Thursday, June 10, 2010

Buprenorphine: First Aid for Overdose?

A couple days ago I read about a new statute in Washington state that protects overdose victims and witnesses from prosecution if they call 911 for help. I assume addicts have died of overdose of illicit drugs either because they feared that calling 911, while possibly summoning help, might also lead to conviction for some kind of narcotic offense.

Whenever I think about illicit drug overdose I recall the scene from Pulp Fiction in which (as I remember it) John Travolta's character jams a needle about three feet long into Uma Thurmond's chest, hoping to save her from death by overdose. He has the angle and approach all wrong for what should be intracardiac injection of epinephrine (I did this myself once with a surgeon at my elbow directing me.), but if only from the pain of her sternum stopping  a large needle, she regains consciousness and survives, maybe even until the end of the film. What this got me wondering was whether even an intoxicated addict faced with an overdose situation might have sufficient cognitive capacity to administer potentially life-saving first aid to self or other with minimal -- or at least acceptable -- risk.

We have known for years that naltrexone and naloxone reverse the effects of opiate agonists like heroin and oxycodone. Show up unconscious in an emergency department, and you'll probably get an injection of naloxone (Narcan) just in case you OD'd on an opiate. But I dare say few opiate addicts keep a supply of naloxone on hand for overdose emergencies. They might, however, have another drug that can block the effects of opiate agonists and can be procured on the street: buprenorphine. And what's more, you can administer the drug by dissolving it under the tongue like nitroglycerin, which is probably safer than swallowing for an unconscious victim. No need for an injection. I even wonder whether it might be adequately absorbed rectally to save a life. Buprenorphine, if it works at all, might also offer the advantage of working longer. Naloxone works rapidly, but has been known to wear off after the patient leaves the ED. Then the drug with which they overdosed, still on board, takes over again, and death ensues.

What would be the downside? Perhaps the worst might be delay in calling for help while attempting this measure, especially if something other than an opiate overdose caused the loss of consciousness. The new WA law might help. And perhaps 911 operators could walk callers through the procedure while help is enroute. Of course if the individual was addicted to opiates and regains consciousness they will likely be in withdrawal. I would be surprised if a number of addicts out there didn't think of this and try it years ago. Should we educate all addicts about it?

What we need now is for experts on management of opiate overdose to collect some evidence and offer their opinions as to whether the idea really works and is safe and feasible, and if so to get the word out. Maybe docs who prescribe opiate analgesics for chronic pain will want to order a few buprenorphine (off label of course) for patients to keep on hand for such emergencies.

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