ANDERSON

Randall K. Anderson
B. Ecker
April 20, 2019

Paramedics Abuse Narcan

And not in the way you would think

Before I get started, I first should explain exactly what Narcan is, for those of you that are

uninformed.

Narcan, or naloxone, is an opioid antagonist. It works by displacing opioids from receptors

in the patient’s brain (and GI tract, etc.). When administered to someone who has overdosed, the

Narcan reverses signs and symptoms associated with opioid overdoses such as depressed

respiratory drive, pinpoint-pupils, and decreased mental status.

In an opioid overdose, the real killer is respiratory depression. The patient’s respiratory

drive, or physiological will to breathe, is severely diminished, sometimes to the point of cessation.

While the patient does not always die from the hypoxia (lack of oxygen) that occurs, causing

profound cyanosis (blue-hued skin), after 6-10 minutes without adequate respirations permanent

brain injury is common.

Being an opioid antagonist, Narcan will only be effective against opiates (opium, morphine),

opioids (heroin) and synthetic opioids (fentanyl), descending in effectiveness in that order. Narcan

will not be effective in any other setting, and has no effect on an individual not under the effects

of opioids.

I believe that paramedics are the worst abusers of Narcan, and will prove it in the following

pages. When I say that paramedics “abuse” Narcan, I mean that they often administer the

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medication when it is completely uncalled for. They do this for a number of reasons. According

to long-time firefighter/paramedic and Assistant Chief, Patrick Fink, this is a complex and multi-

faceted issue.

“A lot of guys use it as a weapon” Assistant Chief Fink explains; “you’ve seen ‘em do it;

slam six milligrams to cause pain. Make ‘em throw up.”

Assistant Chief Fink is talking about administering the drug rapidly, sometimes called

slamming. With Narcan, slamming the drug intravenously will cause an instantaneous, violent

reversal of overdose signs and symptoms. This can cause the patient to vomit, often accompanied

by cramps and a dissociated haze. The experience appears to be unpleasant and painful; with

their receptors immediately stripped of any opioids, the patient begins to rapidly experience

withdrawal. In the best conditions, intravenous Narcan is pushed slowly. This allows for a more

mellow reversal of symptoms.

At the other end, some paramedics may not necessarily want to inflict undue suffering upon

their patient, but they need the psychological validation that reversing an overdose provides.

EMS is largely a thankless job; the hours are long, the pay is disproportionately low, and the

skill required is high. Paramedics are often treated poorly by the public and hospital staff, alike.

Most EMS providers work multiple jobs while attending school, all while staying out all night on

the ambulance. Burn out is very real.

At the end of the day, paramedics can treat very few problems as dramatically and

effectively as heroin overdoses. When you revive someone that has had a heart attack, they

typically do not regain consciousness, and ultimately, die several days later in the hospital. When

treating a stroke, paramedics are mostly just providing support until a doctor can remove a clot.

Even in the big, scary, pulse-pounding traumas they treat, they are little more than blood

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plumbers; stopping leaks with quick fixes. Bubble gum and popsicle sticks. Paramedics even have

a saying for patients that are beyond their capabilities “they don’t need us, they need bright lights

and cold steel."

But giving Narcan for an overdose? EMS providers can see the fruits of their labor

instantly. Typically, the patient transforms from a pale-blue, non-breathing, heap into a walking,

talking person with very little time or effort. “99% of the time, you don’t really make a

difference” Chief Fink advised, “When you give Narcan, you feel like you made a difference. You

can see it”

But the Assistant Chief advised that there is a third, and perhaps worst, party that exists in

the Narcan abuse game: lazy EMS providers.

“We’re lazy, it’s easy to do and doesn’t take any skill” speaking to the relative ease of

administering Narcan. He continued “Like using King Airways (a quick, easy, yet less effective

airway device) and IOs (pretty much a bone IV. Easy, fast, and hard to miss) right away in cardiac

arrests. People are afraid of using their skills. (with Narcan) You stick a MAD up their nose and

it’s done.” A MAD is a mucosal atomization device. It atomizes the medication into a fine mist

that can be delivered intranasally.

Aside from the abuse, Assistant Chief Fink expressed concern over another facet of relying

to heavily on Narcan; mistreating illnesses. “We keep pumping people full of Narcan, when

they’ve actually had a stroke.”

Many illnesses can display similar signs and symptoms. Overdoses, alcohol poisoning,

strokes, diabetic emergencies, and postictal seizure activity all look fairly similar to the untrained

eye. A lack of understanding of each individual illness and the associated, unique, traits can have

deadly consequences.

