Naloxone.

Or it’s more common name: Narcan.

This simple medication has gained a LOT of popularity in the past couple of years, for all of the wrong reasons.  So, let’s talk about the good, the bad, and the butt ugly of this medication.

Naloxone is an opioid antagonist and antidote.  In brief, Narcan removes and/or blocks narcotic receptor sites in the body.  When a person overdoses on an opioid, this causes respiratory depression and sometimes complete failure.  When Narcan is administered, the opioids are removed from the receptor sites to allow the body to begin breathing again.

However, the dosage of this medication can be quite controversial in emergency medicine and here is why: 

In EMS, only enough Narcan is administered to allow the patient to begin to breathe on their own.  Most agencies have an initial dose of Narcan at 2-4mg via nasal atomizer.  In the EMS setting, we don’t want these patients to become fully responsive.  These patients need medical help.  If a larger dose is administered, the patient will become fully alert and oriented and will most likely refuse any further treatment/transport.  The larger problem, however,  is the “half-life” of Narcan, and that is the time the medication has acting effect on the body. So, when we give Narcan it only lasts for a certain amount of time.  If the opioid that the patient has taken is still in their system, it could cause them to overdose all over again.  So repetitive administration of the medication is needed until the patient’s body has had time to metabolize the toxin.

In the event that these patients have become narcotic dependent, their bodies believe that they actually need these substances to survive.   By giving large amounts of Narcan, you are literally stripping away any opioids in their system, and pushing them straight into detoxification.  If you personally, or have seen someone, go through detox you know it isn’t a small feat. Detox has been described as your muscle fibers feeling like they are being ripped apart, and as someone who had to stop taking narcotics after back surgery, I can confirm that this is completely accurate.  So, you have a patient who is quite happy at the moment (more than likely high as a kite), and now you just stripped ALL of that away in the matter of seconds. These patients aren’t going to be happy about this. You will probably never have an overdose patient thank you for saving their life.  They will immediately deny the fact that they overdosed, and then will become very irritated.  So I ask you, do you want to have this in the back of your tin can on wheels, without any backup or safety measures?

Of course not!

Hence we only administer enough medication to ensure that they start breathing again, and THAT IS IT!

So now here is where the trouble comes…

Most hospitals do not understand this.  In their eyes, you withheld a medication that would return the patient to a “safe baseline”.  Most emergency room staff has never worked in EMS, and do not realize the risks that we face in the field.  So from their point of view, we are not doing everything that we can for these patients. If we had the same staffing and equipment that they do in the ER, then it wouldn’t be an issue, but we don’t.  Nearly every time I’ve brought an overdosed patient to the ER, I’ve been questioned by hospital staff if Narcan was administered, regardless if the patient is showing signs of a narcotic overdose or not.

Speaking of narcotic overdose signs, what are those exactly?

Well, we already said respiratory depression/failure, but there is also the finding of “pin point pupils” and the more obvious drug paraphernalia.  So what if you’re unsure if they took an opiate, over some other drug substance? Or what if they mixed substances?

Narcan won’t harm a patient (other than putting them into detox if administered too fast).  So, the general rule of thumb is to administer the medication if there is any possibility of an opiate overdose.  In the event that they haven’t, the medication isn’t going to do anything.

Now, this brings up Narcan administration in a cardiac arrest.  Upon the introduction of Narcan in the EMS setting, it was placed in the American Heart Association’s Cardiac Arrest Algorithm.  However, a few years ago, this medication was removed from the algorithm, which had a lot of kickback from the EMS community.  The reason it was removed was because in the event that your patient is in cardiac arrest, the administration of this medication is not going to do anything to improve the patient’s outcome.  We said earlier that the only function of Narcan was to inhibit the body to breathe on its own after the opiates were removed from the receptors right?  So, you have a patient in cardiac arrest, their heart is not working correctly and you are supplying supplemental oxygen via bag valve mask.  This patient is receiving adequate oxygen administration, and a dead body is unable to breathe on its own.  Therefore, the medication will do nothing to “bring the patient back”.   Now, once you’ve achieved Return of Spontaneous Circulation (ROSC); a return of normal heart function, the medication can be administered in an attempt the body to begin breathing on its own.  Opiates may have caused the cardiac arrest, by stopping the respiratory drive; however it is unable to “restart” this drive if the patient is pulseless.  This is why the AHA has removed it from its algorithm, and most services are coming around to the change.  But at the end of the day, we are all human and we want to do whatever we can to save another person’s life.  So, you won’t hurt the patient with the administration of Narcan during an arrest, but you also aren’t helping either.  As we have discussed in other blogs, high quality CPR and early defibrillation are the best chances the patient has for a positive outcome.  If you are wasting time attempting to administer Narcan, instead of doing one of these IMPORTANT tasks, then you are actively harming your patient, whether intentional or not.

 And finally, I would like to touch on the fact that we are not the only providers that carry this medication.  Now-a-days everyone from EMS, to the fire department, to police, to even every day bystanders carry this medication.  Most of the time, they are unaware of the “correct” dosage of this medication.  So always err on the side of caution.  Always remember scene safety is your number one priority.  Stay safe everyone, and hold on for the ride!