AmboFOAM Podcast: Heroin and Narcan

This is a (relatively) brief podcast regarding the use of naloxone (narcan) to treat heroin overdose.  It is meant to give a background to how management of these patients differs in Australia from North America, and also to provide some insight into how to get the best results out of treating the patient with heroin overdose.

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Heroin and Narcan

Below are some publications that I refer to in the podcast that are quite interesting reading for anyone involved in the care of people affected by drugs and alcohol.

As always, feedback is greatly appreciated, so please feel free to drop me a line here, at angryambulancedriver(at), or on twitter (@AmboFOAM)

Trends in Drug Use and Related Harms in Australia, 2001 to 2013 (PDF)

Trends in Alcohol and Drug Related Ambulance Attendances in Victoria: 2011-2012 (PDF)

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8 Responses to AmboFOAM Podcast: Heroin and Narcan

  1. kiwimedic says:

    Another goodun Rob.
    I’m losing count of the number of uni students who believe the newly re-animated, angry, fist swinging patient is doing so due to a “spoiled buzz”. Happily, I’d be full of the brown stuff if I said I didn’t believe that at some early stage too. Out rural i haven’t seen one in 2 years however! I have a couple of comments/ queries.

    1.) Why not IN narcan in the nasally accessible? Surely remove the sharp and contamination risk.
    2.) For all new players, never forget to explain what you are doing even in the deeply unconscious patient. Talk to them for the entire time you are assisting them. We often judge and don’t bother with the chit chat with these ones but it will help when they awake to calm practitioner and they know what’s going on. On the unconc pt, I’ll never forget visiting CCU to see a post arrest pt who was GCS 3 for our entire contact with him. As soon as I said hello he recognised my voice and knew my name ( he was obviously conscious by then).

    Keep them coming.

    • Hi Rich, thanks for listening.

      Intranasal naloxone is indeed a viable alternative to intramuscular. We have looked at it in Melbourne and it was found to be not quite as effective as IM, but is nevertheless an acceptable alternative. Given that most of these patients are deeply unconscious, sharps management is usually not too much of an issue. That said, there is a cohort of patients who have dropped, but are relatively light. These patients will nod off and drop their respiratory rate right off when left alone, but will respond to stimulus enough to make managing them a little more difficult. In this setting I think IN narcan is an excellent option.

      You are very right about how you go about looking after unconscious patients. It is very important to treat all our patients with respect and as much dignity as we can afford them.

      One of the things that really annoys me is that every now and then you will find a medic who thinks they need to cut the clothes off a heroin overdose patient to give them narcan. I think this is really poor form: first of all, if the patient is being ventilated well, the emergency is over. There is nothing that requires rapid access to the patient. Secondly, these patients are not well off, and don’t have a wardrobe full of Gucci shirts at home. Making their life more difficult for them achieves nothing for anyone and shows perhaps a degree of immaturity. In my opinion.



  2. MattCW says:

    Hi Robbie.
    Nice podcast. Not too long, just right for the otherwise mindless commute! Following on from the IN Naloxone that Rich mentioned, I wonder how far off we are for IN Midazolam – not just in the seizure Pt, but also the agitated Pt?

    There is growing interest regarding the IN route, and in the pre-hospital setting, I believe we could use it more often than we do. Minh had a fascinating blog posting about the use of Ketamine (19 Apr 13) and Midazolam gets a mention over at the RCH (

    You nicely illustrated the uniqueness of the environment that we often treat all Pt’s, not just those overdosed. I’d like to take that a step further and suggest that when we are faced with the Pt requiring sedation (agitated or having a seizure), then the IN route has a distinct advantage over IM/IV – no sharps! We just have to careful how we position/secure the head during the administration of the medication. I would like to see Midazolam given to these Pt’s IN.

    Finally, I agree with your point about scissor happy people, either on the road or in the ED. It’s never nice to see somebody walk out to the ED wearing a gown, carrying a bag of clothing cut to ribbons.

    Merry Christmas.

  3. David says:

    Glad to hear your actively busting the myth about heroin OD’s waking up aggressive because “you’ve ruined their hit”.

    Treated hundreds of narcotic OD’s with IM narcan over the years, particularly throughout the 1990’s & early 2000’s. Have never had one of them wake up aggressive, not 1.

    As you say ventilate them well and reverse the hypoxia and hypercarbia; use IM not IV narcan so they wake up slowly; speak to them and explain what is happening as they are waking up; minimise the number of people around; avoid assaulting them with sternal rubs (and other barbaric painful stimuli); don’t destroy their clothes; be polite and professional towards them and they will be your best friend.

    Once you’ve woken them up and the decision has been made not to transport, always offer them a referral to an appropriate drug rehabilitation service. Most will never take the offer up but occasionally they do as the current situation may just be the catalyst for them to make the decision to quit (or at least try). Every paramedic service using narcan (or even not) should have referral information for local alcohol and drug (including quit smoking) rehabilitation services available to give to patients.

    Just my 0.02c worth

  4. R says:

    Where I live naloxone (Narcan™) kits are available to allows anyone at risk for having or witnessing a drug overdose but public assistance only pays for the kit for a person who is using/abusing narcotics. They can be obtained either by a prescription or from a program that has a pharmacist who has established a collaborative practice agreement with an authorized prescriber.

    Take a look at for more details of how the program works. It is coupled with a good samaritan law that protects the victim and the helpers from prosecution for drug possession if they call for assistance. I know that there are other states in the USA that have similar laws and programs but it is a relatively new initiative that hasn’t become widespread yet. Just like other harm reduction initiatives such as making condoms available in schools or providing clean needles to IV drug users it can be a tough sell in a socially conservative political climate.

    • Hi R

      That looks like an excellent program. Something similar has been suggested here but as far as I am aware there is nothing operating yet. I must confess that the opposition to harm minimization approaches to such issues leaves me a little perplexed. It seems amply clear that prohibition achieves little other than criminalizing people with addictions; it certainly doesn’t reduce the use of drugs, nor harms associated.
      It is not just in the US that such conservative attitudes abound. There has been strident opposition to clean injecting rooms here. Safe injecting rooms would seem to me to be a very good scheme to reduce transmission of disease, and provide an extra layer of safety for those at risk of overdose.
      Fortunately we do have a largely sensible police force who do not appear interested in locking up individuals with drug and alcohol problems, but instead focus their efforts on the suppliers.

      • R says:

        It is tough to overcome a mindset that sees prohibition as the ultimate solution to anything with logical reasoning about harm reduction. My state has a liberal urban population that forms a larger electorate then our stereotypical rural conservative population which allows some of these initiatives to come into being.

        We don’t have any formal safe injection sites but we do have a long history of needle exchanges and some intriguing harm reduction programs based on peer education programs for substance abusers. My community has also achieved significant savings (financial and I suspect humanitarian too) by building a small public housing complex to safely accommodate and provide services the people who are termed “chronic public inebriates” without requiring them to become sober.

        I suspect you’d be interested in reading In the Realm of Hungry Ghosts: Close Encounters with Addiction by Gabor Mate who was the medical director of the clinic at the first safe injection site established in Vancouver, Canada.

  5. Pingback: Podcasts you MUST Listen to! | DOWNSTAIRS CARE OUT THERE BLOG

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