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He goes on “We have gotten away from BLS (basic life support) and want to go straight into

ALS (advanced life support) and IVs.”

Assistant Chief Fink suggests that there is only one clear remedy; “training, training,

training.”

As a firefighter/paramedic and captain of a city department, I have seen a lot of the same

scenarios described by A.C. Fink. I have seen people load up an unconscious patient with

Narcan, employing the mindset that “they’re going to walk to the ambulance. I’m not carrying

this junkie anywhere.” Such attitudes are corrected immediately.

It is easy to lose sight of the fact that opioid addicts that have overdosed are no different

than the heart attack patient that has abused BigMacs for the previous three decades; they are

both victims of their own choices. They were both fully aware of the risks, and indulged anyway.

The ironic, glaring difference is that opioid overdoses create far less, lightyears, even, less strain

and financial burden on society than over-eaters. That, however, is an entirely different research

paper of its own. Our society has assigned a hierarchy of acceptable vices, despite the fact that

gambling, drug use, alcoholism, and obesity can all have similar consequences.

In some settings, however, it is easy to see why the fatigue of constantly caring for overdose

patients would have a lasting, negative effect on a paramedic’s mind. The 2017 Netflix

Documentary directed by Elaine McMillion Sheldon, Heroin(e), follows Deputy Chief Jan Rader

(Huntington, West Viriginia) as she handles the multiple calls for help every day from heroin

addicts and their families. Her city is mired by addiction and poverty, and the calls, frequently

repeat offenders, clearly weigh heavily on her psyche.

In the documentary, Deputy Chief Rader and her crews appear almost numb to it all. In

several scenes, they can be seen treating victims as daily life continues on in the background. It is

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a good portrayal of how little the general public actually knows and understands the nature of

addiction, and how easy it is to become frustrated.

The dangers of “slamming” Narcan

In line with my reasoning is Dr. Bryan Bledsoe, DO,FACEP, FAEMS. Dr. Bledsoe illustrates

in his article in JEMS magazine, The Weaponization of Narcan, that EMS is too heavily dependent

upon the wonder drug., and too quick to use it with negative intentions

According to Dr. Bledsoe “Certainly, there is a role for Narcan, in limited cases. But this

widespread use is ridiculous.”

Dr. Bledsoe suggests the EMS providers instead focus on airway control. As we discussed

earlier, the primary danger associated with opioid overdose is respiratory depression. If you

provide adequate artificial respiratory assistance, via bag valve mask, you can keep a patient alive

until are is transferred to the hospital staff.

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In defense of easing down the use of Narcan, Dr. Bledsoe argues “There are several issues

with the empiric use of Narcan. First, many of these opiate overdoses are in patients who are

opiate-dependent. Giving Narcan will block numerous opiate receptors causing the patient to go

into full-blown opiate withdrawal—an unpleasant experience for all involved”

Dr. Bledsoe elaborates “The primary issue in opiate overdoses is impaired respirations

through the effect of the opiate on the respiratory centers of the brain. These patients can be

treated with mechanical ventilation in the field and later in the emergency department. It is

rarely necessary to administer Narcan. Every level of EMS provider and first responder should

be able to provide artificial/mechanical ventilation. This is the primary treatment for opiate

overdose. Should it be determined that Narcan administration would be of benefit in a particular

patient, providers should administer a small dose to improve respirations and not induce full

blown opiate withdrawal.”

Providing adequate mechanical ventilations is a BLS skill. As it was stated by A.C. Fink

earlier, EMS as a community is becoming too quick to bypass BLS in favor of ALS. It is this hasty

abandonment of low-level, high-success skills that can often be credited with the overall outcome

of a call. All of the advanced equipment in the world can’t save a life if the provider can’t deliver

good respirations with a bag valve mask.

To expand on my point, it is not uncommon to find great paramedics, capable of running

advanced ACLS algorithms with ease, that are somehow find themselves unable to discern good

breath sounds from bad. The reason? The pulse oximeter has been a standard feature on our

cardiac monitors for years. Paramedics no longer have to rely on your knowledge of the skin’s

reaction to hypoxia and quality breath sounds to make a decision. The monitor tells them what

they need, or so they believe.

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The monitor, unfortunately, is not infallible. What’s worse is that they know this to be true,

and relish crowing it to the new students at the onset of every new EMS class. EMS providers are

also, unfortunately, very lazy as a profession. A generation of EMS providers has allowed their

skills to sour on favor of letting the computer make their decisions.

In cases of overdose, this is a dangerous practice. The monitor can’t tell you what

dangerous curveballs might be thrown your patient way in the next five minutes. That’s on the

paramedic. And the dangers are ever-present.

