What if we gave narcan to everyone?

[STXmedic]

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?

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.

 

[Doczilla]

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.

 

[jwk]

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.

 

[STXmedic]

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.

 

[DrParasite]

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.

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.

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...

 

[Smash]

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.

 

[Doczilla]

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.

 

[mycrofft]

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.

 

[Merck]

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....