Does ‘Narcan’ Deserve Any Debate?

While naloxone (marketed under various trademarks including Narcan) is not a new drug, it has enjoyed some incredible news coverage recently as the “safe antidote” for opioid abuse that can bring an overdose victim back “from the dead” simply and safely with “no side effects.” The surge in its popularity is undoubtedly fueled by a growing problem of opioid drug abuse, especially in the New England states coinciding with the recent development of an intranasal administration option of naloxone. However, stories like, “A drug to stop heroin?” from the Georgetown Record that reads at least in part,

“It works like magic. Spray half-a-dose up one nostril, half up the other and you’ve saved a life”

tend to over-simply the issues involved. Sometimes it works that way, but that doesn’t mean it will every time.

During an overdose caused by opiates, (such as heroin, morphine, oxycodone, methadone, hydrocodone, codeine, Fentanyl and other prescription pain medications) the drug is released into the brain where it binds to opioid receptors. When too many of these opioids attach to receptors on the brain stem, it causes depression of the central nervous system, respiratory system, and leads to hypotension.  These conditions result in poor perfusion and can eventually lead to death. The action of naloxone is not completely understood in detail, but basically seems to displace the opioids on these receptors to reverse the depression of critical life functions. It is important to note that naloxone is only effective at displacing opioids and is therefore not effective against respiratory depression due to non-opioid drugs or illnesses affecting the CNS.  Consequently, recognition of the direct cause of respiratory distress is important in determining appropriate treatment.

Still, even when naloxone is effective at reversing CNS depression, there are conditions that the responder must be prepared to encounter as a result of this intervention. Abrupt reversal of opioid depression may result in vomiting, hypo/hypertension, seizures, VTach/VFib, cardiac arrest, pulmonary edema, severe headaches, severe anxiety, and confusion, not to mention the severe agitation brought about when the patient loses the euphoric feeling often sought from the opioid. There is a safety concern for the “rescuer” in addition to a concern whether non-medically trained personnel can adequately perform the physical assessment of the patient required to ensure the condition hasn’t been misdiagnosed. It appears true that naloxone will not directly hurt patients who are not suffering opioid overdose, but the time delay in proper treatment could be detrimental.

There is frustration on the part of families and even communities afflicted by chronic drug abuse because action is not being taken “fast enough” when the “miracle drug” is known and available. Articles such as, “Massachusetts Police can carry Narcan, but not use it“, where it is reported that even though the state has authorized its use there are still local policy restrictions that prevent officers from administering it, seem like petty politics, or possibly even conspiratorial. I do not advocate undue or burdensome restrictions, but rather welcome a healthy dialog to help all would-be rescuers to understand the ramifications of taking certain actions. I want more equipped professionals to have access to the treatment along with tools such as suction devices, BVM, and an AED to handle possible outcomes rather than simply trading death by one route for death by another. My position on Narcan is actually similar to that of administering CPR. While I want everyone to be prepared to do it, everyone should know something about what results from taking that action. Saving a life is an incredible feeling, but it never comes without some personal cost.

7 Comments

  • Morgan says:

    Why do police officer want to give a drug when they don’t do what they are trained to do? Ventilate the patient. Police Officers, at least in my state, attend emergency medical responder class as part of their initial training. They are supposed to attend training every time they renew thier post certification. Why are they not just doing what is right for the patient by ventilating the patient.

  • Gracie says:

    As the mother of a recovering addicted child and a long time Paramedic, I applaud all efforts to make Narcan more available! Granted, training in it’s use should be a major component to it’s First Responder use. There have been too many times I could have used it at home prior to my child’s desire to save himself.

  • Chuck says:

    That is like being able to purchase and be covered with auto insurance, just after u have a crash

  • Kevin says:

    Although no medication is truely benign, one must admit that, of the emergency medications out there, Narcan is one of the safest, when the operator knows what to expect from its administration. When a controlled, titrated amount is administered until, either its max dose without effect or the desired effect is achieved, Narcan can be one of the most useful medications out there. The “delay” in proper treatment is minimal when simple preparations have been met prior to its administration (using a manual maneuver to open the airway so to avoid possible flash pulmonary edema). How can we achieve this kind of responsible administration of this life and quality of life saving medication? I completely agree with Gracie. Like anything else out in the public, education MUST be made available. We’re not talking about college level courses or anything. Something simple would surely suffice. Maybe even including its subject matter in future first aid and public citizen CPR courses. Whatever small amount that it would take isn’t the issue. The issue is that the benefit far outweighs the risk.

  • Chuck McGee says:

    I feel that putting this drug intothe hands of semi trained professionals is a dangerous thing. As was pointed out in the article, not being prepared or equipted for the potential out comes of Narcan can be down right deadly. I’ve seen it thousands of times in my career. I spent 10 years in one of Philadelphias worst heroin infested nieghborhoods. Nacan show be left to the emergency medical community.

  • R.S.E. says:

    Sounds like a media feeding frenzy with an over-simplistic answer to a complicated, multifaceted issue. Access to meds is controlled for a reason. I can envision the headlines after an adverse outcome secondary to a lay rescuer administering Narcan. Long forgotten would be the cry for expanded access. Medics are credentialed through a very demanding process to ensure they are prepared to understand the rational, risk vs benefit, safe admin, and on-going assessment of the pts response to not only Narcan but other medications as well. Moreover, they are prepared to initiate follow-up care based on the individuals response, including adverse reactions. Sure IN admin makes it appealing to roll out to an expanded corps of providers, however education and credentialing is vital to ensure public safety. While there is merit to the topic of expanding the scope of practice for EMT-B, the entire topic is a red herring in that distracts from the core issues surrounding drug abuse/dependency, treatment, and safe/effective emergency treatment.

  • Medic says:

    On its surface the idea of publicly accessible naloxone sounds like a good idea for treatment of opiate overdoses. However, we must first realize that our industry is not merely comprised of skills that can be easily taught to the lay public or health care workers who do not routinely practice in an emergency medicine environment. My concerns with public naloxone administration are as follows.
    1. In any narcotic overdose the mainstay of treatment is airway management and maintenance-this idea appears to be lost on public naloxone admin-simply administering naloxone appears to be the idea.

    2. Duration of naloxone is between 20-90min which poses a risk that a now consciously agitated or combative patient walks away prior to the arrival of definitive care in this case Paramedics/EMTs who can offer a more thorough assessment and subsequent treatment options. Of course, other risks for our now fleeing patient can include a relapse-we cannot help patients if we cannot locate them.

    3. Too high a dose runs the risk of seizures and emesis which further complicate airway management.

    Indeed greater discussion is required. In addition it appears too often that roles are being merged despite their obvious inappropriateness. Police officers are neither social workers nor medical aid. Paramedics are neither police officers nor social workers. As Paramedics we are gradually becoming clinicians. We do not merely carry out an act. Instead we use risk stratification models to defend why we do or do not do something using evidenced based medicine to guide our treatment options.

    Thanks for reading.

    Medic.

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