Elsevier

Resuscitation

Volume 65, Issue 3, June 2005, Pages 315-319
Resuscitation

The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting

https://doi.org/10.1016/j.resuscitation.2004.12.012Get rights and content

Abstract

Objectives:

To examine the relationship between key patient variables and variation in naloxone dose (from the standard dose of 1.6 mg IMI) administered by ambulance paramedics in the prehospital management of heroin overdose.

Methods:

A retrospective analysis of 7985 ambulance patient care records of non-fatal heroin overdose cases collected in greater metropolitan Melbourne. The main outcome measure was the dose of intramuscular naloxone required to increase the level of consciousness and the respiratory rate in patients presenting with suspected heroin overdose. Key patient variables influencing the dose that were recorded included: age, sex, initial patient presentation and reported concurrent alcohol use.

Results:

Multinomial logistic regression revealed that patients with higher levels of consciousness and respiratory rates on arrival of the paramedic crew were more likely to receive a less than standard dose of naloxone. Conversely, patients with lower levels of consciousness and low respiratory rates received greater than standard doses of naloxone for resuscitation. Patients who received greater than the standard dose of naloxone were 2.25 (95% CI, 1.83–2.77) times more likely to have been under the influence of alcohol when consuming the heroin that resulted in overdose.

Conclusions:

The concurrent use of alcohol with heroin resulted in the use of greater than standard doses of naloxone by paramedics in resuscitating overdose patients. It is possible that the higher dose of naloxone is required to reverse the combined effects of alcohol and heroin. There was also a link between initial patient presentation and the dose of naloxone required for resuscitation.

In light of these findings, it would appear that initial patient presentation and evidence of alcohol use might be useful guides as to providing the most effective dose of naloxone 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)

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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.

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