The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting☆
Introduction
Heroin use and related harm are a major public health issue. Heroin overdose occurs commonly among users of the drug and if not treated can have fatal consequences [1]. In Melbourne, the treatment of heroin overdose is undertaken largely by ambulance paramedics [2], and this work comprises an estimated 5.9% of the total workload for the emergency ambulances in the city [3].
In Melbourne, ambulance service treatment guidelines recommend the use of a standard dose of intramuscular naloxone for the treatment of suspected heroin overdose [4]. The aim is to increase the level of consciousness and respiratory rate of the patient to the point that the patient is conscious with a gag reflex and adequate respiratory rate [4]. However, while there is well-documented variation in the dose of naloxone needed to resuscitate heroin overdose patients in the out-of-hospital setting [5], [6], [7], [8], there has been only limited examination of the factors that might influence this dosage.
Cases of non-fatal overdose cases are typically male (70%) with an average age of around 27 years [2], [6], [9], [10]. To our knowledge, there have been no studies that have examined whether the dose of naloxone required to resuscitate patients varies according to these patient characteristics. It is worth noting that heroin-related fatalities are generally older (typically around 29 years of age) than non-fatal overdose patients and the sex distribution of these fatalities is weighted even more towards males (80%) [2], [9], [10], [11], [12], [13], [14].
One study has shown that the dose of naloxone administered to non-fatal overdose patients in Vienna was inversely related to the level of consciousness as measured by the Glasgow Coma Score (GCS) [6]. In this study, patients presenting with an initial GCS of less than 8 received on average 0.76 mg of naloxone, whereas patients presenting with a GCS of 12 or higher received 0.52 mg of naloxone on average [6]. This finding suggests that initial patient presentation is an indicator of the dose of naloxone required to resuscitate heroin overdose patients in the prehospital setting, with patients with greater impairment of consciousness requiring more naloxone.
Previous research has shown that heroin users are at greater risk of overdose if they engage in poly-drug use, particularly with other CNS depressants such as alcohol and benzodiazepines [14], [15], [16], [17], [18]. Naloxone has been shown to reverse the effects of alcohol in a clinical setting [19], but there is no evidence of the effect of naloxone on the effects of alcohol in the context of concurrent alcohol and heroin use. It is possible that the synergistic effect of alcohol produces the profoundly unconscious state found in some heroin overdose patients. It may be that resuscitation of these patients requires greater than standard doses of naloxone, enough to overcome the effects of both heroin and alcohol.
In this study, we examined the relationship between key patient variables (age, sex, initial presentation and concurrent use of alcohol) and the dose of naloxone administered by paramedics in the prehospital setting.
Section snippets
Design
This study consisted of a retrospective analysis of records of non-fatal heroin overdose cases from ambulance service records.
Setting and data source
Melbourne is a city in southeastern Australia with a population of approximately 3.5 million. Metropolitan Ambulance Service (MAS) is the only emergency ambulance service in the greater Melbourne metropolitan area. Ambulance paramedics are required to complete patient care records (PCRs) for each case they attend. In 1997, an electronic database was established to record
Results
Between January 1998 and November 2001, ambulances attended 7985 non-fatal heroin overdose patients in Melbourne. Eighty-six percent of these patients received the standard dose of naloxone. Of the remaining patients, 342 (4%) received less than, and 779 (10%) received greater than, the standard dose of naloxone.
The average age of patients was 27 (range 13–69). While Table 2 shows that patient age was not a significant predictor of naloxone dose, there was a trend towards older patients
Discussion
Naloxone is an opioid antagonist that, when used in the prehospital setting, is an effective treatment for acute heroin overdose that prevents heroin-related fatality (it should be noted that over the equivalent period for this study there were around 900 fatalities). This study showed that the dose of naloxone used in the resuscitation of non-fatal heroin overdose cases in Melbourne varied. This variation was associated with patient sex, initial presentation and reported alcohol use.
Acknowledgments
The authors would like to acknowledge the collaboration and cooperation of the Metropolitan Ambulance Service, Melbourne, in particular the assistance of Ian Patrick and Greg Sassella. They would also like to acknowledge the assistance of Alan Eade and Stephen Burgess. They would also like to acknowledge Stefan Svetkovski of Turning Point Alcohol and Drug Centre. The second author is in receipt of a Public Health Research Fellowship from the Victorian Health Promotion Foundation.
Contributions.
References (21)
- et al.
Heroin and opiate emergencies in Vienna: analysis at the municipal ambulance service
J Clin Epi
(2000) - et al.
Comparison of drug abuse fatalities and emergencies
For Sci Int
(1993) - et al.
Heroin-related deaths in Victoria: a review of cases for 1997 and 1998
Drug Alcohol Depend
(2001) - et al.
Using ambulance service records to examine nonfatal heroin overdose
Aust J Public Health
(1995) - et al.
A comparison of blood toxicology of heroin-related deaths and current heroin users in Sydney, Australia
Drug Alcohol Depend
(1997) - et al.
Fluctuations in heroin purity and the incidence of fatal heroin overdose
Drug Alcohol Depend
(1999) - et al.
The context, management and prevention of heroin overdose in Victoria: the promise of a diverse approach
Addict Res Theory
(2001) - et al.
Ambulance attendance at heroin overdose in Melbourne: the establishment of a database of ambulance service records
Drug Alcohol Rev
(2000) - Currell A. Workload Forecasts 2002–2003 to 2005/2006. Melbourne: Metropolitan Ambulance Service, Melbourne;...
Victorian ambulance clinical practice guidelines
(2002)
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European Resuscitation Council Guidelines for Resuscitation 2015. Section 4. Cardiac arrest in special circumstances
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A Spanish and Portuguese translated version of the Abstract and Keywords of this article appears at 10.1016/j.resuscitation.2004.12.012.