Not So Fast on Naloxone?

Opiate abuse is in the national news more today than at any time in past 20-plus years. Why? Partly because prescription opiate addiction and abuse is at historically high levels and heroin is re-emerging as a common drug of abuse. And it’s partly because naloxone, long utilized by paramedics to reverse opiate effects, is now being endorsed for administration by EMTs, police officers and public citizens through a number of permissive state laws. In fact, federal support of these laws in at least 17 states and the District of Columbia, and specifically of utilization of naloxone by non-paramedic public safety professionals, can be seen in recent direct statements from Attorney General Eric Holder.

America’s opiate abuse is clearly acknowledged by societal leaders with enthusiastic attempts to prevent opiate-related sudden deaths. But is the answer as easy as naloxone in the hands of EMTs and police officers? The answer to that question, from an experienced EMS physician’s view, comes in the answers to these questions, answers that will differ from community to community.

Is naloxone the right treatment for all opiate abuse patients encountered in 9-1-1 emergency calls?

The symptoms of opiate abuse, most often well recognized by paramedics, are not static. These primary effects of altered mental status and depressed respiratory mechanics lie on a spectrum. When a victim is in the extreme form, sudden cardiac arrest, the critical intervention is CPR, not naloxone. This is especially true in the single-rescuer situation, as may occur in initial law enforcement response.

When a victim is merely decreased in alertness but able to maintain an airway and is regularly breathing, abrupt administration of naloxone can precipitate unnecessary opiate withdrawal. Opiate withdrawal brings its own pathophysiology, at times in serious physical stress. One size, one dose of naloxone simply doesn’t fit all, and it can well violate the primary dictum of medicine: First do no harm.

Is naloxone a necessary allocation to EMTs and law enforcement officers?

Are paramedics located in the community being served? If so, what is their typical time of arrival once 9-1-1 is called? In most large urban communities, paramedics typically respond and make patient contact within several minutes. Realistically, will EMTs and/or law enforcement officers be on scene for enough minutes to reliably assess if opiates are the likely cause of the patient’s symptoms, prepare for naloxone administration, and give naloxone, most likely via nasal atomization delivery (or soon, factoring an FDA approval in early April 2014, via an intramuscular auto-injector)? This sequence of assessment, preparation and administration is not one completed in less than 60 seconds, despite the optimism of naloxone’s supporters.

Is naloxone fiscally and operationally feasible for EMTs and law enforcement officers?

A single-dose 2-mg prefilled syringe of naloxone in most parts of the United States costs approximately $20. While one syringe won’t harmfully impact a public safety agency’s budget, what about that one syringe on every police car or fire engine? What about the replacement costs associated with use or expiration? Expiration dates are often less than 1–2 years from the time of initial purchase. How will police officers carry naloxone? Will it be in the squad car’s “front office” or trunk? Will it be carried on their person? That seems unlikely, given the space constraints of an officer’s duty uniform. What about the effect of temperature extremes on the chemical stability of naloxone?

Will naloxone be available to public safety professionals?

Emergency medications are in historically low supply and have been for the past 3–4 years now. Will a sudden surge in naloxone demand to supply BLS fire departments, EMS agencies and law enforcement organizations be met with sufficient manufacturing and distribution capabilities to not only satisfy the new demand but keep paramedic agencies and hospitals in continued supply? Doubts are well founded, recognizing the stressors on current medication availability.

The Right Answer

Reading this, you may surmise that naloxone is not the answer. That is an incorrect conclusion. The right conclusion is that any community honestly wanting to effectively and realistically address opiate abuse among its citizens needs to first ask a series of questions, including those in this article, and let the honest answers drive its decisions.

Naloxone administration by EMTs or police officers will undoubtedly help sustain some lives in some communities. Recklessly adopted, whether due to political pressures or appeasing particularly vocal advocates, naloxone can cause harm to victims that don’t require its use and can create false hopes along with wasted expenditures. Remain realistic about what is or is not needed in your community.

Jeffrey M. Goodloe, MD, NREMT-P, FACEP, is medical director for the Medical Control Board that oversees the EMS system serving metropolitan Oklahoma City and Tulsa, as well as EMS Section chief and director of the Oklahoma Center for Prehospital & Disaster Medicine at the Department of Emergency Medicine, University of Oklahoma School of Community Medicine.