Narcan 4 MG

 I was a big initial fan of the intranasal atomizers both for pain management and opiate overdoses.  I liked them for pain management for their quick access.  I often gave an intranasal dose, and then after getting an IV, gave the rest IV.  Overtime I noticed quite a difference in response between the two methods.  IN might touch them; IV almost always worked.  Recently I have switched to IM for the quick first dose.  Sure it involves a needle stick, but the onset is quicker and it seems more effective.

I have continued to use intranasal Naloxone as my first line for opiate overdose accompanied, of course, by bag valve ventilation, but I have been having second thoughts about the IN route of late.  I have always preached patience, and when I give Narcan IN, my patience is usually always rewarded with a calm, almost placid patient.  Many of my peers have told me they prefer 1.2 mg IM as their starting dose.  That’s what I used before IN came out.  True, it does return their breathing sooner and almost always wakes them, but sometimes it causes symptoms of withdrawal.  I have preferred the more delicate approach, sometimes giving only 0.5 IN in each nare, followed by an IV dose of 0.01 (yes, 0.01) every minute titrated to effect.

This approach works well in the unresponsive patient who may be breathing six times a minute.  I am not so certain it is the appropriate approach for the cyanotic patient breathing at 0-2.  Sure, I can wait on scene bagging for 15 minutes, but bagging is hard to do well, easier in some patients than others.  For these patients now, I give the full 2 mgs IN and am prepared to give a second dose IM if I have not gotten an IV after a few minutes.  I am even considering going back to the 1.2 IM right off the back.

As a paramedic, I have the luxury of multiple options that I can tailor to each individual patient.  EMTs, first responders and the lay public don’t have that ability, and consequently their patients may not be coming around to breathe on their own as quickly as they could.  No doubt this slower response may have an impact on those patients already at risk for anoxia.

I was recently at a statewide conference on opiate overdose prevention and was seated at the table with a salesman for Narcan, who was talking about his company’s product which delivers 4 mg of Narcan IN.  I told him how I thought that was too much for an initial dose, and that we tried to give as little as possible.  Too much can cause withdrawal as well as lead to violence.  While I told him I loved IN Narcan, 4 mg was just too much to start with.  He told me the naysayers were all the wrong side of the fence.  He offered to put me in touch with police and fire chiefs in Massachusetts who loved the product.  I said telling me I was wrong was not a persuasive debating tactic and that while I am sure the police and fire chiefs are nice people, I would prefer to hear from ED doctors.

I enjoy a good argument and appreciate the finer points of debating.  In the end, what is important is not whether I was right or wrong, but whether in the exercise brings me  closer to the truth.  After doing my own review of the product, I have come to believe it should be not just in the layperson’s arsenal, but in the bag of all first responders and EMTs.

Here’s what convinced me:

We currently squirt 1 cc of drug up each nostril.  Each nare is only built for 0.25 ccs.  When I give IN Fentanyl for pain, patients often complain of the drug going into the back of their throat.  I have also seen it run back out of their nose.  No way are they getting all of the drug.  The new product has 4 mg in 0.1 mg.  It is a true nasal spray.  Even at that the bioavailability is only 46%.  In other words, giving 4 mgs IN is the equivalent to a little less than 2 mg IM.

What is the bioavailability then of the atomizer 1 mg in 1 cc in each nostril? Certainly much less.  With the run off in the back of the throat and back out the nose, the 2 mg dose could be as little as 0.2.  Maybe that is why my patients are so placid, and I have never seen withdrawal when given IN alone.

Even the guy who invented the atomizer, admits this new product is a better delivery system.

Intranasal.net

Editorial comment: Even though  I invented the MAD nasal, began the research on nasal naloxone in the 1990s and have used this therapy for 18 years (so have a bit of a historical bent towards the original method of delivery), it seems pretty apparent to me that this new product is probably a better method for delivery of nasal naloxone than the way we have posted here on this website for the last 7 years. The new formulation is more appropriately concentrated, it has a pre-attached atomizer and because of the recent price increased in generic naloxone (single supplier cranked the price last year) this new formulation is not only better formulated, its also less expensive.

