Now days, it seems like everyone has Narcan… EMS, fire, law enforcement, jail and prisons, random business owners, even the general public, everyone has Narcan. There seems to be a shared mindset, that there are no side effects or consequences to giving Narcan. If someone is having an opioid overdose, Narcan might help reverse the effects of it, but if they aren’t, then Narcan won’t do any harm. That is not true at all. There are consequences to every intervention and medication we do for our patients.
It is not uncommon for us to arrive on scene, and someone has given the patient an excessively high dose of Narcan. If 2mg is good, then 4 must be double good. So, 10, 14, 20mg must be superhero levels of good, just give the patient more and more. It is possible to overdose on Narcan, and it can cause some very serious medical issues.
“Narcan-induced noncardiogenic pulmonary edema is a rare but reported entity that can occur following naloxone use in the reversal of opioid overdose. Proposed mechanisms include an adrenergic crisis secondary to catecholamine surge which causes more volume shift to pulmonary vasculature, subsequently leading to pulmonary edema. It appears to be more common when higher doses of naloxone are used.” (NIH, 2021).
Narcan use in young children can even cause seizures, that can become life threatening for the child. There are definite consequences, and we need to think about these. Does the benefit outweigh the risk? When you give any medication, it takes times for that medication to start working. Sometimes the onset is quick and sometimes it’s a little slower. I had a patient recently who got 16mg of Narcan intranasally, in less than 5 minutes prior to my arrival on scene. The effects of Narcan typically begin within two minutes when given intravenously, five minutes when injected into a muscle, and ten minutes as a nasal spray. This means that it takes time for Narcan to start to reverse the effects of an opioid… if you give it and your patient isn’t having any improvement, you probably need to wait a little bit before you give more.
As of 2020, the American Heart Association has stated that when it comes to Narcan, we need to resuscitate before we medicate. That means that if your patient is in cardiac arrest, giving Narcan will not do any good. We’ve all seen the movies and TV shows when someone goes into cardiac arrest due to an overdose, they shoot Narcan into their nose, stick it in a muscle or into a vein, and the patient instantly wakes up, but that is not real life. It doesn’t work that way. If their heart is not pumping, if their blood is not circulating, the drug is just going to sit there, wherever you put it. We need to get their blood flowing, get some high-quality chest compressions going before we give them any medications, otherwise we will not see any effect of the medication.
When giving Narcan, our goal is not to completely reverse their high. We don’t need them waking up, ready to fight, or projectile vomiting on us. Our goal should be to improve their ABCs…. They should be breathing adequately on their own, and their cardiac output should be sufficient to perfuse their body. If we can also improve their mental status, that is good, but as long as their ABCs are good, that’s truly all we should be concerned with. No more, no less. We typically do not need a high dose of Narcan to achieve this goal. That’s why we generally start at a dose of 0.4 to 2mg. Give that some time to work. Sometimes we need to administer more, but remember it takes time for the medication to do its job. Don’t overdose the patient just because you are too impatient to wait, or you think more is better.
References:
NIH. (January 26, 2021). Naloxone induced pulmonary edema. NIH: National Library of Medicine, National Center for Biotechnology Information.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850343/
