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LETTERS: Andrew J Ashworth Emergency naloxone for heroin overdose: Beware of naloxone's other characteristics BMJ 2006; 333: 754-a [Full text]

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Risks and challenges for the use of naloxone by inexperienced physicians.

Mohy K. El Masry   (24 October 2006)

Risks and challenges for the use of naloxone by inexperienced physicians. 24 October 2006
Mohy K. El Masry, Professor of Clinical Toxicology Poison Control Center -Faculty of Medicine - Ain-Shams University - Cairo - Egypt Send response to journal: Re: Risks and challenges for the use of naloxone by inexperienced physicians.	Emergency use of naloxone to reverse severe respiratory depression associated with heroin overdose is generally approved. Naloxone indeed is a drug used in coma cocktail, viewing its high safety and potential to revert opiate related respiratory depression. However, challenges in its use do exist. 1. Naloxone as a drug of diagnostic implication. Naloxone used in coma cocktail offer two advantages. The first is therapeutic. The second advantage is diagnostic as its failure in reverting coma, entails other possible diagnosis. The conventional initial dose of naloxone [2mg IV] may fail, however, to reverse overdose by narcotics possessing opiate like effects as tramadol that require larger naloxone dose. In such conditions rapid opiate immunoassays are likely to give negative result, as tramadol does not cross react with opiates, making diagnosis more problematical. Heroin combined to other drugs as benzodiazepines complicates more the clinical picture as it does not appreciably respond to naloxone. In our series, 23% of overdoses are due to poly-medications. 2. An acute severe withdrawal reaction commonly follows the IV administration marked by vomiting, irritability, severe body aches and greatly disturbed mood; a reaction that triggers the patient to leave the hospital against medical advice and reject the offers for further management and observation. Objection of the medical team is usually faced by aggression from the overdosing patient. This constitutes the cause of secondary opiate overdose. For this reason an overdosing patient brought alive in a well equipped hospital might not be given naloxone but mechanically ventilated, thus, avoiding the sudden opiate withdrawal and the resulting consequences. 3. Inability to supply available naloxone by inexperienced user constitutes a breach of duty of care and may expose the emergency or ER physician to claims. 4. Although not confirmed, non cardiogenic pulmonary edema that may follow heroin overdose might be related to the use of naloxone and the consequent catecholamine surge. Competing interests: Treatment of acute intoxications - Drug of Abuse - complications of Detoxification