I had heard tales of my peers responding to scenes where first responders equipped with Narcan atomizer set up had difficulty putting the device together.  I recently saw it myself on a scene where the responder handed the poorly assembled device to me and said you do it.  The three working parts, the bristojet, the screw in vial and the atomizer were together but not solidly.  I had to refit them properly.

I have also heard drug users tell me they had difficulty putting the devices together when suddenly having to use them on a fellow user.

In a recent study of the new 4 mg nasal device, 90% of people were able to administer it effectively with no training.

So, now we have a device that is FDA approved and is easier to use.  But still what about that dose of 4 mg (even if it is only the equivalent of 2 mg IM)?  Is the dose too much?

The salesman’s argument was that all the stronger Fentanyl based derivatives require more Narcan than regular heroin.  I had heard that, but that had not been my experience.  We have lots of Fentanyl here.  Maybe it is my patience, but I am usually able to get people back with only 2 mgs.  I hear my fellows say they have to often use 4.  I think maybe region wide, the larger doses are tied to the IN dose of 2 mg not really being 2 mgs.  Maybe 6 mgs of Narcan IN with an atomizer is still less than 2 IV.  I searched the literature to see if there were studies that showed that Fentanyl requires more Narcan than heroin.  And while I could find nothing, I attended a toxicologist’s talk and posed the question.  Yes, the answer was, while Fentanyl may be a 100 times stronger than heroin, it should require more Narcan than heroin due to the stronger binding of Fentanyl to the brain’s receptors.  Not 100 times more Narcan, but it would be reasonable scientifically that it would require more.

Finally, I had a physician friend query colleagues of his across the nation whose systems have gone to the 4 mg IN initial dose to see if they have had withdrawal problems, and the answer was no they hadn’t.  They were very pleased with the device.

So, I am for it.  I am for it for it for laypeople for its ease of use and its strength of dose to get OD patients breathing sooner, and keeping them from suffering anoxic injury or death.  I also support it for first responders to get the patient breathing on the their own sooner, and help prevent extended one man bagging, which is often not done well, and even if done well, is not as effective as a person breathing on their own.

The Connecticut statewide medical advisory subcommittee on protocol revisions last week passed the proposal to update our statewide treatment protocols to enable a 4 mg Naloxone IN first dose for opiate overdose.   It still needs to approval by the statewide EMS Advisory Board and the Commissioner of Public Health, but I expect it to pass easily.  Bravo to the committee.

 

Hear the Drumming

Another three dead of heroin overdoses in Hartford in the last 16 hours.  The slaughter continues.  Hartford led the state in overdose deaths in 2015 with 56.  The 2016 numbers, which are not complete, are estimated to be in the high 70s.  Already there have been 5 known heroin deaths in 2016.   I recently did a cardiac arrest of a male in his 40's just out of rehab, found dead on the couch.  No heroin paraphernalia was seen, but who's to say the scene wasn't sanitized before we got there or maybe he snorted outside and walked into the house and collapsed.  Not certain if he ended up as a medical examiner case, but if he did, the evidence will be in the blood, and his name will be added to the tally.

Next week, at our hospital EMS CME, a death investigator from the office of the state Medical Examiner will be speaking to us about heroin and fentanyl.  I am very excited to hear her talk.

I am encouraged that people are the crisis seriously.  From police to health care workers to elected representatives, an extraordinary number of people are paying attention and working together to try to find a solution.

I think it is time to take our thinking to the next level.  Years ago, needle exchange programs were very controversial.  They have proven their worth in helping halt the AIDS epidemic.  I think it is time we consider safe areas, monitored by medical personal, where addicts can use.  There they can get counseling if they want it, and maybe get into rehab.  If they are not ready for it, at least if they OD, they can be revived before hypoxia kills them.

Dead people can't recover.

Three Dead From Suspected Overdoses Within 16 Hours In Hartford

Listen to Hartford Deputy Police Chief Brian Foley describe the change in the police department's attitude toward substance users.  The Hartford Police Department gets it!

You can follow D/C Foley on twitter at D/C Foley.

***

Greg Friese of EMS1.com added a message about Boston's safe haven for users.  Thanks, Greg!

Boston to offer a safe place for heroin users to be high

Peace to all. 

