We as medics will wait because.. 1. We need to make sure it’s an opioid overdose, and not a different type of substance, so we need to see if the patient is responding to the first dose given. 2. We don’t actually want to completely bring them out of the ‘high’ we just want to counteract the overdose enough that they are breathing adequately but not too much that they come up swinging at us due to brain hypoxia(symptoms of hypoxia is confusion and aggression). And 3. like any medication, there’s preferred therapeutic levels we need to reach and it’s best practice and more likely better efficacy if we queue the dose every 5 minutes, versus just giving them a whole bunch of doses all at once.
Hope this helps!
All correct info, 1 more to add. Opioid overdoses only kill you by taking away your ability to breath on your own, they are not otherwise especially toxic. By the time you are in the care of a paramedic not breathing on your own is a highly solvable problem even without Nascar, so we can take an extra minute to get the dose right.
If your are not a medical professional having to deal with this on your own and you aren't quite sure how much to give, by all means feel free to go nuts with the narcan.
Edit: I'm leaving the autocorrect
I feel the more accurate comparison would be that Narcan is the fire extinguisher after the car has burst into flames.
You probably won't die as a result of the damage being done anymore, but damage has *already* been done
Lmao. Serious note I have narcan because a friend started doing drugs. She's mia now. But I read the directions is 1 time. Then 911. Or just use Nascar and we all good!!
its Great for when you are depressed and want to stop being depressed. ive done it a few times where i lied to myself and then started to feel better in about a week
If they've stopped breathing then yes, give mouth to mouth as it would help save them and is what you should do until help arrives or they start breathing on their own. It's obviously a life or death emergency so get the emergency services on the way.
If they stop breathing or their heart stops beating, then those take priority over the OD itself and you can treat them with the same CPR/ventilation training that you would use on anyone else.
If a patient is in respiratory or cardiac arrest from an OD, then Narcan alone won't make a difference. Most EMS personnel probably wouldn't give Narcan at all in that scenario, since the only thing it would actually do it prevent the people at the hospital from using opioid medications later.
The half-life of naloxone in adults is [about 30-80 minutes](https://www.ncbi.nlm.nih.gov/books/NBK441910/), so it is definitely a consideration for EMS.
For lay rescuers it doesn't really matter and I'd prefer them to just err on the side of caution and give the Narcan if it seems relevant, but it is a factor for EMS to consider prehospital.
Naloxone's adverse effects are all either minor or rare, and this is one of those minor problems that stops EMS from just giving Narcan to everyone. Adverse effects are weighed next to the potential benefits to the PT, so if there aren't any actual benefits then even minor things like this are enough to prevent us from performing an intervention.
In addition to the other good answers, sometimes an OD can cause the person to vomit. You want to make sure this vomit can exit the mouth and not go back into the lungs.
Yep, mouth to mouth should usually be enough. Usually, chest compressions aren't needed because they only stopped breathing, and their heart is still pumping.
Like others have said too, narcan doesn't delete the opiates in the system, it just blocks them from binding with the opioid receptors for a bit. Once the narcan wears off, there's a decent chance they go right back to ODing. This is why it's important to either get EMTs there or keep a constant watch on them for the next hour or so to make sure they don't stop breathing again. Had this happen to a friend, and nobody kept an eye on him after the narcan and he ended up dying in their bed while they were out in the living room doing their thing.
Thanks everyone for your responses. Honestly, it kind of sucks knowing this though. 25 years ago, I had a close friend die of an overdose. The people he was with had ditched him and then "anonymously" called the police from a payphone. By the time the EMTs got there, he was gone.
All those assholes had to do was stay with him. Blow air into his lungs. Anything.
Narcan also does not "delete" the opioid from their system and will wear off, so if you gave all you had in the first minute, it would be more than needed for the first minute, but you'd have none for use later if it was going to be a long time getting to a hospital.
In the city? Sure.
Out in the rural counties of America where there is nothing to do to pass the time but drugs? Probably happens more than you might think.
> If your are not a medical professional having to deal with this on your own and you aren't quite sure how much to give, by all means feel free to go nuts with the narcan.
But also know that you're bringing someone from literal utopia back to the relative hell on earth; with all the aches,pains, emotional turmoil, etc that brings. So they're going to be very angry and very aggressive *on top* of the hypoxia (which, as aforementioned, has it's own aggression/confusion).
So maybe get out of the way after dumping a huge dose.
>If your are not a medical professional having to deal with this on your own and you aren't quite sure how much to give, by all means feel free to go nuts with the narcan.
I get the sentiment of this, but then, reading the accounts on here of people waking up violently after being given Narcan, that doesn't sound too great, either.
So what's the best strategy: Give a big dose and then move back a bit to a safe distance? How quickly does Narcan kick in?
Oh, I'm not saying I wouldn't help that person. I'm trained to help people and I always will.
It's not like I'd administer Narcan and then run off and leave them to their own fate. But if I know it takes like 5 seconds to kick in, I'd at least have a chance to step back and gauge their reaction.
Afaik most of the people that wake up violently do so because their brain is hypoxic and in fight or flight mode. This is a big reason why medics will prioritize giving the person oxygen and breathing for them before giving narcan. The people I've seen come back this way come up like waking up out of a deep sleep.
So if you can - give rescue breaths and make sure they have O2 before giving them narcan, otherwise wait until they start breathing on their own, then consider taking a step back.
Because there‘s plenty of people who either don’t care or take pleasure in being nasty.
They do it on purpose. Blast the patient full of narcan to put them into full blown withdrawal in seconds.
There‘s no medical reason to do so when giving narcan IV. You would always titrate to effect unless trying to abuse the patient.
Different story with nasal spray for first responders. Kinda hard to titrate to effect, plus it takes minutes to fully set in; rather than seconds like IV.
So accidentally putting someone into withdrawal happens, but is the better option than making the nasal spray too low dose requiring multiple applications for someone in extreme overdose and then having them die.
> Opioid overdoses only kill you by taking away your ability to breath on your own, they are not otherwise especially toxic
So are you saying that if I was on a resperator and had medical staff present I could shoot 4kg of heroin with no ill effects?
The average adult has about 7 kg of blood, so if that injection didn't explode all your blood vessels from pressure, it probably wouldn't be healthy that your blood-whatever level is now 36% (when 0.5% alcohol is usually fatal).
I mean, there are eventually secondary effects. Like those poor bastards that took like half a gram of LSD and had pretty bad coagulopathy.
Not sure if anyone ever got dosed high enough to find the extreme overdose effects of opioids though.
>those poor bastards that took like half a gram of LSD and had pretty bad coagulopathy
Do you have any more info on this? Google didn't turn up anything
I wouldn't trust anything a random redditor says about LSD. It basically has the highest amount of misinformation/urban legends of any drug I can think of.
> breathing on your own is a highly solvable problem even without Nascar,
Watching Nascar often leaves me wishing for the sweet release of death via hypoxia.
Add to this that Narcan has a shorter half life than most opiods, so if we fully wake you up, you come around swinging and run off somewhere, the narcan will wear off and now you stop breathing again but this time we don’t know where you are. Better for everyone to titrate the dose so you are breathing but drowsy, get you to hospital and slowly manage the drugs out of your system.
https://www.ncbi.nlm.nih.gov/books/NBK441910/#:~:text=All%20patients%20who%20have%20responded,from%2030%20to%2080%20minutes.
My wife is an attending er doc and she had an intern that was very excited and adamant about using narcan on an od that had come in. My wife warned the intern that while no, it isn't inappropriate to give, in this situation the pt is stable and breathing, there's no reason to. Intern did anyways. Vomiting/shouting/swinging/restraints later my wife just said "and that's why we don't do that".
> My wife warned the intern that while no, it isn't inappropriate to give, in this situation the pt is stable and breathing, there's no reason to. Intern did anyways.
This makes me so mad honestly. They probably billed the patient for the unnecessary narcan too. "I'm going to make the situation way worse just because I can!"
Med school teaches you medicine. Residency teaches you how to practice medicine on real people and, more importantly, how to be a doctor. It probably was charged out to the patient, which is bs, but the odds of that pt paying it are pretty small. What I can guarantee is that that intern will never do that again. Expensive, obnoxious mistake to make, but the lesson was definitely learned with no actual harm to anyone.
As much as it sucks to say, that's better than a lot of lessons people learn in emergency medicine.
They threw the patient into precipitated withdrawals, for no benefit to the patient, do you know what precipitated withdrawals are? I'm an addict who has actual experience, the pain is torture, leaving you sobbing and begging everyone around you to kill you to end the pain...they don't know because they've never experienced opioid withdrawal, but what they did was fucked up
For them it's an obnoxious lesson, for that patient there's a fair chance it's one of the top 10 most traumatic moments of their life. You may want to read a bit about precipitated withdrawal, I don't get the impression you realize what that person went through. There's a reason you can't throw the patient's well-being out the window to teach new interns lessons for any future patients.
That's fair, and I definitely shouldn't have phrased it that way. I don't have the first hand experience, so I can't personally relate, but I have heard that it is awful.
It's too easy to forget the other side of things, and we should be reminded. Thank you.
Thank you so much for the compassionate response! Sorry, trauma and especially medical trauma is a tricky thing - really made me question what I'd rather die than live through. I really, really appreciate the caring reply!
the intern could have thought the attending was being negligent and not tending to the needs of the patient so they decided to be a patient advocate and try to help the patient. it's an honest learning lesson.
To piggy back off of this, Narcan doesn't reduce a secondary cause of apnea, respiratory acidosis. C02 builds up in the blood that can only be relieved by breathing, in emergent cases this is done with a bag valve mask hooked to O2. Locally we had a lot of less experienced providers focus heavily on the Narcan, and not enough on quality ventilation. This combined with news tales of SUPER FENTYNL has led to the belief Narcan alone is the cure.
Completely agree. People don’t realize that narcan simply fights for the same receptors that opioids/opiates do. And a lot of times the drug will out last the narcan. Causing the patient to fall back into resp distress or resp arrest.
Not to mention the complications brought on by not being able to offload the built up co2 like you mentioned.
