What if we gave narcan to everyone?

[DrParasite]

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.

 

[EpiEMS]

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

 

[EpiEMS]

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.

 

[Handsome Robb]

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.

 

[adamjh3]

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.

 

[Medic Tim]

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.

 

[usalsfyre]

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".

 

[Merck]

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).

 

[Tigger]

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.

 

[STXmedic]

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?

 

[Medic Tim]

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?

 

[STXmedic]

How about an IM dose before leaving?

 

[Doczilla]

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.

 

[Medic Tim]

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.

 

[STXmedic]

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.

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.

 

[Remeber343]

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

 

[usalsfyre]

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

Only if we got to share...

 

[Doczilla]

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?

 

[Aidey]

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

Only if we got to share...

Word.

 

[Dwindlin]

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.