

 

[rescue1]

I saw them used in PA, where it has become OTC. The police all use them too. The only problem I've had is the police giving 8mg to patients before EMS arrival (not a typo), which usually leads to a combative patient on arrival. I think that's more of a problem with the autoinjector dosing though.

I guess the family ones help? It's hard to say. I had a patient this summer who ODed, was resuscitated by a friend with Narcan that they had bought at a CVS, and then ODed again (permanently this time) an hour later when his friends were gone. I doubt being transported would have stopped him from shooting up again, but I wonder if being told "maybe don't get high by yourself with a new batch" by a semi-professional would have done anything.

 

[DWR]

I live and work in a part of NC that has a alarming number of overdoses every year. Every law enforcement agency and fire department carrie Naloxone in some form or another. Not only that but a majority of pharmacies (CVS, Rite Aid etc) offer Naloxone auto injectors to the public for free. Since none of this is new let me speak to what I'm experiencing in my system at this time.

It's common for us to obtain a patient refusal on opiate overdoses. Trust me, I know what allot of people are thinking reading this. Liability, was it only opiates and a bunch of other questions come to mind. Our overdose protocol reads that naloxone is administered "NOT TO RESTORE CONSCIOUSNESS". Allot of the time by the time a ambulance arrives the patient has already had 2mg IN +/- administered by fire personnel or 4mg IM +/- (auto injector) administered by law. At that point it's assist respirations and go from there. What we see allot is patients receiving enough naloxone prior to EMS arrival that they are awake and do not whatsoever want to go to the ER. These are individuals that are conscious, alert, oriented with a GCS-15 that deny transport, option to talk with a counselor or social worker or potential placement into a rehab facility pending bed availability. At that point it is explained in extent the dangers of the decision that they are making, have them sign and then they are given 2mg IM injection of Naloxone and let go. What we have found in this exclusively hospital based system that runs about 66,000 calls a year is that allot of the patients that are transported leave AMA when ever given the opportunity and deny rehabilitation resources. Most of the transports that we will perform involve some type of polysubstance abuse and not just opiates. My system is also seeing a growing number of instances of layperson administration of naloxone due to the widespread availability of the drug. More than once this year has the 911 caller attempted to cancel responding units to a overdose by saying "it's okay now, I just gave them narcan and they are awake". We have also seen instances of people justifying their use of recreational opiates because a friend or family member that's with them is carrying naloxone and almost holding them regards to a designated driver. We can ask the question, is the distribution of naloxone to the layperson enablement?

This is just my experience in my system specifically. Unfortunately this discussion will be a double double edged sword for some time to come.

 

[TransportJockey]

Opiates aren't the drug of choice out here. I don't know the last time someone had an opiate overdose that wasn't an intentional suicide attempt for my service. Our Narcan usually expires before it gets used

 

[VFlutter]

Not to be overly pessimistic however it still requires the family to physically fill, and I am assuming pay, for the prescription. So unless the hospital pharmacy is able to fill the script, preferably at low to no cost, and give them the Narcan before leaving the hospital then I am not sure how much good it will really do. We gave cost-free prescriptions for Plavix to our impoverished PCI patients for a while but still got a decent amount back with stent occlusions and then started giving filling the script prior to discharge. It helped a little.