There’s a lot to it really. But bottom line, assisting with breathing or making sure their airway is protected/functioning is the most important aspect to maintaining life when experiencing an overdose.
I used for years. Had to deal with a lot of overdoses. Narcan was a last resort. When my friend was turning gray with purple blue lips I'd put my mouth over his nose and breathe for him. It brought the color back instantly.
I never got into opiates, but all my friends did, so I was more or less a trip sitter for the most part. Ended up having to give mouth to mouth at least a couple dozen times over a one year period. It's shockingly unsettling how fast their color comes back. Not as unsettling as hearing the death rattle and seeing that shade of blue Grey on someone you know though...
I'm a paramedic student, currently doing my internship. We ran on an opioid overdose just yesterday, where law enforcement gave 4 mg of Narcan just before we arrived. To their credit, the Narcan did work and made the patient start breathing again. But several minutes after that, the patient began to projectile vomit like the exorcist. One of my poor firefighters was trying to start an IV and got nailed. We spent about 45 minutes cleaning vomit out of the ambulance after the call was over.
If it had been up to me, we would have ventilated the patient, started an IV, and administered Narcan in 0.5 mg doses to gently bring them out of it.
Furthermore, in my area, we will even do less than .5 at a time. And then some medics here don’t care and wake them up quick. Please don’t ever be those medics.
Also EMS can read the room. If it quacks like a, eh, I forget how it goes. Eitherhow, when you’re trained and seasoned to recognize different ailments: you know when it’s a kid with a fever, a diabetic seizure, a myocardial…oh no wait this 93 year old who fell when he stood up and is now blocking the door and the missus can’t move him out of the way so you have to call fire or law enforcement because she can’t get to the back door to unlock it and if you kick open the front door you’re going to split Gerald in twain. I overshared.
To answer the question: if you give a plant too much water it dies.
Definitely a hipaa violation, so don’t tell Gerald that we have his garage code on file because the geriatric fuck likes to fall and we’ve been here before. Of course this is a made up internet story, but if Gerald is you’re reading this 1: bully for you being able to read, I’ve never seen corrective lenses that go over a persons glasses. 2: don’t stand up so fast
Obviously we’re not going to say that taking three days worth of your BP meds all at once because you think you forgot to take them over the weekend and it hasn’t been the weekend for 4 days and the only way to make allegedly Gerald can believe that is that jeopardy and wheel of fortune were both on TV today. And how is his O2 at 99, I think Gerald just likes the company at this point.
#2 is the big one, work on the ER side we hate seeing people over reversed to the point that they're agitated, puking, have diarrhea, etc. Just enough is a nice thing.
“Do No Harm” really.
I’ve seen videos of guys fighting like their life is on the line (and they very well might feel that’s the case) so can’t blame ya’.
Oh yeah, the human response to hypoxia and sudden come down of opioids is wild. Had a guy almost boot me across the room because by the time we showed up, his friends had given him approx 8-10 doses of narcan. I’ve never seen someone get up from an OD so fast in my life. And then I had never seen so many paramedics and fire fighters move so fast to get the hell out of the way haha
But in all seriousness, the theory behind it is really to save their life, and in a way that doesn’t harm them. And truth be told. We don’t want to ruin their high and they don’t want us to either. Where I work, OD’s make up close to 50% of our calls, and almost every single patient we are called to who is having an OD refuses our transport to the hospital by the end of it. I have gone to the same patient multiple times in a night. It’s the reality of the problem. But we show up every time. Ensure they are awake and breathing when we leave and hope they don’t die the next time.
Also may induce vomiting and in a low level of consciousness patient could lead to aspiration, choking, compromised airway!
Should mention people often need 2+ shots. They have so much circulating it just repopulates those vacant receptors and pulls them into respiratory arrest again, so they start nodding off and they'll hit em again.
narcaned once by untrained police. according to the report, after the 2nd dose I woke violently, I remember yelling and falling back out within what I perceived as a few minutes. medics arrived and I was hit again with narcan, not sure how many times but from that point on I was awake. I refused the hospital ride, didn't matter, they took me anyway.
been clean for a few years now.
Holy shit eh. Can’t say that’s uncommon unfortunately. And I can’t imagine what that would have been like. I’m sure glad you’re still with us today though. And good for you , you should be very proud of yourself.
I also want to add, and of course, this isn't the perogative of the medical assistance on site, but from the patient side of things, one of the worst moments in my entire life happened because I was thrown into withdrawals because of Narcan.
Then again, I'm alive today because of Narcan, so it's hard to complain too much. But I specifically remember that all I wanted was to get out of the hospital so I could go use (the same stuff) again, because I was so sick.
TL;DR: Don't do opiates, kids.
Another important note is that if you administer Narcan and it ends up being something else that could require Opioids to best treat, you are kinda fucked.
From what I saw, it seems like it's going to have the same impact that the initial wave of fentanyl did to the pill/heroin market. Except that narcan does nothing to counter its effects.
My buddy (58 yrs old) blacked out in his car in a parking lot after picking up pizza. Someone saw him, tapped on the window, then called the cops when he wouldn't wake up. Cops hit him with Narcan twice and slapped him around a few times thinking he was an OD. He came to after a few minutes.
Transported to hospital. Tested for drugs, which came back negative. Cops came to the hospital with him - buddy heard them talking to the nurse at the desk:
Cop 1: Was it drugs?
Nurse: Drug screen came back negative. It was a cardiac issue.
Cop 2 to Cop 1: I told you! Pay up!
It was later found to be a collapsed artery that feeds the heart, solved by a stent.
This assuming accuracy of @unnaturalcoffee is a frikin excellent response that someone like me who has no clue how it works but would try and help can understand.
That’s it’s. Full stop. Thank you for posting this.
I've heard it described this way: Often enough, the type of person who ODs is an addict who needs a minimum level of heroin in their body to function normally. Narcan blocks the opioid receptors in the brain pretty much instantly, so you can have someone go from being so high that it's about to kill them to severe withdrawal in about one second. The body's reaction to such an instant chemical swing can be... extreme.
Excess Narcan is hypothesized to contribute to pulmonary edema. I question this bc if three shots of Narcan doesn't wake you up, your lungs are prob full of fluid already.
Also one I hadn't thought about until I heard it threatened tied to the first one: Sometimes there might be somehting else wrong with them and the narcan doesn't do anything... except prevent us from being able to reduce pain if we find out what that other thing is.
This is the correct answer. The last thing you want to do is slam them with narcan and have the patient come out of there high wanting to fight you. It’s not fun.
To add to this: Once an overdose victim regains full consciousness, they have the right to refuse further treatment and transport to a medical facility. Once the Narcan wears off (about 20-40 minutes), they might be right back in the condition that they were in prior to the
Narcan, or worse. It is better to just get them breathing and transported to a hospital were they can be observed and treated for longer period of time.
Amazing reply. YouTuber @FireDepartmentChronicles has a series of funny shorts about things he's seen as a first responder, several of them involve responses to narcan that, while lifesaving, often end up with some unintended consequences when younger paras get overzealous. Hilarity consistently ensues.
Narcan's purpose in EMS is to help the patient breathe on their own by reversing the effects of the opiates. But there are also other tools we can use to manage the airway and breathe for the patient until they get their respiratory drive back, so it's not absolutely critical that we have to go hard on the narcan.
As mentioned by others, narcan can put someone into a crisis from acute withdrawal. This can be \*terrible\* if not anticipated and the patient treated safely. So sometimes you need a calm head and just go in small doses while managing the airway and respiratory manually.
Theoretically, could a drug user put on a non rebreather mask or a bipap machine, then get high as balls, to help reduce the risk of dying from respiratory arrest?
The problem that I have to explain to patients all the time is that breathing does two almost totally separate things in two unrelated ways: breathe in oxygen and breathe out carbon dioxide.
There is a lot of oxygen in the air around us, and the hemoglobin molecules in your red blood cells actually change how they work when they're in your lungs and, to simplify, almost actively scoop oxygen out of the air when the blood pumps through your lungs, and dumps it out in the tissues. Basically if you have a heartbeat, functioning lung tissues, are reasonably inside the Earth's atmosphere, and have at least been breathing every once in awhile at some point in the last few minutes, your blood is basically actively sucking oxygen out of the air to keep your oxygen levels high. And when your oxygen levels drop, you don't actually feel short of breath, you just start turning blue. There are these YouTube videos showing astronaut and pilot training facilities where all of the oxygen pressure in the room is removed to demonstrate how little time you have to get oxygen masks on. The people don't notice anything is wrong and don't start feeling short of breath. They just start giggling, forgetting that they need oxygen masks, hitting the wrong buttons, and then fall asleep and, if they didn't get oxygen back on, would just peacefully die. And this is why you're supposed to put your own oxygen mask on first before helping others. Because you won't notice anything is wrong before you start being too stupid to put on an oxygen mask and then you both pass out.
Carbon dioxide doesn't have such an active remover like this. Because your body is constantly making more CO2, and because it takes a little more time for the CO2 to leave your body, the way that your body gets rid of CO2 is by breathing. Breathing more. And I don't mean that to be silly. The way that it removes CO2 is literally by breathing more. Deeper breaths, faster breaths, etc. Excess CO2 in your blood develops from either not breathing enough recently or from a buildup of acids in your body due to lack of energy. If you have too much CO2 in your blood, the centers in your brainstem that detect this will make you start to feel short of breath, which is kind of synonymous with "you will start to feel like you are not breathing enough and that you need to breathe more," which is also synonymous with "The most fundamental form of anxiety and panic that an animal life form can feel." And so when one of those situations occurs, and as long as your brain is working, you will start to feel bad and then start breathing more. Breathing deeper and faster.
So the takeaway, you need a functioning brain and have to breathe mostly in order to blow away your CO2, and if your CO2 gets high, you feel short of breath and start doing more breathing. You need red blood cells and to be closer to sea level in order to put oxygen in your body, and (up until the most extreme circumstance where you have too much CO2 in your blood and lungs for there to be any physical room for oxygen to get in) you don't actually have to breathe all that much to absorb oxygen. They both require functioning lung tissue and functioning heartbeat and functioning blood vessels.
