Dear Editor, I am writing in response to the article ‘Treating the unexpected: the opiate overdose patient’ (Willis, 2010) which I found very interesting as it highlighted a number of aspects in appropriate and ethically sound treatment of the opiate overdose patient and also the difficulties that ambulance clinicians face in delivering such care.
I was intrigued about the discussion regarding the use of Naloxone Hydrochloride (Narcan). The author stated: ‘Those patients who are physically dependent on narcotic drugs are at risk of violent withdrawal symptoms and so the IV route is preferred under these circumstances in order to keep the patient in a groggy state’ (Willis, 2010).
I agree with this theory but in my experience, intravenous cannulation in the field of a known opiate user has many additional risks which need to be considered. The intravenous user may be at a greater risk of contracting blood borne diseases such as hepatitis and HIV through the sharing of syringes. This creates an additional risk to the paramedic who decides that IV cannulation is appropriate.
After the consumption of alcohol and/or drugs, the seemingly comatose patient receiving the pain associated with the insertion of a cannula may suddenly wake and lash out during such an intervention.
Therefore, the paramedic needs to adhere to their PPE policies strictly and proceed with caution to minimize the risk of an accidental needle stick injury, especially if they are single responder.
Secondly, I agree with the fact that the IV administration of Narcan, tailored to response would give a more controlled effect. However, the intramuscular route does allow for a slower, if somewhat uncontrolled release into the circulation.
It is not uncommon for users of opiates to refuse care and transport to hospital on regaining consciousness and I personally have had experience of such patients refusing for the cannula to be removed so that they are later able to use this as a port to inject heroin.
The principle of nonmaleficence is relevant here i.e. given the existing problem, would it be better not to do something than to risk doing more harm than good? Was I to know that the patient would later potentially be administering lethal doses of heroin through a cannula that I had sited? Possibly not. This is why I would argue that sometimes a loading dose of Narcan given intramuscularly may be more appropriate.
It is very difficult decision though as no practitioner is able to predict the temperament or intentions of the patient on regaining consciousness.
The article later states that the patient was treated using 800 mcgs of narcan and had the drug delivered intramuscularly because the patient's respiratory rate had dropped below that compatible with life and that they were GCS 3.
The choice of drug route may have been appropriate because it can be prepared relatively quickly and administered safely. However, in a patient that may have consumed alcohol, benzodiazepines, opiates and possibly more who is now bradypnoiec and GCS 3, I would have thought it to be important that IV access is sought as the patient is now in a peri-arrest state.
Rapid reversal is sought in such circumstances, which is most easily gained through the IV administration of narcan as the drug is immediately available in the circulation.
Obviously you would need to address any airway and breathing problems first which you did by assisting ventilation with a bag-valve-mask but you would then also have a port to administer IV fluids to address shock for example, and other drugs as required.
In conclusion, the choice between IM and IV administration of narcan is very subjective with many issues that need to be considered both in the patient and circumstances.
The users of opiates and other drugs for that matter can be a very unpredictable patient group so the ambulance clinician needs to use their knowledge and experience and practice caution in their decision-making and treatment choice.