What Do You Know About Narcan?
I’ve spent the majority of 45 years dealing with medically indicated prescription narcotic use. That management is often difficult because you want to avoid patient death due to overdose, withdrawal, or participation in drug diversion.
As many probably know, opioids include prescription meds like hydrocodone, oxycodone, Oxycontin (long-acting oxycodone), morphine, meperidine (Demerol), fentanyl, and Dilaudid (hydromorphone) as well as illicit drugs such as the street version of fentanyl, cocaine, heroin, xylazine (not an opioid) and nitazene. Naloxone is a class of medications called opiate (narcotic) antagonists and is used to reverse or block (antagonize) opioid overdose.
This Substack article is not intended to be a Centers for Disease Control and Prevention (CDC) short how-to course on taking care of patients on street versions of narcotics or tranquilizers.
It is rather my observations from my many years of working with patients on narcotics. Most of us have heard of Narcan, but what does the average person know about its use? It’s not often understood that even a first dose of Narcan may precipitate withdrawal at the scene of the overdose or in the ambulance. On the other hand, many drugs outlast the effectiveness of a single dose of Narcan. Since many narcotics outlast the first dose of Narcan, a second or even a third dose of Narcan may be needed to manage overdose symptoms. Narcan is the most popular brand name for the generic drug naloxone, but there are many brand names for the medication.
Emergency treatment of withdrawal from illicit drugs or alcohol is complicated. Half of the patients suffering from an overdose of narcotics come to the emergency room in the middle of the night. Even though there are agencies around the state which profess to care for patients suffering from addiction, you can spend hours on the phone at 3 or 4 in the morning on a Saturday or Sunday trying to find somebody who will even answer the phone, much less take these patients. In North Dakota, there is a list of seven or eight hospitals or treatment centers that are on the list to take these patients, but during the day this generally requires leaving a message on an answering machine and waiting for a return call. The receptionist returns the call. Then the receptionist passes the call on to a nurse. Just talking to one hospital or treatment center can take half an hour once the message is returned several hours later. At night, my experience is the phone is never answered, so you are unable to even leave a message.
This lack of response from organizations who are supposedly responsible for taking care of these patients leaves us in the emergency room with a patient who may well become combative. When patients are particularly combative, nurses don’t want to take care of them because they are concerned for their own safety. And who wouldn’t be? I’ve never seen a police officer come to the hospital to help take care of these patients. In fact, I’ve had police officers refuse to transport these patients to other facilities.
In the field, a final problem to remember is that your treatment might work too well. There is the possibility of precipitating withdrawal in narcotic-dependent subjects. This applies mostly to the doctors taking care of patients in the hospital, but could occur at home or in the ambulance. Withdrawal is no joke. These people can hallucinate and become extremely violent. Be prepared. It is difficult to treat withdrawal at the scene or in the ambulance. The most common treatment would be Ativan (lorazepam). Ativan is a benzodiazepine and is not reversible with naloxone.
Naloxone comes in many forms, including an auto-injector, a nasal spray, an atomizer and of course, a syringe. It can be given into the nose, into the muscle, under the skin, sublingual (under the tongue) or in the vein. To my knowledge, Narcan has been around since the late 1970s when we would give it IM (in the muscle) to lethargic newborns exposed to narcotic pain relievers in utero while their moms were in labor. The dose of naloxone started at 0.4 mg/0.4mL for babies. But today with the auto-injector, you have 2 mg/0.4 mL. With a nasal spray you can go with 8mg/0.1 mL, 4mg/0.1mL or 2 mg/0.1 mL and for injection you can go with .4 mg/mL, 1 mg/mL or 2 mg/mL.
Paramedics, police, and even illicit drug users keep naloxone around. In 2021, the FDA approved an 8 mg dose to be given in the nose. Administration of naloxone by nose is now the most popular way to give naloxone, but of course, the patient has to be breathing for nasal administration to work.
Do NOT be confused by the dosing or the routes of administration. Choose the one you like and use it. Time is of the essence and don’t waste it trying to make up your mind what to do. Using any form of naloxone is superior to nothing or delayed treatment.
One problem with using naloxone is giving it and then not carefully watching the patient. Naloxone has a relatively short duration of action, meaning, the amount of time that it actually works in the body. Whoever gives the naloxone needs to understand that the duration of action of the drug the patient has taken can’t be known because the overdosed drug may be unknown. Whatever the drug is, it can well last longer than the naloxone. Sometimes a second administration of naloxone is needed, or even a third.
The potency of the illicit drug the patient has taken needs to be considered. Nitazene, for example, is going to require more naloxone than a medication like morphine, but often this information about the drug is unavailable to the treating physician.
The person doing the resuscitation must observe the patient 100 percent of the time and be ready and able to give a second and third dose of naloxone if necessary. Do not rest on your laurels. This observation needs to begin at the scene and continue through the ambulance ride, through the emergency department, and into the ICU until it is clearly understood that the danger from the drug responsible for the overdose has passed.
Today, the new drug on the block is the most potent and dangerous of all the opioids. These are the benzimidazole-opioids, or more commonly called nitazenes. There are approximately 20 drugs in this class. Potent, cheap and available, they were synthetized by the Swiss company CIBA in the late 1950s. They were never approved for use in the U.S. Today their precursors are readily made in China, assembled anywhere, and cross our borders without difficulty. Potency varies between drugs in this class and can range from similar to morphine to a lot stronger than fentanyl.
Fentanyl, a synthetic opioid similar to morphine, is up to 100 times more potent than morphine. It is 50 times more potent than heroin. According to the Centers for Disease Control and Prevention (CDC), it is among the most abused pain relievers in the U.S. and the leading cause of overdose deaths. This drug can also be mixed with ketamine or barbiturates, and can be given in the vein, in the muscle, through the nose, or by mouth. When given in the muscle or in the vein, (the most common ways) it can cause very serious tissue damage, and even death.
Yes, to say that we have a problem with the use of controlled substances in our country is an understatement. We have learned a little bit about the use of naloxone, but we haven’t begun to close our borders to the influx of illegal controlled substances. The time, energy and above all, money, that these government agencies spend criminalizing healthcare providers whose main crime is taking care of patients, would be much better spent making our borders less permeable to the influx of illicit controlled substances. Actually, helping physicians take care of narcotic and alcohol-dependent people would be money, energy and time well spent for the benefit of everyone in our nation.
In my last practice I had 15 or 20 patients who were elderly and had many aches and pains. Some had been on a controlled level of pain killers for 30 years. With the right amount of hydrocodone or oxycodone, they could mow their grass, plant their garden, wash their windows, do their laundry and fix the storm doors, and continue to live independently. It’s hard to say that these people should not have been on medication, especially since the alternative would probably have been their going to a nursing home. So, these patients and ALL of society benefited. You really need to stretch your imagination to call this controlled use of pain killers criminal.
The state governments, led by the federal government, are dead wrong on how to deal with drug addition. In the first place, I have never found a correlation between giving patients needed controlled narcotic medications leading to their illicit use. As a matter fact, the opposite is true. Many people who can no longer get medically indicated narcotic or other controlled substances have no choice but to turn to street drugs out of desperation. Yes, many of them die in the process.
The proper use of naloxone can and will save lives as well as the controlled use of narcotics for medicinal purposes. However, no federal or state agency should be trying to create an atmosphere of fear among physicians to prevent physicians from providing needed pain medication to patients who have demonstrated they can use narcotics responsibly.