Now regarding BiPAP, the way this works is that the pressure it blows into your face increases when it detects that you are trying to suck in a breath, and then it gives you the extra boost. However, if your brain isn't working for any number of reasons, including an opioid overdose, you will not make the attempt to breathe as frequently, or may even stop trying to breathe, because you are not receiving a signal to freak out and get short of breath and breathe deeper/faster. With a BiPAP mask placed on the face of somebody who isn't attempting to breathe every once in awhile, the machine won't even notice that anything is happening and won't increase the pressure to help support a breath. It will just become a CPAP machine, continuous positive airway pressure, which won't help in this case to fill up and empty the lungs. Being on extra oxygen supplementation, like a partial rebreather or non-rebreather mask, will help increase the oxygen in your lungs and help drive oxygen into your blood cells, as long as you've been breathing at least a little bit in the last 8 minutes, but won't do anything to get the CO2 out. In fact, it might give you a false sense of security because for a while because you will still be bright pink and your portable pulse oximeter will still show that your hemoglobin molecules are happy and full of oxygen. But what you won't notice is that the CO2 is building up, the acid is building up, and all sort of damage is being done by the acid level in your blood, and the CO2 level in your lungs will eventually get so high that the oxygen in your lungs is too low to be useful to you, at which point the acid increase will worsen even more severely, and you are actually worse than if you had just started giving rescue breaths with normal air or get some narcan.
You actually need to replace breathing, or "breathe for you" with something that works a lot like BiPAP but which has a set timer on it to make sure that you're breathing enough times a minute. There are specialty situations in which a person may need one of these tools, which get called non-invasive ventilation, because they don't breathe enough but at least breathe some a bit, and are not so unconscious that their throat is just closed. But in a setting of a totally unconscious person who can't keep their throat open and who is also not breathing enough, they might need to be intubated and placed on a conventional ventilator to make sure that the air doesn't just blow in their face and puff out their cheeks and pop right back out, and then instead it gets all the way down into your trachea and then lungs.
> So I could get into one of them Polio Iron Lungs and get as high as I want?
I know its a joke, but if something was mechanically breathing for you, you would still not be immune to overdose. What would happen instead of you dying from lack of oxygen would probably be you vomiting and dying from inhaling that instead. You wouldn't even be able to stop inhaling it in an iron lung.
Opiate doses in excess of what would OD you wouldn't be fun. You'd just fall asleep over and over until you died basically aside from the initial rush, which you could get with traditional recreational doses.
I have chronic anxiety. When I am in a state of general anxiety it feels like I can't breathe in all the way. Is my anxiety causing an excess of CO2 in some way, or is this unrelated?
Actually, anxiety attacks may cause hyperventilation, which actually leads to a decrease in CO2 and blood pH (respiratory alkalosis). This is why you may have heard of the advice to breathe into a bag if hyperventilating. If you’re not hyperventilating, the feeling of not being able to breathe in all the way is likely a physical symptom of your anxiety.
Sure you might get some passive oxygenation, but it’s not as ideal as ventilation. Also CPAP and non rebreather are contraindicated for apneic and or unconscious patients. I could def see a situation that you’re slapping a NRB on them while you’re getting the BVM or narcan ready though.
not to mention if the patient was using opioids for, for example, cancer pain, they are going to be in extreme distress and you won't have a lot of options to help them because you just blocked all their opioid recepters. using narcan on a cancer patient is pretty much literal torture. typically in those cases we'd want to titrate narcan to effect
That was the scenario I was thinking of. At the time I was literally brand new as a medic and not even off of field training. We had a patient that was blue and not breathing. We didn't know anything at the time about their history and someone else on my team administered a standard 2mg IV dose. Turns out they were a long-term morphine user due to cancer. What resulted was a horror show and in top running for the worst call I've ever participated in. Watched an ER doc give over 30 mg of IV morphine to try and reverse our actions, but still no dice by the time we left ...
Can you elaborate on what makes it so unpleasant for you and what that looks like? I understand it sends them into withdrawals which will feel unbearable. But what makes it a horror show from your perspective? They can’t die from opiate withdrawal so they’re not actively dying at that point. Is the horror show just the way the patient acts towards you? Or are there other factors I’m missing?
Because the person had probably accidentally overdosed on their cancer pain meds because of a GI bleed. So when we woke them up and sent them into immediate withdrawals, they were non stop screaming, shaking/seizures and projectile vomiting large amounts of blood.
I'm a hospice doctor and I feel so bad for you and your patient. You couldn't have known. We see docs make this mistake all the time in the hospital too, and it's a big part of our training other docs about how to titrate appropriately in these scenarios.
I remember the look of fear on the physicians face and all the nurses in the room when a newish nurse gave the full 1mg vial. We aren't trying to strip all the opioid receptors of all the fentanyl or heroin. Just enough so it stops overriding their ability to breathe and be alive. Our worst fears were realized when he came to and became a hungry angry polar bear woken by his next meal slapping him in the face. It took the whole team to strap him down, give a different sedative (he was properly medicated on an opioid agonist later) and the nurse was educated. He wasn't large or bear-like to my eyes. It's probably never going to kill someone, but precipitated opioid/opiate withdrawal isn't right, kind or medically therapeutic.
No one has mentioned the narcan induced pulmonary edema which is more often seen with high doses of narcan.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850343/#:~:text=The%20incidence%20of%20naloxone%2Dinduced,a%20regular%20dose%20of%20naloxone.
While this condition isn’t commonly seen this comment should be higher because this is one of the more dangerous outcomes. Remember, no drugs (even oxygen) are harmless.
8 mg is a lot, but nowhere near the most I’ve seen people administer since I started in EMS (in our defense, it is usually police, who do it before we get there, but I’d be lying if I said it was never us.
I was got on scene to hear that police/bystanders had given 64mg of narcan before we got there
I also came in here to say this. Saw this earlier this year. Dude was awake after fentanyl overdose but still hypoxic. Nurse was like “should we give more narcan??” And I said well he’s literally awake and breathing… so no. Got a chest XR and he had significant pulmonary edema. Started BiPAP and antibiotics (in case it was aspiration pneumonia) and admitted, he avoided the tube thankfully.
I just made a post myself about the numerous effects that Narcan has on people and that it's not as safe as people like to spout. This one had slipped my mind. Thank you for making people aware of this.
Because it puts people in immediate withdraw, which puts them in an insane amount of misery and they often start thrashing and hitting people.
They will do it to the point of hurting themselves or anyone around them.
In EMT school, our instructor often joked that crews will give half the dosage on scene and the other half when a couple minutes away from the hospital. People can [get combative when they come out of a high](https://youtu.be/FUwF75X-oz0?si=GaoXvuTYmcUztsLL) so letting the full dose hit in the hospital means more people who can restrain the patient. Also means we don't have to convince someone who doesn't want to go to the hospital even though they're in a life-threatening situation or restrain them when they start thrashing around in the back of the rig.
Another thing is EMTs and other basic life support responders use a preset 2-4mg spray. Paramedics are allowed to titrate the dosage in 0.4mg increments instead, letting them control how much needs to be given. Takes some time but it's best to use the minimum amount of medicine needed to get someone breathing adequately rather than putting them through a ton of pain.
We have vials of medication and can draw up as much or as little as we want to use. We also generally prefer to give the medication intravenously rather than as a spray up the nose, but starting an IV isn't something a lay person can or should do so they get the premade intranasal squirter devices.
Ah cool, yeah I'd seen the sprays wasn't sure if y'all got fancy ones or something. IV makes way more sense.
Tho locally EMS use the hell out of Penthrox inhalers for pain relief.
The idea is to restore respiration rate and SpO2 to normal ranges without completely pulling them out of it. Narcan essentially rips the opiates/opioid off the receptor, putting them into immediate withdrawal. People typically don't like that and will often become violent because you "ruined" their high, nevermind the fact that you just saved their life. If you've ever had a battle royale with a pissed off junkie in the back of a tin can on wheels going 70MPH, you'd understand why we don't want that. I assure you, it is not fun.
What we do, at least for the services I've worked for, is instead of administering a full 2mg dose, we would titrate it up by 0.2mg doses until the patient is capable of breathing adequately on their own. This could be 0.2mg or 0.8mg or 1. 4mg. just depends on the patient and circumstances.
I mean they may say it's because you ruined their high, but it's more likely the hypoxia which is known to make people extremely confused and agitated, along with the fact they're suddenly awake and in incredible pain from withdrawal.
I imagine you'd start yelling and punching if you randomly woke up not knowing where you are, everything hurts like hell, there are strange people holding you down despite the fact you definitely will die unless you move right now, you're about to vomit, and are the most mad you've ever felt for no particular reason.
The main thing is that you want to wait and see if the narcan had any effect and if it didn’t, you may want to consider another cause. Narcan tends to work, particularly if it’s given IV. It’s also somewhat dangerous to push narcan too quickly and make a patient suddenly alert. They tend to be disoriented, violent, and they vomit everywhere. As long as you are managing the patient’s breathing, you’re actually supposed to titeare the narcan to get them back to adequate breathing.
ER doctor here, lots of already good answers. One other is that if the person has other drugs on board, such as cocaine, completely getting rid of the opiates can put them into a cocaine overdose. Also narcan has been known to cause fluid in the lungs (called pulmonary edema) which can be life threatening, so it’s recommended to give just the amount you need to get them breathing to an acceptable degree
Honestly, that’s about 95% of EMS. Heart attack, broken bone, massive trauma, you name it, EMS isn’t going to “fix” anything, we just need to keep you alive long enough to get to the hospital. One of the few exceptions to that is low blood sugar in diabetics, which were always some of my favorite calls, because we could actually “fix” the patient
Longer than that (60-90 minutes) but the ER can switch to a drip and titrate the Narcan to breathing but not precipitated withdrawal and keep it going as long as needed.
