When myths are more dangerous than reality

The falsehood of naloxone-induced aggression and assault

This article originally appeared in the Paramedic Chief Leadership Briefing, An EMS Medicare option | Naloxone myths | Early recruitment success.

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By Ryan Marino, MD, and Jeremiah Escajeda, MD

Recently, a passenger on a Delta flight died from an apparent overdose, sparking widespread media attention, with coverage attributing the death to a lack of naloxone on board.

The coverage of this incident prompted dramatic and polarized responses across social media. One common theme of concern expressed that naloxone administration can cause aggression in patients who receive it and administration of naloxone risks assault to either bystanders or healthcare providers. While anecdotes were shared to justify this theory, there is a paucity of substantive data to corroborate this urban legend.

When titrated to restoration of breathing, rather than given punitively, naloxone is overwhelmingly unlikely to cause any adverse reactions at all.
When titrated to restoration of breathing, rather than given punitively, naloxone is overwhelmingly unlikely to cause any adverse reactions at all. (Image/Drugabuse.gov)

Anecdotes are not the same as facts

It is unclear where this rumor started. The only available evidence to support the phenomenon seems to come from two case reports from 1992 – notably, not even in substance users. Even more notably, naloxone-induced assaults have not been reproduced over the subsequent decades. All of the credible evidence that we have, suggesting administering naloxone will result in provider assault, are two case reports from the 1990s. 

Treating patients with altered levels of consciousness, whether related to substances like drugs, low oxygen, low blood glucose or any other cause, can be challenging. Treating these patients, as with treating most patients, often involves working in close proximity, which can be a risk for assault, and assault of healthcare workers is a serious issue that cannot be blamed on these patients.

The problem with attributing aggression and assault to patients who use drugs is that this is not supported by any evidence after decades of treating overdoses. It also adds to the stigma that these patients experience, which, in turn, can worsen the care they receive. In the case of naloxone for opioid overdoses, the alternative can be deadly. Additionally, there has been recent data demonstrating that assault of EMS professionals is on the rise, however, there has been no discovered causation as a result of increased naloxone administration in the prehospital setting. 

Unfairly tarnishing a very safe, very old, very good and very safe drug

Naloxone has been approved to reverse opioid overdose since 1971. An often-overlooked component of its longstanding use is that it is used to reverse over-sedation in hospital settings all the time, and has been for decades. If naloxone reversal were associated with increased incidence of aggression or assault, this would be well known and examples would be more common than just second-hand hearsay. In fact, a recent review of naloxone to treat heroin poisoned patients found a less than 3% rate of behavioral disturbance, not assault.

In case there is any concern that hospital administration of naloxone is different than out-of-hospital administration, Tim Gauthier, MScN, NP, who has personally responded to hundreds of overdoses in his eight-plus years as the clinical coordinator of Vancouver’s Insite supervised drug injection site, says, “It is exceptionally rare for anyone to be combative when coming out of an OD, especially if we pay attention and attend to cues that we are scaring or triggering folks during emergence. Give space, genuine reassurance, and be gentle.”

When titrated to restoration of breathing, rather than given punitively, naloxone is overwhelmingly unlikely to cause any adverse reactions at all.

Every life is worth saving

Despite increased awareness, significant biases still exist in medicine and directly impact patient care and continue to adversely affect patients who use drugs, even after years of highly-publicized coverage of epidemic overdose deaths. A recent analysis of overdose patients in emergency departments at multiple hospitals showed significant biases affecting whether take-home naloxone was provided to patients after opioid overdoses.

One particular bias in delivering naloxone is a preference for more invasive respiratory support maneuvers. While bag-valve-mask ventilation is a mainstay of basic life support and is crucial to provide during resuscitation of an overdose, it should not preclude the administration of naloxone. BVM ventilation is susceptible to many areas for errors, and in the setting of an overdose, this can mean anoxia and irreversible brain injury.

Furthermore, depending on the lay public – the vast majority of whom are not trained in advanced resuscitation techniques – to provide BVM ventilation is not a reasonable expectation and not an appropriate response to (easily preventable) widespread civilian deaths.

The responsibility of EMS and all healthcare providers is to deliver the best care possible to our patients, and in the setting of respiratory failure from an overdose, restoring the patient’s ventilation via the antidote naloxone is the definitive management, whereas BVM ventilation is not. Also, naloxone distribution, when deployed to the community, has been shown to be safe, life-saving and cost effective.

The mission of EMS is to provide the best quality, evidence-based care to all patients in all settings. We cannot let theoretical concerns about unfounded myths influence practice; human lives depend on it. After almost half a century, naloxone remains the definitive EMS therapy to treat respiratory failure in opioid overdose.

About the authors

Ryan Marino (@RyanMarino) is an emergency medicine physician and medical toxicologist at University Hospitals Cleveland Medical Center and an assistant professor of Emergency Medicine at Case Western Reserve University School of Medicine. He specializes in treating patients with substance use disorders and believes in treating all people better.

Jeremiah Escajeda (@jerescajeda) is an emergency medicine physician and EMS medical director at the University of Pittsburgh’s School of Medicine/UPMC’s Department of Emergency Medicine. He pays special mind to substance use disorders, and how we can better treat substance use disorder patients prehospital. He is also a contributor to the PEC (Prehospital Emergency Care) podcast.

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