Contributor: Taylor Lynch, MD
Educational Pearls:
Opioid Epidemic- quick facts
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Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45.
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In 2021, opioids were involved in nearly 75% of all drug overdose deaths
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The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths
What is Narcan AKA Naloxone?
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Competitive opioid antagonist. It sits on the receptor but doesn’t activate it.
When do we give Narcan?
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Respiratory rate less than 8-10 breaths per minute
Should you check the pupils?
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An opioid overdose classically presents with pinpoint pupils BUT…
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Hypercapnia from bradypnea can normalize the pupils
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Taking other drugs at the same time like cocaine or meth can counteract the pupillary effects
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Basilar stroke could also cause small pupils, so don’t anchor on an opioid overdose
How does Narcan affect the body?
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Relatively safe even if the patient is not experiencing an opioid overdose. So when in doubt, give the Narcan.
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What if the patient is opioid naive and overdosing?
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Use a large dose given that this patient is unlikely to withdraw
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0.4-2 mg every 3-5 minutes
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What if the patient is a chronic opioid user
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Use a smaller dose such as 0.04-0.4 mg to avoid precipitated withdrawal
How fast does Narcan work?
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Given intravenously (IV), onset is 1-2 min
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Given intranasal (IN), onset is 3-4 min
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Given intramuscularly (IM), onset is ~6 min
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Duration of action is 60 mins, with a range of 20-90 minutes
How does that compare to the duration of action of common opioids?
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Heroine lasts 60 min
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Fentanyl lasts 30-60 min, depending on route
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Carfentanyl lasts ~5 hrs
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Methadone lasts 12-24 hrs
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So we really need to be conscious about redosing
How do you monitor someone treated with Narcan?
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Pay close attention to the end-tidal CO2 to ensure that are ventilating appropriately
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Be cautious with giving O2 as it might mask hypoventilation
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Watch the respiratory rate
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Give Narcan as needed
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Observe for at least 2-4 hours after the last Narcan dose
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Larger the dose, longer the observation period
Who gets a drip?
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If they have gotten ~3 doses, time to start the drip
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Start at 2/3rds last effective wake-up dose
Complications
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Flash pulm edema
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0.2-3.6% complication rate
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Might be from the catecholamine surge from abrupt wake-up
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Might also be from large inspiratory effort against a partially closed glottis which creates too much negative pressure
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Treat with BIPAP if awake and intubation if not awake
Should you give Narcan in cardiac arrest?
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Short answer no. During ACLS you take over breathing for the patient and that is pretty much the only way that Narcan can help
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Just focus on high quality CPR
References
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Elkattawy, S., Alyacoub, R., Ejikeme, C., Noori, M. A. M., & Remolina, C. (2021). Naloxone induced pulmonary edema. Journal of community hospital internal medicine perspectives, 11(1), 139–142. https://doi.org/10.1080/20009666.2020.1854417
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van Lemmen, M., Florian, J., Li, Z., van Velzen, M., van Dorp, E., Niesters, M., Sarton, E., Olofsen, E., van der Schrier, R., Strauss, D. G., & Dahan, A. (2023). Opioid Overdose: Limitations in Naloxone Reversal of Respiratory Depression and Prevention of Cardiac Arrest. Anesthesiology, 139(3), 342–353. https://doi.org/10.1097/ALN.0000000000004622
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Yousefifard, M., Vazirizadeh-Mahabadi, M. H., Neishaboori, A. M., Alavi, S. N. R., Amiri, M., Baratloo, A., & Saberian, P. (2019). Intranasal versus Intramuscular/Intravenous Naloxone for Pre-hospital Opioid Overdose: A Systematic Review and Meta-analysis. Advanced journal of emergency medicine, 4(2), e27. https://doi.org/10.22114/ajem.v0i0.279
Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
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