Review of:Robertson TM, Hendley GW, Stroh G, et al: "Intranasal naloxone is a viable alternative to intravenous naloxone for prehospital narcotic overdose." Prehospital Emergency Care. 13(4):512 515, 2009.
This is a retrospective study comparing the use of two administration methods for naloxone -- intranasal (IN) versus intravenous (IV) administration for suspected acute opioid overdoses. The time span was over 17 months, which included 154 patients who were eligible for the study: 50 treated via IN and 104 treated via IV. In all, 34% of the patients treated with IN naloxone required a second dosing, and three more required subsequent dosing by IV or IM. The authors conclude that despite the time difference in clinical response, IN naloxone is a safe alternative to IV administration in acute opioid overdoses.
Intranasally administered naloxone has already been proven as clinically effective as intramuscular (IM) or IV. No one disputes that it works. But should we incorporate it into our prehospital care protocols? Dr Wesley isn't sure how it works, while Medic Marshall clearly sees the potential benefit of fewer needle sticks.
Doc Wesley:The proliferation of intranasally administered agents is rapidly changing our practice. Many of these patients are either difficult to obtain IVs on and represent a significant blood-bourne pathogen risk. I believe this study clearly showed that the IN naloxone is a reasonable alternative to IM or IV. The question the authors pose but failed to answer is whether it resulted in fewer IVs being established. Their protocol was included in the paper. It's a step-by-step process of IN, IM and then IV. The researchers stated that three patients required "rescue" IV naloxone. Did all 50 IN naloxone patients have an IV established in preparation for that potential event? If so then they didn't reduce the number of potential needle sticks.
Perhaps they did only for this study, and that's fine. But the question is, do we take this study and incorporate it into our practice in such a manner whereby when we encounter a suspected narcotic overdose (OD) we don't establish and IV, instead going directly to IN naloxone and awaiting a response. What do you do if it isn't a narcotic OD? Now it's 20 minutes later, and you still have to start an IV. I know that I'm playing the devil's advocate here, but we need to be sure to take the best information from this paper. That is that if you're confident you are dealing with a narcotic OD, then using IN naloxone alone may be an appropriate alternative.
Additionally, what are you going to do with the patient after they wake up? Most services will still transport the patient, and would they not still require an IV for safety? Perhaps not? Several years ago, the Chicago Fire Department published a study in which they administered IV naloxone and released patients from the scene. The patients didn't turn up in the morgue during the following 72 hours, leading the authors of that study to think it was safe to treat and release narcotic ODs.
Medic Marshall:Comparing the differences of a clinical procedure to improve safety and well-being of pre-hospital providers is a great research topic. Because of the general type of patient, requiring naloxone is at greater risk for blood-borne pathogens and looking at safer ways to reduce exposure is exactly what our industry needs. Abusers of opiate narcotics tend to use IV over other forms and subsequently have poor vascular access. As a result, it may prove very difficult to obtain vascular access on this population -- even for medics.
The differences between the two respectively -- 12 minutes versus eight -- doesn't really seem significant from a medic perspective. It just means assisting ventilations for a little longer. The actual time of patient contact to clinical response was still the same. Since IV drug users have a higher incident of carrying blood-borne pathogens and diseases, protecting yourself from blood exposure is of critical importance. So, I believe IN naloxone is a safe and viable alternative treatment to acute opiate ODs.
The last thing in this study that I found interesting was where the investigators noted a potential public health use for IN naloxone. Disseminating IN naloxone from methadone clinics, needle exchange clinics and other mediums (even possibly through EMS) is a very real alternative. But strong education is required for these people about the use of naloxone. They must be reminded that it is not a "safety net."