# 283 Naloxone: Antidote or distracting delay?
There are currently several efforts to expand distribution of Naloxone kits to combat "the opioid epidemic."
- Firstly, OEND= "Opioid Education and Naloxone Distribution' for drug users, treatment programs, and significant others to have rescue at hand.
- Secondly, NHT= Naloxone Take Home for users in the ED to be discharged with instructions and a supply.
- Thirdly, to encourage First Responders and Police to have an antidote for encountered victims.
- Fourthly, to assuage the fears of Law Enforcement who feel at risk from the purported hazards of contamination by Fentanyl and other super-potent opioids incidental to their work (although this is not supported by medical literature, and reported episodes, so far, are not supported by available evidence and are easily explainable otherwise (anxiety, hyperventilation, etc.).
These are laudable goals; however, the focus is upon the miracle of the antidote; but is there needed emphasis upon the correct and necessary supportive care? There is an air of "Stand back, and watch this!" Television depictions, even 'real life' occurrences do not show airway and respiratory support prior to "the antidote." There is difficulty persuading people to give mouth-to-mouth respiration to a "junkie" and fear of infection.
We hope that well-trained personnel would do things in the correct order. Indeed, were an antidote not present, 'supportive care', especially to airway and breathing is mainly all that is needed until the drug wears off. And, some vigilant supervision is usually provided after the antidote to ensure there is not relapse or complication. Although some field 'treat and release' programs are successful.
Leon Gussow's excellent blog, The Poison Review, in 2015 reviewed the once-popular "Coma Cocktail" citing the article "Flumazenil, naloxone and the 'coma cocktail'" and affirmed the correctness of its assertion:
". . .the modern approach to a patient with an altered level of consciousness should not be protocolized, empirical administration of fixed doses with an end point of analepsis, but rather the targeted correction of immediate threats to life. . . With both flumazenil
and naloxone, even pharmacologically ideal antidotes are no substitute for basic airway management and modern principles of targeted resuscitation and supportive care."
It is never correct to delay respiratory support, while preparing, giving, and awaiting the effects of the presumed antidote. If there is an admixture of drugs taken, or a dose taken outside the expected range of effect for the antidote, all will be for naught as 'Hypoxia not only stops the machine, it wrecks the machinery'. "J. S. Haldane, 1921"
Sivilotti, M. L. (2016). Flumazenil, naloxone and the 'coma cocktail'. British journal of clinical pharmacology, 2015 Aug 7. 81(3), 428-436. [PDF] {Free Access}
Gussow, Leon, MD. Use of flumazenil and naloxone in poisoned patients. The Poison Review. November 2, 2015, 11:08 pm.
Haldane, J. S., 1921. Quoted in Ward, D. S., Karan, S. B., & Pandit, J. J. (2011). Hypoxia: developments in basic science, physiology and clinical studies. Anaesthesia, 66, 19-268. [PDF]
All Tips: 2013 2014 2015 2016 2017 2018 - Updated! (11/04/2018)
