December 20, 2024

Welcome to EMS-I’s Pharmacy Phriday. As we push through the winter weather and prepare for the holidays, we should also prepare for some related calls that come with this season. One of those calls involves the overdose of narcotics. 

“Opioid use disorder can be an unwelcomed guest during the holiday season. Holidays can be a stressful time of year, especially when there is family tension, financial strain, loneliness, grief, or seasonal affective disorder looming around. As a result, many individuals turn to their addiction as a crutch to help them through the holiday season. According to the CDC, the most dangerous time of the year for drug-and-alcohol-related deaths is during the holiday season, specifically December and January.”1 

Our recognition and diagnosis in these emergencies are important as a specific antidote is available for use. Beyond the provider’s observations of the scene, recalling the classic triad of opioid overdose is beneficial. These signs include: 

• decreased respirations 

• a decreased level of consciousness 

• constricted pupils  

Opioids, such as heroin and Fentanyl, easily attach themselves to opioid receptors found in the brain and continue to affect the patient as long as they are attached. The presence of these opioids causes CNS depression and decreased respiratory drive. Due to the elevated CO2 levels from hypoventilation, unconsciousness follows. 

Remember: the primary treatment for such a circumstance is assisted ventilations with a BVM! Supplemental ventilations should correct the CO2 levels, and the patient should regain consciousness. Naloxone is then administered to improve the patient’s respiratory drive and avert the need for invasive airway measures. 

Naloxone will dislodge the opioids, blocking the effects of the drugs. The patient should start ventilating normally again, reducing CO2 levels and consciousness should return. The dosing of Naloxone is essentially titrated to the patient’s respiratory drive. The goal of its use is to reverse hypoventilation, not to reverse all the effects of the opioids fully. The complete reversal of the opioids can often create an agitated, combative patient that is difficult to control. If the patient is breathing normally but drowsy, Naloxone is not needed. 

Once again, the dosage for Naloxone is titrated to effect and can start as low as 1 mg via the IV/IO/IM route. Within the Medications section of the UH protocols, the Naloxone dose is listed as 2-4 mg IV, IM, or IO, repeated every 2 minutes to a maximum of 12 mg. Intranasal administration is an option and is also used by basic EMTs. For the Advanced or Paramedic provider, it is a slower route, and it is harder to titrate the dosing via the nasal route. For the pediatric patient, the dosing is 0.1 mg/kg to a maximum of 2 mg per dose or 1 mg IN. Again, the dosing can be repeated every 2 minutes to a maximum of 12 mg.  

Many texts and resources recommend the optional routes only when an IV line is not available. The IV route, though it requires time to establish, can be the most effective route and allows the medication to be titrated to the desired effect more reliably. Ideally, patients can receive additional doses (1 mg IV max is recommended) as ventilations begin to decrease or ETCO2 begins to increase. If withdrawal symptoms occur, chemical sedation is recommended. 

If any patient fails to respond to the Naloxone, the provider should continue to assist ventilations and consider other possible causes of the unconsciousness. Monitor ventilations and ETCO2 and respond to any changes as the effects of the Naloxone wear off. Expect the need to titrate the use of Naloxone and assisted ventilations as the duration of Naloxone is often less than that of the opioid abused. This point also supports the importance of transporting any suspected overdose that is alert and oriented following the administration of Naloxone, be it from EMS, another first responder, or the public.

As we close, we would like to wish you and yours the happiest of holidays! Stay safe!

Sincerely, 

The UH EMS-I Team 

University Hospitals 

Source:  

1. Opioid Use During the Holidays - Pinelands Recovery Center of Medford 

April 7, 2023

Dear colleagues:

Welcome to UH EMS-I Pharmacy Phriday. Recent headlines regarding the availability of Narcan as an Over the Counter (OTC) medication initiated this week’s review. Seen as a critical tool in addressing opioid overdoses, efforts have continued beyond Project DAWN and other programs to make Narcan accessible to those in need, and the FDA has responded.

Opioid overdose remains a significant problem in the United States. In Ohio, the administration of Narcan by EMS providers peaked in 2017 but has consistently remained high since, with over 38,000 doses administered in 2022. Unfortunately, UH EMS coverage areas are a significant part of the top counties with cases in Ohio. Nationwide, the overdose crisis has been linked to more than 100,000 deaths a year.

To reduce deaths from opioid overdoses, Narcan was made available through community groups and pharmacies without prescriptions. Last month, the FDA approved the 4 milligram (mg) Naloxone nasal spray medication for over-the-counter sales. Locations that one can access Narcan now may include stores without pharmacies, such as convenience stores, grocery stores, gas stations, and online sites. Some of the thinking in this move is that putting the medication out on the shelves allows individuals to obtain it without any stigma attached. Manufacturers hope to make the nasal spray available in these additional sites by late summer. However, there are still many questions as to how many stores will carry it and what the prices will be. 