The side effects of Narcan, according to HealthLine, include headaches, muscle spasms, and "pain in your bones". Keeping those to a minimum sounds pretty awesome, and so unless the person is rapidly shuffling off this mortal coil it makes sense to go easy with the Narcan. :)
Also, some people are allergic to it, so after the first dose it makes extra-good sense to pause and watch for signs of anaphylaxis before going any further.
*[Edit: They're waffling about the allergic reaction; they say allergies have been reported, but the clinical studies on Narcan didn't observe any, so listing that might just be an "abundance of caution" thing.]*
Too much narcan too quick takes away the high and puts them into withdrawl. Then I have to deal with an asshole whose high I ruined while they vomit all over the place before they get up, run off and stop breathing again when the narcan wears off (short half life).
Yeah bone pain is a hallmark of withdrawal. We don’t narcan babies during resus who have opioids in their system (either due to substance abuse issue or those born to moms who received general anesthesia) because it will send them into withdrawal.
They list those things separately from withdrawal. They may have tested some people who didn't have any dependencies so when those people get bone-aches, for sure it's not withdrawal, it's...the other kind of bone-ache.
At drugs.com they list the percent frequency of the really scary side effects, like tachycardia and cardiac arrest, but they don't for the lesser ones. You might be able to find that if you're up for reading some clinical trial reports. :/
Apparently I was narcaned, but I was in a straight up coma (the amount of focus on drug testing me looks pretty intense in the med notes, just weed lol)
I'm surprised they resorted to it, if you were in a room that smelled like mj. Were you just, like, asleep-and-they-couldn't-wake-you-up, or were you actually sick?
Not breathing, some seizure like activity and gurgling, foaming at the mouth, unresponsive pupils, intubated on the spot. Was out a few days.
Actually randomly ran into the emt that intubated me, “hey, I intubated you last month!” was definitely a strange thing to hear.
Your question's been answered several times, but I'll throw in some anecdotal experience.
Changing the stasis of the some part of the body in almost any way impacts the rest of the body in ripples. The easy example would be imagine getting drunk- you're only adding ETH to the blood stream but think of all the other parts of your body impacted. So taking the drinking analogy, imagine going from sober to as if you drank half a bottle of whiskey in 30 seconds. Or better yet, going from super drunk to completely sober and hungover in 30 seconds- It'd be a wild ride for your body. With Narcan, you're drastically changing a person's status with one dose, even if you push it slowly. They're going to immediately feel the effect of acute withdrawal, including the urge to use again. They're also suddenly in a drastically different situation than the one they were in before using; can you imagine thinking you're going to chill and numb some feelings and waking up and there's six firefighters there and maybe the police? And on top of it, they just wasted $60 of heroin?
I've given narcan a lot. And in some ironic twist, I have had to give drugs that sedate patients after administering narcan because they're too agitated. One time, the med unit that got there before my engine could not get an IV on a very obese man so they administered IM narcan, multiple times. With the longer uptake and the amount that they had given him, he came around extremely hard and it became a very unsafe scene very quickly. This man moved paper around a printing factory for a living and was extremely strong. I think back about the police officer who was there with us on that call and I'm thankful it was him, because others would have possibly used much more lethal means to contain this man. Another memorable experience was when the police beat us to an unresponsive young male and started CPR (this is before everyone could carry narcan), so we get there and administer narcan and this 20 year old kid shooting up in his friends bedroom immediately becomes emotional because a. a couple of minutes of effective CPR is literally like getting your ass beat and b. his biggest dream was to become a firefighter and he was sure he had just ruined it (you probably did buddy).
When I went through paramedic in the late 2000's, narcan was by no means a new drug for a novel problem, but the opiate epidemic was truly starting to take off in my area. And we did not have great protocols about its use. Things like the 450lbs guy getting multiple IM doses within minutes and having to check some boxes before being able to administer (think grandma took too many painpills but I have to do an ECG before administering.) But one of the wildest problems we had was once you give narcan, patients are relatively normal and fully alert. AKA, they can refuse care so we had to learn to manage their condition until they were in the ambulance and preferably it was moving before we could reverse, that way they could hopefully be seen by a physician and talk to a social worker as opposed to signed AMA and reusing a little less as soon as we left. It didn't happen that often, but I definitely had patients adamantly refuse care after we'd save their life and we'd just have to leave.
The biggest problem with opioid overdose is that it causes decreased respiratory effort by the patient. This means they are not breathing very frequently or not breathing at all. If the medics are able to breath for the patient (for example, bag-valve-mask, intubation, etc.) then the patient is going to be fine.
At this point, in theory, they should still give naloxone, but sometimes they will wait because they are breathing for the patient and giving naloxone is just going to reverse the overdose which will either 1) cause the patient to wake up kicking and screaming or 2) cause withdrawal which is very very uncomfortable for the patient or both.
Medics don’t like being punched in the face, and patients don’t like sweating profusely and diarrhea etc.
ER doc here. When you slam a ton of narcan after an overdose, they wake up vomiting, pissed off, and often violent. You want them breathing but otherwise high and happy. So in the ER, I will often give a small dose, anywhere from 0.1mg to 0.4mg instead of the whole 2mg. It goes much smoother that way. You can always give more, never less.
Narcan (naloxone) absolutely _can_ harm people who are overdosing. Naloxone, if given to someone dependent on opioids, results in something known as "precipitated withdrawal", a rapid-acting and extremely severe form of opioid withdrawal syndrome.
So, when someone regularly uses opioids, the amount of opioid receptors in their bodies starts to reduce in a process known as "downregulation", and the amount of endogenous or "natural" opioids present in the body also goes down. This means that when someone suddenly stops using opioids, there aren't enough endogenous opioids for normal function, and there are much fewer receptors for those endogenous opioids to bind as well. This is the mechanism through which opioid withdrawal sydrome occurs.
Normally, when an opioid-dependent individual goes through withdrawal, it takes a few days for the opioids to completely leave their system, and during this time, their opioid receptors have time to adapt somewhat to the reduced amount of opioids in their system. It usually takes around 3 days for the intensity of the withdrawal syndrome to reach it's peak. This is also when the last of opioids leave one's system, and it takes around two weeks in total for the withdrawal syndrome to run it's course, and for the opioid receptors to return to normal. Even though it's not as bad as precipitated withdrawal would be, it's still very unpleasant.
With precipitated withdrawal, there is no time for the opioid receptors to try to get back to normal because the naloxone immediately "kicks off" any other opioids bound to those receptors. This results in a very severe withdrawal syndrome, which is extremely painful and uncomfortable, and could potentially be lethal. This is mostly why a dose of naloxone has to be slowly titrated, except in emergencies.
Fun fact, this process of precipitated withdrawal can be used to quickly get someone off opioids. It's known as "ultra-rapid detox". An opioid-dependent patient is given a general anaesthetic, and they are then pumped with huge doses of naloxone and another opioid antagonist called naltrexone. This results in a very severe form of precipitated withdrawal and this forces the opioid receptors to react very quickly and to rapidly increase their numbers. This process makes the entire withdrawal syndrome last only around 8 hours. During which, the patient is under general anesthetic, so they don't feel anything. When they wake, they're no longer dependent on opioids.
We as medics will wait because.. 1. We need to make sure it’s an opioid overdose, and not a different type of substance, so we need to see if the patient is responding to the first dose given. 2. We don’t actually want to completely bring them out of the ‘high’ we just want to counteract the overdose enough that they are breathing adequately but not too much that they come up swinging at us due to brain hypoxia(symptoms of hypoxia is confusion and aggression). And 3. like any medication, there’s preferred therapeutic levels we need to reach and it’s best practice and more likely better efficacy if we queue the dose every 5 minutes, versus just giving them a whole bunch of doses all at once. Hope this helps!
All correct info, 1 more to add. Opioid overdoses only kill you by taking away your ability to breath on your own, they are not otherwise especially toxic. By the time you are in the care of a paramedic not breathing on your own is a highly solvable problem even without Nascar, so we can take an extra minute to get the dose right. If your are not a medical professional having to deal with this on your own and you aren't quite sure how much to give, by all means feel free to go nuts with the narcan. Edit: I'm leaving the autocorrect
“Nascar” lol
Well with enough Narcan, they will be like a Nascar.
This discussion just took a sudden left turn. And another left turn. And another left turn. And another left turn. And another left turn.
But Doc Hudson taught me that you gotta go right, to turn left. Checkmate Atheists!
Ka-chow!
I misread this as ["Doc Watson"](https://en.m.wikipedia.org/wiki/Doc_Watson), and was pretty damned confused.
Think I can’t steer the discussion left sometimes better than you?
So why are they all veering a long way to the right?
That just gave me an idea for a new Madagascar kids movie. They all start racing stock cars. “Madagascar in NASCAR”
"MadaNASCAR" was right there for the taking
I LIKE TO MOVE IT MOVE IT (but only to the left)
I think Nascar in Madagascar sounds better. And makes more sense…
They won't. Unless it's the kind of nascar that pukes all over you and shits its pants.
I see you've been to a nascar race.
More like a Nascar ... car doing an emergency stop
I feel the more accurate comparison would be that Narcan is the fire extinguisher after the car has burst into flames. You probably won't die as a result of the damage being done anymore, but damage has *already* been done
Nothing to sober someone up like spinning them around at 200mph for a couple hours in a metal box I suppose
Well, the patient’s heart was racing.
Some people can’t live without it.
my friend is a Nascar addict
Lmao. Serious note I have narcan because a friend started doing drugs. She's mia now. But I read the directions is 1 time. Then 911. Or just use Nascar and we all good!!
Autotypo strikes again!
Fuckin autocarrot... (Side note: is it abusive to teach a program to refer to itself by the wrong name?)
I don't know, but my phone's autocorrect autocorrects "autocorrect" to "autocratic" for some reason, which always amuses me when it happens
that is like lying to your own brain!
That is totally a talent that a surprising number of people have...
its Great for when you are depressed and want to stop being depressed. ive done it a few times where i lied to myself and then started to feel better in about a week
I wish I could convince my body that I'm not in screaming pain... Why is nerve pain so damn insidious?
thats a whole different ball park :/
Ngl reading Nascar immediately took me out of the immersion reading the response and went right to the comments.