Snowbank

 It is six in the morning and we get called for an overdose outside.  The address is not a surprise -- a side street off Park.  Yet when we arrive, we find no one.  We are about to clear when a police officer who has also responded finds a backpack in the snow and sure enough coming down the street is a man who seems somewhat confused.  One side of him is dripping wet as if he had been laying in the snow.  He has come to claim his backpack.  I ask him why half his clothes are soaking wet.  He hesitates a moment, and then says he was helping a friend shovel.  This answer makes no sense.  It is after all six in the morning and the snowstorm was the day before, ending well before sunset.  

We tell him we were called for an overdose, but he knows nothing about it.   I ask him if he has been using drugs in the last several hours.   “Ohhh, nooo,” he says.  “Well, maybe seven years ago, but not for s long time.”

He knows the date and his name and has no interest in going to the hospital.   I suggest we take him to the hospital anyway.  He can get his clothes dried out and get something to eat, and maybe even get a checkup.  He says no, mumbles a thank you anyway, and says he will just be going on his way.   He picks up his bag and heads up the street toward Park.

The cop and I exchange some small talk, and then as I start toward the ambulance, I see something on the sidewalk.  I reach down and pick it up.  It is a retainer with three false teeth on it.  I start down the street to see if can catch up to the guy.  “Hey,” I call.  “Hey, dude!”

It is still pitch black and I am hurrying down an icy street holding some guy’s teeth.  EMS Moment 1538. I finally catch up to him.  “Oh, yeah,” he goes, “I was missing those, thanks.”  He puts them in his mouth, and thanks me.

“You sure you don’t want to go to the hospital?

“No, I’m good,”he says, and he continues on to Park Street and I head back to the ambulance.

About a half hour later, another crew gets called for a man in the snow on a street several blocks away.  It turns out to be a cardiac arrest.  I listen to the patch.  The man is the same age as my patient.  From the patch, they mention they have given him Narcan to no effect.  

I talk to the crew later and am relieved the man had a brown coat where my guy’s coat was black.  I ask if the medic saw any heroin paraphernalia or bags at the seen.  He says no.  The other medic who responded saw the fresh track marks, but that was it.  He was just dead in a snow bank.  Asystole on their arrival, PEA with some epi.  Called dead at the hospital.

2nd fatality of the morning as a crew from the south end worked and called a man found by his family in the bathroom by his family with the needle still in his arm.  ODs ebb and flow in the city, but the last couple of days have been on the high end.  Another bad batch or just the same old kill you anyway stuff sold on the streets of Hartford.

“So there I was running down the street, going 'Dude your teeth!'" might have been the end of the story, but then, a month later.

I am taking a man from jail to the hospital for chest pain.  He checks out fine and we end up talking about the heroin trade.  I ask him what the strong brands are and I am a bit upset that the two he names as the most potent I have yet to encounter in my search for empty heroin bags.  He tells me about a month ago he was working in a heroin house.  A heroin house is a place where people can go to buy their heroin ($4-$5 a bag), a clean needle ($2), and they can shoot up under the watchful eyes of drug workers.  (I did not ask if there was a house fee or a fee if one of the house workers with IV expertise gets paid for helping the patron find a vein).  When they are done, they are free to go on their way, safe in the knowledge they have no heroin or heroin paraphernalia in their possession.  And if they OD, the workers have Narcan to revive them.  Not a bad deal.

Except the workers are not the most reliable people.

In other countries, and it is being considered in some states here, there are safe houses overseen by substance abuse professionals who can not only protect the people against overdose, but are there to help guide them to rehab if they are ready.  They are licensed professionals.  In this Hartford heroin house, the staff works for heroin.

The man in my ambulance relates to me how three people overdosed at one time.  The guy who was supposed to be watching was talking to his girl on the phone and went out to the hallway where they had an argument.  My passenger checked in his room, and saw two overdosed dudes, including one who was blue and seizing.  He struggled to give them all Narcan.  The directions on the box he says were not too easy to understand.  “We have to call 911,” he said to the other worker who was higher up the chain.

“No, way.”

I interject to say that you can call 911 for an overdose and have liability from prosecution.

He shakes his head.  “This is a drug house.”

“Point taken,” I say.

He goes on to describe the argument they had and how in the end, the staff took outside in the snow.

The street she mentions is the same street where I had the encounter with the dude who had lost his teeth.