Narcan is a narcotic antagonist (inhibits the physiological action of opioids like fentanyl, carfentanyl, morphine, etc.) provided in our UH drug boxes as a prefilled syringe or a nasal spray. When administered, the medication will compete for opiate receptor sites in the brain as well as displace opioid molecules from the receptors. The goal of giving Narcan to the overdose patient is to improve ventilation, not a complete reversal of the opioids. This can cause severe withdrawal symptoms such as aggression, tachycardia, in some cases, pulmonary edema, and possibly cardiac arrest. In fact, acute withdrawal is the most common adverse effect of Narcan. 

The dosage for Narcan administration per the UH protocols is 2-4 mg IV, IM, or IO, repeated every 2 minutes to a maximum of 12 mg. Intranasal administration is an option and is also used by basic EMTs. For the Advanced or Paramedic provider, it is a slower route, and it is harder to titrate the dosing via the nasal route. For the pediatric patient, the dosing is 0.1 mg/kg to a maximum of 2 mg per dose or 1 mg IN. Again, the dosing can be repeated every 2 minutes to a maximum of 12 mg. If the patient fails to respond to the Narcan, the provider should consider other possible causes of the unconsciousness.

Many texts and resources recommend the optional routes only when an IV line is not available. The IV route, though it requires time to establish, can be the most effective route and allows the medication to be titrated to the desired effect more reliably. Ideally, patients can receive additional doses (1mg IV max is recommended) as ventilations begin to decrease or ETCO2 begins to increase. If withdrawal symptoms do occur, chemical sedation is recommended.

It is worth noting that Narcan is not the first line of treatment in the suspected opiate overdose. Following the proper use of PPE, assuring adequate ventilations with the BVM is the priority. The opiate overdose patient is unconscious due to hypoventilation and increased CO2. The best and fastest way to treat this condition is ventilatory support! Our #1 priority should be ventilation, bagging the patient to a normal ETCO2 (35-45). Only after ventilations should the provider consider Narcan. 

Following treatment and resuscitation, the goal should be to transport all opioid OD patients. The half-life of Narcan is about 2 hours, and depending on many factors, the patient can relapse into unconsciousness. After the Narcan wears off, the opioids may again attach to the receptors in the brain. Another advantage to the transport is the fact that the patient can be referred to outpatient resources for addiction treatment, provided suboxone before leaving the Emergency Department, or in some cases, admitted for further treatment and evaluation. Statistics indicate a high one-year mortality rate for patients that have overdosed using opioids.

Considering recent OTC approval by the FDA, it is also important to remember to ask about the use of Narcan or other treatments prior to EMS’ arrival and to document them accordingly. 

Till next week, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

September 5, 2022

Dear Colleagues,

In the past several years, Naloxone, or Narcan, has become a medication easily recognized by the public. With the passage of the Naloxone Access Law, anyone can purchase Narcan spray at any pharmacy without a doctor’s prescription. It’s not uncommon for law enforcement officers, schools, and community organizations to carry the life-saving drug.

Project DAWN (Deaths Avoided with Naloxone) is an opioid education and Narcan distribution program created by the Ohio Department of Health. Its acronym comes from Leslie Dawn Cooper, the victim of a fatal overdose in 2009. Although it was witnessed, there was no medication available at the time. The program has now grown to over 340 Naloxone distribution sites in the state.

Opioids, such as heroin and Fentanyl, easily attach themselves to opioid receptors found in the brain and continue to affect the patient as long as they are attached. Narcan can dislodge the opioids, blocking the effects of the drugs. As you would expect, this treatment does not last long, and its effectiveness depends on the amount of opioids in the system.

Signs of an opioid overdose include decreased respirations and level of consciousness, as well as constricted pupils. The UH protocol allows the titration of Narcan to improve the respiratory effect rather than to restore full consciousness. It may induce serious withdrawal symptoms in patients who are opioid dependent, resulting in violence or agitation.

The dosage is 2-4mg IN/IM/ IV or IO. Intranasal is preferred for the speed of the first dose and is the only option for basic EMTs. However, subsequent doses should be given by other routes when the nasal route is ineffective. The medication is generally repeated every 2 minutes as needed, with a maximum dose of 12mg. 

It is safe for pediatric patients, and they normally receive 1mg IN or 0.1mg/kg IM/IV/IO. Children also have a maximum of 12 mg.

Till the next time, stay safe!

Sincerely,

The UH EMS-I Team

University Hospitals