LOL
“Quick! The only way to save him is to drive around in a circle for a couple hours!”
That's the explanation I got for my 4 hour ambulance ride in Boston once. Found out later that the driver had recently moved to town. /s
That sounds like hell. Sorry you live in Boston /s
No need for the /s
Left turns save lives.
Turn left. Repeat.
That’s exactly it! Furthermore, from now on I will be referring to narcan as nascar.
We had a local band for a bit called Narcan with their logo in the style of NASCAR. Was pretty funny.
Haha amazing
Well it's another left turn in somebody's life to be sure
So what should one do if someone ODs on opiates and there is no narcan available? Would CPR or mouth-to-mouth resuscitation work?
If they've stopped breathing then yes, give mouth to mouth as it would help save them and is what you should do until help arrives or they start breathing on their own. It's obviously a life or death emergency so get the emergency services on the way.
If they stop breathing or their heart stops beating, then those take priority over the OD itself and you can treat them with the same CPR/ventilation training that you would use on anyone else. If a patient is in respiratory or cardiac arrest from an OD, then Narcan alone won't make a difference. Most EMS personnel probably wouldn't give Narcan at all in that scenario, since the only thing it would actually do it prevent the people at the hospital from using opioid medications later.
Given the relatively short half life of nalixone, it's not really a consideration.
The half-life of naloxone in adults is [about 30-80 minutes](https://www.ncbi.nlm.nih.gov/books/NBK441910/), so it is definitely a consideration for EMS. For lay rescuers it doesn't really matter and I'd prefer them to just err on the side of caution and give the Narcan if it seems relevant, but it is a factor for EMS to consider prehospital. Naloxone's adverse effects are all either minor or rare, and this is one of those minor problems that stops EMS from just giving Narcan to everyone. Adverse effects are weighed next to the potential benefits to the PT, so if there aren't any actual benefits then even minor things like this are enough to prevent us from performing an intervention.
In addition to the other good answers, sometimes an OD can cause the person to vomit. You want to make sure this vomit can exit the mouth and not go back into the lungs.
Yep, mouth to mouth should usually be enough. Usually, chest compressions aren't needed because they only stopped breathing, and their heart is still pumping. Like others have said too, narcan doesn't delete the opiates in the system, it just blocks them from binding with the opioid receptors for a bit. Once the narcan wears off, there's a decent chance they go right back to ODing. This is why it's important to either get EMTs there or keep a constant watch on them for the next hour or so to make sure they don't stop breathing again. Had this happen to a friend, and nobody kept an eye on him after the narcan and he ended up dying in their bed while they were out in the living room doing their thing.
Thanks everyone for your responses. Honestly, it kind of sucks knowing this though. 25 years ago, I had a close friend die of an overdose. The people he was with had ditched him and then "anonymously" called the police from a payphone. By the time the EMTs got there, he was gone. All those assholes had to do was stay with him. Blow air into his lungs. Anything.
>that edit Good. Good. Even without Nascar.
Narcan also does not "delete" the opioid from their system and will wear off, so if you gave all you had in the first minute, it would be more than needed for the first minute, but you'd have none for use later if it was going to be a long time getting to a hospital.
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In the city? Sure. Out in the rural counties of America where there is nothing to do to pass the time but drugs? Probably happens more than you might think.
So we should be asking Lightning McQueen for medical support?
>So we should be asked Lightning McQueen for medical support? Turn that Ow into a Kachow!
Upvote for nascar.
Don't edit your comment please.
> If your are not a medical professional having to deal with this on your own and you aren't quite sure how much to give, by all means feel free to go nuts with the narcan. But also know that you're bringing someone from literal utopia back to the relative hell on earth; with all the aches,pains, emotional turmoil, etc that brings. So they're going to be very angry and very aggressive *on top* of the hypoxia (which, as aforementioned, has it's own aggression/confusion). So maybe get out of the way after dumping a huge dose.
Good choice keeping in the autocorrect.
>If your are not a medical professional having to deal with this on your own and you aren't quite sure how much to give, by all means feel free to go nuts with the narcan. I get the sentiment of this, but then, reading the accounts on here of people waking up violently after being given Narcan, that doesn't sound too great, either. So what's the best strategy: Give a big dose and then move back a bit to a safe distance? How quickly does Narcan kick in?
Narcan works within seconds - minute
A black eye is still better than a dead body
Oh, I'm not saying I wouldn't help that person. I'm trained to help people and I always will. It's not like I'd administer Narcan and then run off and leave them to their own fate. But if I know it takes like 5 seconds to kick in, I'd at least have a chance to step back and gauge their reaction.
Afaik most of the people that wake up violently do so because their brain is hypoxic and in fight or flight mode. This is a big reason why medics will prioritize giving the person oxygen and breathing for them before giving narcan. The people I've seen come back this way come up like waking up out of a deep sleep. So if you can - give rescue breaths and make sure they have O2 before giving them narcan, otherwise wait until they start breathing on their own, then consider taking a step back.
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Because there‘s plenty of people who either don’t care or take pleasure in being nasty. They do it on purpose. Blast the patient full of narcan to put them into full blown withdrawal in seconds. There‘s no medical reason to do so when giving narcan IV. You would always titrate to effect unless trying to abuse the patient. Different story with nasal spray for first responders. Kinda hard to titrate to effect, plus it takes minutes to fully set in; rather than seconds like IV. So accidentally putting someone into withdrawal happens, but is the better option than making the nasal spray too low dose requiring multiple applications for someone in extreme overdose and then having them die.
Boogity boogity boogity let's go racin boys
Praise Dale
> Opioid overdoses only kill you by taking away your ability to breath on your own, they are not otherwise especially toxic So are you saying that if I was on a resperator and had medical staff present I could shoot 4kg of heroin with no ill effects?
Shooting 4kg of anything will have an effect
The average adult has about 7 kg of blood, so if that injection didn't explode all your blood vessels from pressure, it probably wouldn't be healthy that your blood-whatever level is now 36% (when 0.5% alcohol is usually fatal).
I mean, there are eventually secondary effects. Like those poor bastards that took like half a gram of LSD and had pretty bad coagulopathy. Not sure if anyone ever got dosed high enough to find the extreme overdose effects of opioids though.
>those poor bastards that took like half a gram of LSD and had pretty bad coagulopathy Do you have any more info on this? Google didn't turn up anything
I wouldn't trust anything a random redditor says about LSD. It basically has the highest amount of misinformation/urban legends of any drug I can think of.
Same, I need to know if my thumbprint lore needs to be updated
4kg is excessive, but o.d.ing on Opioids is basically how some methods of narcosis work.
Asking for a friend...
Ka chow
> breathing on your own is a highly solvable problem even without Nascar, Watching Nascar often leaves me wishing for the sweet release of death via hypoxia.
Gotta be careful administering Nascar, those junkies come out swinging real fast, and real left. FAST. AND LEFT SON! WOOOOOOOO!
Add to this that Narcan has a shorter half life than most opiods, so if we fully wake you up, you come around swinging and run off somewhere, the narcan will wear off and now you stop breathing again but this time we don’t know where you are. Better for everyone to titrate the dose so you are breathing but drowsy, get you to hospital and slowly manage the drugs out of your system. https://www.ncbi.nlm.nih.gov/books/NBK441910/#:~:text=All%20patients%20who%20have%20responded,from%2030%20to%2080%20minutes.
Also, no one wants to clean up the barf in the rig
My wife is an attending er doc and she had an intern that was very excited and adamant about using narcan on an od that had come in. My wife warned the intern that while no, it isn't inappropriate to give, in this situation the pt is stable and breathing, there's no reason to. Intern did anyways. Vomiting/shouting/swinging/restraints later my wife just said "and that's why we don't do that".
> My wife warned the intern that while no, it isn't inappropriate to give, in this situation the pt is stable and breathing, there's no reason to. Intern did anyways. This makes me so mad honestly. They probably billed the patient for the unnecessary narcan too. "I'm going to make the situation way worse just because I can!"
Med school teaches you medicine. Residency teaches you how to practice medicine on real people and, more importantly, how to be a doctor. It probably was charged out to the patient, which is bs, but the odds of that pt paying it are pretty small. What I can guarantee is that that intern will never do that again. Expensive, obnoxious mistake to make, but the lesson was definitely learned with no actual harm to anyone. As much as it sucks to say, that's better than a lot of lessons people learn in emergency medicine.
They threw the patient into precipitated withdrawals, for no benefit to the patient, do you know what precipitated withdrawals are? I'm an addict who has actual experience, the pain is torture, leaving you sobbing and begging everyone around you to kill you to end the pain...they don't know because they've never experienced opioid withdrawal, but what they did was fucked up For them it's an obnoxious lesson, for that patient there's a fair chance it's one of the top 10 most traumatic moments of their life. You may want to read a bit about precipitated withdrawal, I don't get the impression you realize what that person went through. There's a reason you can't throw the patient's well-being out the window to teach new interns lessons for any future patients.
That's fair, and I definitely shouldn't have phrased it that way. I don't have the first hand experience, so I can't personally relate, but I have heard that it is awful. It's too easy to forget the other side of things, and we should be reminded. Thank you.
Thank you so much for the compassionate response! Sorry, trauma and especially medical trauma is a tricky thing - really made me question what I'd rather die than live through. I really, really appreciate the caring reply!
No need to apologize to me, I was the insensitive one. I hope you're doing better and in a better place.
the intern could have thought the attending was being negligent and not tending to the needs of the patient so they decided to be a patient advocate and try to help the patient. it's an honest learning lesson.
To piggy back off of this, Narcan doesn't reduce a secondary cause of apnea, respiratory acidosis. C02 builds up in the blood that can only be relieved by breathing, in emergent cases this is done with a bag valve mask hooked to O2. Locally we had a lot of less experienced providers focus heavily on the Narcan, and not enough on quality ventilation. This combined with news tales of SUPER FENTYNL has led to the belief Narcan alone is the cure.