(I need to inject here that when I talk to heroin users and or dealers I tell them I am not interested in any of the specifics that would lead to anyone either being prosecuted or killed or merely harmed.  I am EMS, my job is to help people, and to understand how the culture of heroin as much as I can so I can try to use the information I gain to help people stay alive and maybe find a way out of the heroin trap.)

My partner and I drive back along the street later that day.  I keep my eye out for bags.  There are many, and among them is one of the brands he mentioned that were particularly powerful. (The next day I find the second in the Park).   My collection is back up to snuff, and the mystery  of the dude with the teeth is, perhaps, answered.

My thesis is they gave both patients Narcan.  The guy with the teeth was left in the snow on the same street as he was likely already coming around.  The second guy perhaps was carried or driven farther away as he was still not breathing.  I do not know if that is true or if these patients were related or had anything to do with the supposed heroin house, but the whole story is quite curious.  Always after talking with someone I think of questions I would have liked to have asked.

 

Happy

 I ask my patients who are addicted to heroin how they got started.  Many tell the same tale.  Injury.  Prescription for Percocet or Oxycontin.  They got addicted.  Prescription either went away or couldn’t keep up with their growing tolerance.  They started buying pills on the street.  Then they learned heroin was cheaper and worked even better and was more widely available.

But not all people become addicted to heroin this way.  Here are three patients' stories.

Shelly worked in a restaurant.  She was a twenty-eight year old single mom, who was going through a hard time.  Her daughter’s father had left them and she was staying with her mother and stepdad who she felt were always judging her poorly.  She noticed one her coworkers was happy all the time, no matter what was going on in his life.  She asked him how that was.  He said he used heroin.  So she tried it with him one night.  And she had never felt so good.  All her cares when away.  Three years later I am taking her from jail to the hospital for nausea.  She was arrested for missing a court date on a theft charge.  She no longer lives with her mother and stepfather who have custody of her child.  The address she gives me is different from the one on the booking sheet, different from the one in our computer, and different from the one on the hospital face sheet.   She moves about.  She says she was on methadone for awhile and that actually was working for her, but because she didn’t have insurance and wasn’t on Medicaid yet, they charged her $65 a week and when she fell behind, they kicked her out of the program.  She went back to injecting heroin.  She has recently gotten on Medicaid and hopes to get back on methadone.   She says heroin still makes her feel great though not quite as happy as she first felt.  She regrets trying it.  She is tired of living like this.

Janet is a twenty-years old with a one year old boy.  She is staying at a shelter for addicted moms.  The baby tripped trying to take a step and has a bump on his forehead.  He cried immediately and is acting normally, sucking on his pacifier.  She has him in a car seat all ready for us.  She has been on methadone for two years, but is gradually weaning herself off of it.  As a teenager, she used to pick up heroin for her father.  He’d give her the money and tell her where to meet his dealer.   He was happy all the time, she said,  so one day she decided to try it, and got hooked.  Now she has a son she says she has no desire to have anything to do with heroin again.  He gives her the strength every day to fight off the urge to go back.

Ervin is fifty-eight and has been doing heroin since the late seventies.  I am taking him to detox from the hospital.  He tells me he got into heroin recreationally with his friends.  They partied every weekend --booze, weed, coke -- and then one weekend one of his buddies brought along a friend who had heroin.  Some of Ervin's friends who graduated to injecting, died of heroin overdoses over the years, but Ervin has been careful.  He snorts his heroin and tries not to get too greedy.  He is cautious particularly with the powerful Fentanyl that is around these days.  When he gets money, he uses heroin until his money runs out, and then he checks himself into rehab.  He comes out clean and then when he gets enough money, he starts doing heroin again until he is broke, and then he goes back to rehab.  It is the only choice he has.  He says it’s either rehab or robbing or killing someone to get the money to buy more heroin to feel his habit.  He is not a violent man and can not stomach causing harm to anyone but himself.  The cycle is his life and he sees no end for it.  He loves heroin he says --he is never more happy than when he is high, but he wishes heroin had never showed up that night.  He wonders what his life would have been like had he never let that demon in.  Don’t ever start, he says.

A drug company CEO who says his product is not addictive, a happy co-worker, a father too lazy to buy his own dope, and a friend of a friend -- all selling happiness.  Fate comes in many forms.  There but for the grace of God go we.