Dr. Mitchell Maulfair and Alexis Dressler, pointed out the dangers of reversing overdose

patients in the field in their February, 2019 article in EMS World Magazine, “The Revival of

Refusal.”

“The complete and sudden effect of opiate withdrawal caused by naloxone is not benign.

Patients are not only uncomfortable, they can have nausea, vomiting, abdominal cramping, and

agitation. The increase in serum catecholamines has been associated with hyperventilation,

hypertension, arrythmias, myocardial infarction, and, rarely, death,” the article explains.

While Narcan itself is a relatively benign drug, the effects of reversing the overdose can be

as dangerous as the are unpredictable.

The ill effects of reversal, however, are rare. Typically, they can also be easily handled by

competent EMS providers. It becomes a matter of risk. Why should a life be risked for a quick

outcome when the long-term option is just as likely to be effective, with none of the dangers.

Katie Wedell of the Dayton Daily News discussed the life-saving effects Narcan in her

article Naloxone Credited for Drop in Local Overdose Deaths.

“The county had a record 104 drug overdose deaths last year, but the second half of 2017

saw a slow down that has continued into 2018. Through March 14, the Clark County coroner’s

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office had handled just seven suspected overdose fatalities.” The article continues “Montgomery

County officials have noted the same decrease in deaths and attribute it in part to the availability

of naloxone.”

The amount of Narcan given to the general public is effective, Wedell’s article states that at

least 33 lives had been saved through a group called Project Dawn. The amount of Narcan they

are given pales in comparison to what is provided in the back of an ambulance.

The Narcan supplied to the general public by Project Dawn is packaged in single-use, 2-

milligram doses. This is delivered intranasally, and is just enough to provide weak respirations

and gently revive a patient. In the ambulance, I have seen as much as twelve milligrams given to

a single patient, and another 30 at the hospital.

In closing, I believe that I have argued my point well. Paramedics abuse Narcan by relying

too heavily on its quick reversal times. I believe that this habit is borne of both laziness and

apprehension. It is difficult to go against an entire community of their peers and argue an

unpopular opinion.

In the end, I believe that adopting the practice of giving less medication and focusing more

on adequate respirations will save money, lives, and careers.

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Works Cited

Bledsoe, Bryan “The Weaponization of Narcan” JEMS Friday, December 21st, 2018

https://www.jems.com/articles/2018/12/the-weaponization-of-narcan.html

Caroline, Nancy; Pollack, Andrew N. “Nancy Caroline’s Emergency Care in the Streets”

Volume 1 Jones & Bartlett Learning p.708-773, p.1341-1342. 2013 ISBN:978-1-4496-4586-1

Fink, Patrick. Interview candidate. Veteran Firefighter/Paramedic and Assistant Chief of

local department. Asst. Chief Fink has been involved in EMS since it’s inception, and has seen

many opioid crises come and go.

Ireland, Sam “STOP USING NALOXONE” FOAMfrat June 10th, 2018 https://

www.foamfrat.com/single-post/2018/06/09/STOP-USING-NALOXONE

Lewis, Mallory. Interview Candidate. Experienced paramedic. Current EMS Lieutenant at

City of Eaton Fire/EMS Division, former Captain at Charleston County (SC) EMS.

Li, Kai; Armenian, Patil; Mason, Jessica; Grock, Andrew “Narcan or Nat-Can’t: Tips and

Tricks. to Safely Reversing Opioid Toxicity” Annals of Emergency Medicine, July, 2018

72(1): 9-11. (3p). Peer reviewed. Ohio Link. Sinclair Library, 9/11/2018.

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Maulfair, Mitchell D.; Dressler, Alexis S. “The Revival of Refusal” EMS World February,

2019 https://www.emsworld.com/article/1222060/revival-refusal

McMillion Sheldon, Elaine “HEROIN(e)” Netflix Documentary, 2017. Follows a fire chief, a

judge, and a street-missionary in opioid-stricken West Virginia. Oscar-Nominated

M. Orkin, Aaron; Buchman, Daniel Z. “Commentary on McAuley et al. (2017) Naloxone

Programs Must Reduce Marginalization and Improve Access to Comprehensive Emergency

Care” Addiction. (Great Britain Social Service) Feb2017, Vol. 112 Issue 2, p309-310. 2p. Ohio

Link. Sinclair Library.

Wedell, Katie “Naloxone Credited for Drop in Local Overdose Deaths” Dayton Daily News

April 10th, 2018. https://www.daytondailynews.com/news/local/naloxone-credited-for- drop-

opioid-deaths/p7NYKz4Ji5PSmfCSc2H0lJ/

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