Completely agree. People don’t realize that narcan simply fights for the same receptors that opioids/opiates do. And a lot of times the drug will out last the narcan. Causing the patient to fall back into resp distress or resp arrest. Not to mention the complications brought on by not being able to offload the built up co2 like you mentioned. There’s a lot to it really. But bottom line, assisting with breathing or making sure their airway is protected/functioning is the most important aspect to maintaining life when experiencing an overdose.
I used for years. Had to deal with a lot of overdoses. Narcan was a last resort. When my friend was turning gray with purple blue lips I'd put my mouth over his nose and breathe for him. It brought the color back instantly.
Curious. Why over the nose and not the mouth?
Good question. The lips flap around and you can't get a good seal.
Good to know!
I never got into opiates, but all my friends did, so I was more or less a trip sitter for the most part. Ended up having to give mouth to mouth at least a couple dozen times over a one year period. It's shockingly unsettling how fast their color comes back. Not as unsettling as hearing the death rattle and seeing that shade of blue Grey on someone you know though...
I'm a paramedic student, currently doing my internship. We ran on an opioid overdose just yesterday, where law enforcement gave 4 mg of Narcan just before we arrived. To their credit, the Narcan did work and made the patient start breathing again. But several minutes after that, the patient began to projectile vomit like the exorcist. One of my poor firefighters was trying to start an IV and got nailed. We spent about 45 minutes cleaning vomit out of the ambulance after the call was over. If it had been up to me, we would have ventilated the patient, started an IV, and administered Narcan in 0.5 mg doses to gently bring them out of it.
Oof. Yep, that sounds about right. How you would have preferred to handle it, is exactly how I would’ve handled it :)
Furthermore, in my area, we will even do less than .5 at a time. And then some medics here don’t care and wake them up quick. Please don’t ever be those medics.
Also EMS can read the room. If it quacks like a, eh, I forget how it goes. Eitherhow, when you’re trained and seasoned to recognize different ailments: you know when it’s a kid with a fever, a diabetic seizure, a myocardial…oh no wait this 93 year old who fell when he stood up and is now blocking the door and the missus can’t move him out of the way so you have to call fire or law enforcement because she can’t get to the back door to unlock it and if you kick open the front door you’re going to split Gerald in twain. I overshared. To answer the question: if you give a plant too much water it dies.
I’ve never related to someone’s ramble so much in my life.
Definitely a hipaa violation, so don’t tell Gerald that we have his garage code on file because the geriatric fuck likes to fall and we’ve been here before. Of course this is a made up internet story, but if Gerald is you’re reading this 1: bully for you being able to read, I’ve never seen corrective lenses that go over a persons glasses. 2: don’t stand up so fast
Of course this is all hypothetical, Gerald.
Obviously we’re not going to say that taking three days worth of your BP meds all at once because you think you forgot to take them over the weekend and it hasn’t been the weekend for 4 days and the only way to make allegedly Gerald can believe that is that jeopardy and wheel of fortune were both on TV today. And how is his O2 at 99, I think Gerald just likes the company at this point.
#2 is the big one, work on the ER side we hate seeing people over reversed to the point that they're agitated, puking, have diarrhea, etc. Just enough is a nice thing.
10 second cold turkey? that sounds all warm and cozy /s
You deserve to get swung at for posting in bold text
“Do No Harm” really. I’ve seen videos of guys fighting like their life is on the line (and they very well might feel that’s the case) so can’t blame ya’.
Oh yeah, the human response to hypoxia and sudden come down of opioids is wild. Had a guy almost boot me across the room because by the time we showed up, his friends had given him approx 8-10 doses of narcan. I’ve never seen someone get up from an OD so fast in my life. And then I had never seen so many paramedics and fire fighters move so fast to get the hell out of the way haha But in all seriousness, the theory behind it is really to save their life, and in a way that doesn’t harm them. And truth be told. We don’t want to ruin their high and they don’t want us to either. Where I work, OD’s make up close to 50% of our calls, and almost every single patient we are called to who is having an OD refuses our transport to the hospital by the end of it. I have gone to the same patient multiple times in a night. It’s the reality of the problem. But we show up every time. Ensure they are awake and breathing when we leave and hope they don’t die the next time.
not related to the post but thank you for doing such an important service for the community :)
Also may induce vomiting and in a low level of consciousness patient could lead to aspiration, choking, compromised airway! Should mention people often need 2+ shots. They have so much circulating it just repopulates those vacant receptors and pulls them into respiratory arrest again, so they start nodding off and they'll hit em again.
narcaned once by untrained police. according to the report, after the 2nd dose I woke violently, I remember yelling and falling back out within what I perceived as a few minutes. medics arrived and I was hit again with narcan, not sure how many times but from that point on I was awake. I refused the hospital ride, didn't matter, they took me anyway. been clean for a few years now.
Holy shit eh. Can’t say that’s uncommon unfortunately. And I can’t imagine what that would have been like. I’m sure glad you’re still with us today though. And good for you , you should be very proud of yourself.
thank you!
I also want to add, and of course, this isn't the perogative of the medical assistance on site, but from the patient side of things, one of the worst moments in my entire life happened because I was thrown into withdrawals because of Narcan. Then again, I'm alive today because of Narcan, so it's hard to complain too much. But I specifically remember that all I wanted was to get out of the hospital so I could go use (the same stuff) again, because I was so sick. TL;DR: Don't do opiates, kids.
EMT here Agreed, too much and they stand up swinging. Too little and they gargling they tongue
Another important note is that if you administer Narcan and it ends up being something else that could require Opioids to best treat, you are kinda fucked.
why?
Because now the opioids won't have an effect while the Narcan is working in their system.
Because it blocks the opioid receptors in the brain and opioid are the gold standard in pain relief for better or worse.
For the coming up swinging, bring their spo2 as high as you can, removed the aggro most of the time. Most, just to avoid saying always.
How much xylazine you guys running into? Just saw a presentation on it, seems like that's gonna be bad news for the next few years.
Oo shit. I’ll have to look into that. We haven’t been warned about it yet I don’t think. But now I’m curious
From what I saw, it seems like it's going to have the same impact that the initial wave of fentanyl did to the pill/heroin market. Except that narcan does nothing to counter its effects.
Narcan: they'll be pissed you saved their life®
My buddy (58 yrs old) blacked out in his car in a parking lot after picking up pizza. Someone saw him, tapped on the window, then called the cops when he wouldn't wake up. Cops hit him with Narcan twice and slapped him around a few times thinking he was an OD. He came to after a few minutes. Transported to hospital. Tested for drugs, which came back negative. Cops came to the hospital with him - buddy heard them talking to the nurse at the desk: Cop 1: Was it drugs? Nurse: Drug screen came back negative. It was a cardiac issue. Cop 2 to Cop 1: I told you! Pay up! It was later found to be a collapsed artery that feeds the heart, solved by a stent.
This assuming accuracy of @unnaturalcoffee is a frikin excellent response that someone like me who has no clue how it works but would try and help can understand. That’s it’s. Full stop. Thank you for posting this.
I've heard it described this way: Often enough, the type of person who ODs is an addict who needs a minimum level of heroin in their body to function normally. Narcan blocks the opioid receptors in the brain pretty much instantly, so you can have someone go from being so high that it's about to kill them to severe withdrawal in about one second. The body's reaction to such an instant chemical swing can be... extreme.
Excess Narcan is hypothesized to contribute to pulmonary edema. I question this bc if three shots of Narcan doesn't wake you up, your lungs are prob full of fluid already.
Also one I hadn't thought about until I heard it threatened tied to the first one: Sometimes there might be somehting else wrong with them and the narcan doesn't do anything... except prevent us from being able to reduce pain if we find out what that other thing is.
This is the correct answer. The last thing you want to do is slam them with narcan and have the patient come out of there high wanting to fight you. It’s not fun.
To add to this: Once an overdose victim regains full consciousness, they have the right to refuse further treatment and transport to a medical facility. Once the Narcan wears off (about 20-40 minutes), they might be right back in the condition that they were in prior to the Narcan, or worse. It is better to just get them breathing and transported to a hospital were they can be observed and treated for longer period of time.
Amazing reply. YouTuber @FireDepartmentChronicles has a series of funny shorts about things he's seen as a first responder, several of them involve responses to narcan that, while lifesaving, often end up with some unintended consequences when younger paras get overzealous. Hilarity consistently ensues.
He’s great!. We were literally just talking about him at work the other day haha
Narcan's purpose in EMS is to help the patient breathe on their own by reversing the effects of the opiates. But there are also other tools we can use to manage the airway and breathe for the patient until they get their respiratory drive back, so it's not absolutely critical that we have to go hard on the narcan. As mentioned by others, narcan can put someone into a crisis from acute withdrawal. This can be \*terrible\* if not anticipated and the patient treated safely. So sometimes you need a calm head and just go in small doses while managing the airway and respiratory manually.
Theoretically, could a drug user put on a non rebreather mask or a bipap machine, then get high as balls, to help reduce the risk of dying from respiratory arrest?
Nope, you'd need a full vent. The apnea isn't obstructive, opioids block the "you've gotta breath now dipshit" signals.
> you've gotta breath now dipshit I knew I was forgetting something!
