Russell E. Berger, MD Melisa Lai Becker, MD Division of Medical Toxicology

1. Narcan: Practice Considerations for our opiate intoxicated patients Russell E. Berger, MD Melisa Lai Becker, MD Division of Medical Toxicology Cambridge Health Alliance

2. Case A 33 year old male is found down, unconscious and unresponsive. His girlfriend calls 911. On arrival, EMS finds patient with agonal respirations. 2mg of intranasal narcan is administered. The patient immediately wakes up and is agitated. He is transported to the ED for evaluation.

3. On arrival, the patient demands to leave. • He refuses medical care and won’t let his providers check a finger-stick let alone keep him in the ED for observation. • Can this patient sign out against medical advice? At what point is he safe for discharge?

4. To answer this question, you need to know the expected duration of effect of narcan and the duration of effect of the opiate your patient was exposed to. • It also requires that your patient accurately relay to you exactly what he took.

5. Half-Lives of Common Opiates Seen in the ER Vicodin 3-4 hours Percocet 2-4 hours Dilaudid 2-3 hours Fentanyl 2-4 hours Methadone 8-60 hours Buprenorphine 24-42 hours

6. Narcan • Half life is 0.5 hours to 1.5 hours • As already stated, it takes 4-5 half-lives for a drug to be effectively eliminated. • Thus, narcan would be expected to reverse opiate toxicity from 2 hours to 6 hours after administration.

7. Current approach • First, CHA does not have a policy specifically addressing this scenario. • Thus, this is an individual provider judgment based on your patient assessment and the advice below is a recommendation only:

8. From a consensus poll of our medical toxicology colleagues, observation should be AT LEAST 2 hours for heroin and AT LEAST 4 hours for known or suspected methadone or mixed-opioid/polysubstance OD. • If necessary, observe the patient under a safety/security watch until minimum guideline time has passed and restrain the patient if needed