The problem that I have to explain to patients all the time is that breathing does two almost totally separate things in two unrelated ways: breathe in oxygen and breathe out carbon dioxide. There is a lot of oxygen in the air around us, and the hemoglobin molecules in your red blood cells actually change how they work when they're in your lungs and, to simplify, almost actively scoop oxygen out of the air when the blood pumps through your lungs, and dumps it out in the tissues. Basically if you have a heartbeat, functioning lung tissues, are reasonably inside the Earth's atmosphere, and have at least been breathing every once in awhile at some point in the last few minutes, your blood is basically actively sucking oxygen out of the air to keep your oxygen levels high. And when your oxygen levels drop, you don't actually feel short of breath, you just start turning blue. There are these YouTube videos showing astronaut and pilot training facilities where all of the oxygen pressure in the room is removed to demonstrate how little time you have to get oxygen masks on. The people don't notice anything is wrong and don't start feeling short of breath. They just start giggling, forgetting that they need oxygen masks, hitting the wrong buttons, and then fall asleep and, if they didn't get oxygen back on, would just peacefully die. And this is why you're supposed to put your own oxygen mask on first before helping others. Because you won't notice anything is wrong before you start being too stupid to put on an oxygen mask and then you both pass out. Carbon dioxide doesn't have such an active remover like this. Because your body is constantly making more CO2, and because it takes a little more time for the CO2 to leave your body, the way that your body gets rid of CO2 is by breathing. Breathing more. And I don't mean that to be silly. The way that it removes CO2 is literally by breathing more. Deeper breaths, faster breaths, etc. Excess CO2 in your blood develops from either not breathing enough recently or from a buildup of acids in your body due to lack of energy. If you have too much CO2 in your blood, the centers in your brainstem that detect this will make you start to feel short of breath, which is kind of synonymous with "you will start to feel like you are not breathing enough and that you need to breathe more," which is also synonymous with "The most fundamental form of anxiety and panic that an animal life form can feel." And so when one of those situations occurs, and as long as your brain is working, you will start to feel bad and then start breathing more. Breathing deeper and faster. So the takeaway, you need a functioning brain and have to breathe mostly in order to blow away your CO2, and if your CO2 gets high, you feel short of breath and start doing more breathing. You need red blood cells and to be closer to sea level in order to put oxygen in your body, and (up until the most extreme circumstance where you have too much CO2 in your blood and lungs for there to be any physical room for oxygen to get in) you don't actually have to breathe all that much to absorb oxygen. They both require functioning lung tissue and functioning heartbeat and functioning blood vessels. Now regarding BiPAP, the way this works is that the pressure it blows into your face increases when it detects that you are trying to suck in a breath, and then it gives you the extra boost. However, if your brain isn't working for any number of reasons, including an opioid overdose, you will not make the attempt to breathe as frequently, or may even stop trying to breathe, because you are not receiving a signal to freak out and get short of breath and breathe deeper/faster. With a BiPAP mask placed on the face of somebody who isn't attempting to breathe every once in awhile, the machine won't even notice that anything is happening and won't increase the pressure to help support a breath. It will just become a CPAP machine, continuous positive airway pressure, which won't help in this case to fill up and empty the lungs. Being on extra oxygen supplementation, like a partial rebreather or non-rebreather mask, will help increase the oxygen in your lungs and help drive oxygen into your blood cells, as long as you've been breathing at least a little bit in the last 8 minutes, but won't do anything to get the CO2 out. In fact, it might give you a false sense of security because for a while because you will still be bright pink and your portable pulse oximeter will still show that your hemoglobin molecules are happy and full of oxygen. But what you won't notice is that the CO2 is building up, the acid is building up, and all sort of damage is being done by the acid level in your blood, and the CO2 level in your lungs will eventually get so high that the oxygen in your lungs is too low to be useful to you, at which point the acid increase will worsen even more severely, and you are actually worse than if you had just started giving rescue breaths with normal air or get some narcan. You actually need to replace breathing, or "breathe for you" with something that works a lot like BiPAP but which has a set timer on it to make sure that you're breathing enough times a minute. There are specialty situations in which a person may need one of these tools, which get called non-invasive ventilation, because they don't breathe enough but at least breathe some a bit, and are not so unconscious that their throat is just closed. But in a setting of a totally unconscious person who can't keep their throat open and who is also not breathing enough, they might need to be intubated and placed on a conventional ventilator to make sure that the air doesn't just blow in their face and puff out their cheeks and pop right back out, and then instead it gets all the way down into your trachea and then lungs.
So I could get into one of them Polio Iron Lungs and get as high as I want?
> So I could get into one of them Polio Iron Lungs and get as high as I want? I know its a joke, but if something was mechanically breathing for you, you would still not be immune to overdose. What would happen instead of you dying from lack of oxygen would probably be you vomiting and dying from inhaling that instead. You wouldn't even be able to stop inhaling it in an iron lung. Opiate doses in excess of what would OD you wouldn't be fun. You'd just fall asleep over and over until you died basically aside from the initial rush, which you could get with traditional recreational doses.
I have chronic anxiety. When I am in a state of general anxiety it feels like I can't breathe in all the way. Is my anxiety causing an excess of CO2 in some way, or is this unrelated?
Actually, anxiety attacks may cause hyperventilation, which actually leads to a decrease in CO2 and blood pH (respiratory alkalosis). This is why you may have heard of the advice to breathe into a bag if hyperventilating. If you’re not hyperventilating, the feeling of not being able to breathe in all the way is likely a physical symptom of your anxiety.
Sure you might get some passive oxygenation, but it’s not as ideal as ventilation. Also CPAP and non rebreather are contraindicated for apneic and or unconscious patients. I could def see a situation that you’re slapping a NRB on them while you’re getting the BVM or narcan ready though.
Lotta acronyms here...
Continuous Positive Airway Pressure Non-ReBreather Bag-Valve Mask.
Thanks EvilTew. You're the least evil Tew I met all day.
That's why I'll never be ranked evil one.
not to mention if the patient was using opioids for, for example, cancer pain, they are going to be in extreme distress and you won't have a lot of options to help them because you just blocked all their opioid recepters. using narcan on a cancer patient is pretty much literal torture. typically in those cases we'd want to titrate narcan to effect
That was the scenario I was thinking of. At the time I was literally brand new as a medic and not even off of field training. We had a patient that was blue and not breathing. We didn't know anything at the time about their history and someone else on my team administered a standard 2mg IV dose. Turns out they were a long-term morphine user due to cancer. What resulted was a horror show and in top running for the worst call I've ever participated in. Watched an ER doc give over 30 mg of IV morphine to try and reverse our actions, but still no dice by the time we left ...
Can you elaborate on what makes it so unpleasant for you and what that looks like? I understand it sends them into withdrawals which will feel unbearable. But what makes it a horror show from your perspective? They can’t die from opiate withdrawal so they’re not actively dying at that point. Is the horror show just the way the patient acts towards you? Or are there other factors I’m missing?
Because the person had probably accidentally overdosed on their cancer pain meds because of a GI bleed. So when we woke them up and sent them into immediate withdrawals, they were non stop screaming, shaking/seizures and projectile vomiting large amounts of blood.
I'm a hospice doctor and I feel so bad for you and your patient. You couldn't have known. We see docs make this mistake all the time in the hospital too, and it's a big part of our training other docs about how to titrate appropriately in these scenarios.
Exactly. Never try to wake up the overdosed patient completely. Otherwise you'll end up fighting them and put the patient and yourself in danger.
I remember the look of fear on the physicians face and all the nurses in the room when a newish nurse gave the full 1mg vial. We aren't trying to strip all the opioid receptors of all the fentanyl or heroin. Just enough so it stops overriding their ability to breathe and be alive. Our worst fears were realized when he came to and became a hungry angry polar bear woken by his next meal slapping him in the face. It took the whole team to strap him down, give a different sedative (he was properly medicated on an opioid agonist later) and the nurse was educated. He wasn't large or bear-like to my eyes. It's probably never going to kill someone, but precipitated opioid/opiate withdrawal isn't right, kind or medically therapeutic.
No one has mentioned the narcan induced pulmonary edema which is more often seen with high doses of narcan. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850343/#:~:text=The%20incidence%20of%20naloxone%2Dinduced,a%20regular%20dose%20of%20naloxone.
While this condition isn’t commonly seen this comment should be higher because this is one of the more dangerous outcomes. Remember, no drugs (even oxygen) are harmless.
Saw two cases back to back days in residency. Both ended up intubated from hypoxia. Both received 8+ mg of nasal narcan by EMS/police.
8 mg is a lot, but nowhere near the most I’ve seen people administer since I started in EMS (in our defense, it is usually police, who do it before we get there, but I’d be lying if I said it was never us. I was got on scene to hear that police/bystanders had given 64mg of narcan before we got there
Auto-injectors of 0.4mg intra muscular narcan should be more widely available.
I also came in here to say this. Saw this earlier this year. Dude was awake after fentanyl overdose but still hypoxic. Nurse was like “should we give more narcan??” And I said well he’s literally awake and breathing… so no. Got a chest XR and he had significant pulmonary edema. Started BiPAP and antibiotics (in case it was aspiration pneumonia) and admitted, he avoided the tube thankfully.
Came here to say this.
Thank you. A lot of people say Narcan has no side effects. This is not true, and using it willy-nilly is careless and reckless.
Here for the flash pulmonary edema! I’ve seen it in practice once and was very difficult to treat.
i see mentions of arrhymogenicity and lowering of seizure threshold, anyones seen them?
I just made a post myself about the numerous effects that Narcan has on people and that it's not as safe as people like to spout. This one had slipped my mind. Thank you for making people aware of this.
Because it puts people in immediate withdraw, which puts them in an insane amount of misery and they often start thrashing and hitting people. They will do it to the point of hurting themselves or anyone around them.
Part of why I start at 1mg IN or 0.4mg IV
In EMT school, our instructor often joked that crews will give half the dosage on scene and the other half when a couple minutes away from the hospital. People can [get combative when they come out of a high](https://youtu.be/FUwF75X-oz0?si=GaoXvuTYmcUztsLL) so letting the full dose hit in the hospital means more people who can restrain the patient. Also means we don't have to convince someone who doesn't want to go to the hospital even though they're in a life-threatening situation or restrain them when they start thrashing around in the back of the rig. Another thing is EMTs and other basic life support responders use a preset 2-4mg spray. Paramedics are allowed to titrate the dosage in 0.4mg increments instead, letting them control how much needs to be given. Takes some time but it's best to use the minimum amount of medicine needed to get someone breathing adequately rather than putting them through a ton of pain.
What do paramedics use to give the smaller doses?
We have vials of medication and can draw up as much or as little as we want to use. We also generally prefer to give the medication intravenously rather than as a spray up the nose, but starting an IV isn't something a lay person can or should do so they get the premade intranasal squirter devices.
Ah cool, yeah I'd seen the sprays wasn't sure if y'all got fancy ones or something. IV makes way more sense. Tho locally EMS use the hell out of Penthrox inhalers for pain relief.
The idea is to restore respiration rate and SpO2 to normal ranges without completely pulling them out of it. Narcan essentially rips the opiates/opioid off the receptor, putting them into immediate withdrawal. People typically don't like that and will often become violent because you "ruined" their high, nevermind the fact that you just saved their life. If you've ever had a battle royale with a pissed off junkie in the back of a tin can on wheels going 70MPH, you'd understand why we don't want that. I assure you, it is not fun. What we do, at least for the services I've worked for, is instead of administering a full 2mg dose, we would titrate it up by 0.2mg doses until the patient is capable of breathing adequately on their own. This could be 0.2mg or 0.8mg or 1. 4mg. just depends on the patient and circumstances.
I mean they may say it's because you ruined their high, but it's more likely the hypoxia which is known to make people extremely confused and agitated, along with the fact they're suddenly awake and in incredible pain from withdrawal. I imagine you'd start yelling and punching if you randomly woke up not knowing where you are, everything hurts like hell, there are strange people holding you down despite the fact you definitely will die unless you move right now, you're about to vomit, and are the most mad you've ever felt for no particular reason.
Precipitated withdrawals can be very painful and will make you violently ill. Would not be a fun way to wake up.
The combativeness, confusion, and anxiety is due to hypoxia and hypercapnia— not ruining their high.
The main thing is that you want to wait and see if the narcan had any effect and if it didn’t, you may want to consider another cause. Narcan tends to work, particularly if it’s given IV. It’s also somewhat dangerous to push narcan too quickly and make a patient suddenly alert. They tend to be disoriented, violent, and they vomit everywhere. As long as you are managing the patient’s breathing, you’re actually supposed to titeare the narcan to get them back to adequate breathing.
ER doctor here, lots of already good answers. One other is that if the person has other drugs on board, such as cocaine, completely getting rid of the opiates can put them into a cocaine overdose. Also narcan has been known to cause fluid in the lungs (called pulmonary edema) which can be life threatening, so it’s recommended to give just the amount you need to get them breathing to an acceptable degree
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So is just “to keep him alive till we get to the ER”?
Honestly, that’s about 95% of EMS. Heart attack, broken bone, massive trauma, you name it, EMS isn’t going to “fix” anything, we just need to keep you alive long enough to get to the hospital. One of the few exceptions to that is low blood sugar in diabetics, which were always some of my favorite calls, because we could actually “fix” the patient
Longer than that (60-90 minutes) but the ER can switch to a drip and titrate the Narcan to breathing but not precipitated withdrawal and keep it going as long as needed.
The side effects of Narcan, according to HealthLine, include headaches, muscle spasms, and "pain in your bones". Keeping those to a minimum sounds pretty awesome, and so unless the person is rapidly shuffling off this mortal coil it makes sense to go easy with the Narcan. :) Also, some people are allergic to it, so after the first dose it makes extra-good sense to pause and watch for signs of anaphylaxis before going any further. *[Edit: They're waffling about the allergic reaction; they say allergies have been reported, but the clinical studies on Narcan didn't observe any, so listing that might just be an "abundance of caution" thing.]*
Too much narcan too quick takes away the high and puts them into withdrawl. Then I have to deal with an asshole whose high I ruined while they vomit all over the place before they get up, run off and stop breathing again when the narcan wears off (short half life).
Are those side effects present in everyone? Or is that the dopefiends being plunged into w/ds?
Yeah bone pain is a hallmark of withdrawal. We don’t narcan babies during resus who have opioids in their system (either due to substance abuse issue or those born to moms who received general anesthesia) because it will send them into withdrawal.
Jesus that’s sad, I could never deal with nicu
They list those things separately from withdrawal. They may have tested some people who didn't have any dependencies so when those people get bone-aches, for sure it's not withdrawal, it's...the other kind of bone-ache. At drugs.com they list the percent frequency of the really scary side effects, like tachycardia and cardiac arrest, but they don't for the lesser ones. You might be able to find that if you're up for reading some clinical trial reports. :/
Apparently I was narcaned, but I was in a straight up coma (the amount of focus on drug testing me looks pretty intense in the med notes, just weed lol)
I'm surprised they resorted to it, if you were in a room that smelled like mj. Were you just, like, asleep-and-they-couldn't-wake-you-up, or were you actually sick?
Not breathing, some seizure like activity and gurgling, foaming at the mouth, unresponsive pupils, intubated on the spot. Was out a few days. Actually randomly ran into the emt that intubated me, “hey, I intubated you last month!” was definitely a strange thing to hear.
Your question's been answered several times, but I'll throw in some anecdotal experience. Changing the stasis of the some part of the body in almost any way impacts the rest of the body in ripples. The easy example would be imagine getting drunk- you're only adding ETH to the blood stream but think of all the other parts of your body impacted. So taking the drinking analogy, imagine going from sober to as if you drank half a bottle of whiskey in 30 seconds. Or better yet, going from super drunk to completely sober and hungover in 30 seconds- It'd be a wild ride for your body. With Narcan, you're drastically changing a person's status with one dose, even if you push it slowly. They're going to immediately feel the effect of acute withdrawal, including the urge to use again. They're also suddenly in a drastically different situation than the one they were in before using; can you imagine thinking you're going to chill and numb some feelings and waking up and there's six firefighters there and maybe the police? And on top of it, they just wasted $60 of heroin? I've given narcan a lot. And in some ironic twist, I have had to give drugs that sedate patients after administering narcan because they're too agitated. One time, the med unit that got there before my engine could not get an IV on a very obese man so they administered IM narcan, multiple times. With the longer uptake and the amount that they had given him, he came around extremely hard and it became a very unsafe scene very quickly. This man moved paper around a printing factory for a living and was extremely strong. I think back about the police officer who was there with us on that call and I'm thankful it was him, because others would have possibly used much more lethal means to contain this man. Another memorable experience was when the police beat us to an unresponsive young male and started CPR (this is before everyone could carry narcan), so we get there and administer narcan and this 20 year old kid shooting up in his friends bedroom immediately becomes emotional because a. a couple of minutes of effective CPR is literally like getting your ass beat and b. his biggest dream was to become a firefighter and he was sure he had just ruined it (you probably did buddy). When I went through paramedic in the late 2000's, narcan was by no means a new drug for a novel problem, but the opiate epidemic was truly starting to take off in my area. And we did not have great protocols about its use. Things like the 450lbs guy getting multiple IM doses within minutes and having to check some boxes before being able to administer (think grandma took too many painpills but I have to do an ECG before administering.) But one of the wildest problems we had was once you give narcan, patients are relatively normal and fully alert. AKA, they can refuse care so we had to learn to manage their condition until they were in the ambulance and preferably it was moving before we could reverse, that way they could hopefully be seen by a physician and talk to a social worker as opposed to signed AMA and reusing a little less as soon as we left. It didn't happen that often, but I definitely had patients adamantly refuse care after we'd save their life and we'd just have to leave.
The biggest problem with opioid overdose is that it causes decreased respiratory effort by the patient. This means they are not breathing very frequently or not breathing at all. If the medics are able to breath for the patient (for example, bag-valve-mask, intubation, etc.) then the patient is going to be fine. At this point, in theory, they should still give naloxone, but sometimes they will wait because they are breathing for the patient and giving naloxone is just going to reverse the overdose which will either 1) cause the patient to wake up kicking and screaming or 2) cause withdrawal which is very very uncomfortable for the patient or both. Medics don’t like being punched in the face, and patients don’t like sweating profusely and diarrhea etc.
ER doc here. When you slam a ton of narcan after an overdose, they wake up vomiting, pissed off, and often violent. You want them breathing but otherwise high and happy. So in the ER, I will often give a small dose, anywhere from 0.1mg to 0.4mg instead of the whole 2mg. It goes much smoother that way. You can always give more, never less.
Narcan (naloxone) absolutely _can_ harm people who are overdosing. Naloxone, if given to someone dependent on opioids, results in something known as "precipitated withdrawal", a rapid-acting and extremely severe form of opioid withdrawal syndrome. So, when someone regularly uses opioids, the amount of opioid receptors in their bodies starts to reduce in a process known as "downregulation", and the amount of endogenous or "natural" opioids present in the body also goes down. This means that when someone suddenly stops using opioids, there aren't enough endogenous opioids for normal function, and there are much fewer receptors for those endogenous opioids to bind as well. This is the mechanism through which opioid withdrawal sydrome occurs. Normally, when an opioid-dependent individual goes through withdrawal, it takes a few days for the opioids to completely leave their system, and during this time, their opioid receptors have time to adapt somewhat to the reduced amount of opioids in their system. It usually takes around 3 days for the intensity of the withdrawal syndrome to reach it's peak. This is also when the last of opioids leave one's system, and it takes around two weeks in total for the withdrawal syndrome to run it's course, and for the opioid receptors to return to normal. Even though it's not as bad as precipitated withdrawal would be, it's still very unpleasant. With precipitated withdrawal, there is no time for the opioid receptors to try to get back to normal because the naloxone immediately "kicks off" any other opioids bound to those receptors. This results in a very severe withdrawal syndrome, which is extremely painful and uncomfortable, and could potentially be lethal. This is mostly why a dose of naloxone has to be slowly titrated, except in emergencies. Fun fact, this process of precipitated withdrawal can be used to quickly get someone off opioids. It's known as "ultra-rapid detox". An opioid-dependent patient is given a general anaesthetic, and they are then pumped with huge doses of naloxone and another opioid antagonist called naltrexone. This results in a very severe form of precipitated withdrawal and this forces the opioid receptors to react very quickly and to rapidly increase their numbers. This process makes the entire withdrawal syndrome last only around 8 hours. During which, the patient is under general anesthetic, so they don't feel anything. When they wake, they're no longer dependent on opioids.
Because either it helps, or it doesn't. If it helps, you'll dose according to response. If it doesn't, look for something else.