As the overdose crisis escalates, so do law enforcement’s misconceptions about Narcan, the nasal-spray formulation of the opioid-overdose antidote naloxone. It’s common for officers to believe that Narcan doesn’t work on fentanyl, or that giving someone four or five doses is helpful, or that chest compressions are more important than rescue breathing. Police officers learn it from other police officers, corrections officers from other corrections officers, and so forth.
Some are already aware that these claims aren’t true, or aren’t interested one way or the other. But some are receptive to the information once they have it, and see that it’s not incompatible with their training objectives regarding officer safety or public safety. Often the myths passed down from cop to cop make overdose response more difficult and less safe, both for the overdose victims they’re responding to and for the cops themselves.
It’d be preferable to everyone if law enforcement officers weren’t the ones getting dispatched to overdoses, but for the time being that’s the world we live in. The following information is applicable regardless of personal ideology or experience level using Narcan. It just makes using it safer and easier.
You Don’t Need to Wake Them Up to Reverse the OD
It’s a misconception that an overdose isn’t over until the person is fully conscious. On the streets, cops are often dispatched after 911 operators established that the victim was “unresponsive.” In prisons and jails, corrections officers will call over the intercom that they have an “unresponsive inmate,” then step away and wait for backup without checking if the person has a pulse or is breathing. Narcan is administered until the person is “responsive,” which is understood to mean “until the person is awake.” It’s supposed to mean “until the person is breathing on their own.”
The safest way to administer Narcan is to give them one dose, then wait at least two minutes before considering whether to give them a second. If they start to breathe on their own and are taking at least eight breaths per minute—whether or not they’ve opened their eyes yet—then they don’t need any more Narcan.
Eight breaths per minute is a somewhat subjective benchmark for “normal breathing.” You might read elsewhere that the number of breaths per minute is as low as five, or at least 12. There isn’t an exact consensus, but most experts would consider eight to 10 breaths per minute to be safe.
Likewise, some overdose-reversal resources might say to give someone a second dose of Narcan if normal breathing hasn’t resume after three minutes, rather than two minutes. There isn’t a definitively correct answer, but you should always wait at least two minutes and never more than five.
Extra Narcan Doesn’t Make It Work Better
When you’re mailing a letter, you need one stamp, maybe two. You can put a bunch of extra stamps on the envelope “just to be safe,” but that doesn’t mean they’re necessary, and they won’t make the letter get there any faster.
Narcan works by going to the same receptors in the brain that opioids go to, and bumping off whatever opioids happened to be there first. Once it hits about half the relevant receptors, the overdose is reversed. This generally takes between two and five minutes.
If you give someone additional doses of Narcan right after you gave them the first one, it won’t make the first dose reach those receptors any faster. When it looks like it doesn’t work until you hit them with three or four or five doses, but it’s only been a couple of minutes, then what you’re seeing is the effect of the first dose getting where it needs to go.
If you ask colleagues how they know that multiple doses of Narcan were needed, they’re probably going to tell you that multiple doses of Narcan were used. It’s a case of “correlation not causation,” which is common in narratives about illicit drugs. Another example is the purported rise in THC overdose among children, based on the volume of calls to Poison Control Centers. Which doesn’t indicate how many children actually overdosed on THC, but the number of times someone said they did.
It’s true that “every second counts” when someone’s not getting oxygen to their brain, but faster-acting alternatives like Opvee are more harmful than Narcan without being any more effective. While waiting for Narcan or any overdose-reversal agent to kick in and allow the person to breathe on their own again, the important thing is that someone else breathe for them.
You Can Save Them Without Narcan
If you can’t find any Narcan, or are waiting on someone to bring it, rescue breathing can take its place until backup arrives or the overdose dissipates naturally. The latter might take hours, but as long as the person keeps getting oxygen delivered to their brain, they don’t need Narcan to survive. They should also receive rescue breathing after the first dose while waiting to see if a second is necessary.
Most overdose-reversal resources underemphasize rescue breathing and overemphasize chest compressions. However, this is generally to “increase participation from lay personnel” who might be less willing to try the former than the latter. First responders trained in chest compressions and rescue breathing are advised to do both, but there’s actually very little evidence that chest compressions are beneficial in the context of opioid overdose. Rescue breathing, on the other hand, is the tried-and-true method of keeping someone alive until Narcan can be administered, and while you wait for it to work.
Narcan Works on Fentanyl
Higher-potency versions of Narcan aren’t necessary to counteract higher-potency opioids, nor are longer-acting versions necessary because Narcan “wears off too quickly.” Regular Narcan works the same way on all opioids, including fentanyl and fentanyl analogs, regardless of their potency.
It is true that people who were just given Narcan often overdose again within the next few hours, but this phenomenon is due to people adding more opioids to their system, rather than residual opioids in their system reactivating.
Compared to lower-potency opioids like heroin, fentanyl overdoses are more dangerous because they happen more quickly. Someone can fall into respiratory depression and die in the time it takes for someone else to arrive with Narcan, which is why it’s critical to carry it on your person and why it needs to be especially accessible to the people most likely to be in close proximity to an overdose.
Too Much Narcan Is Harmful
The most effective version of naloxone, the main ingredient in Narcan, is the 0.4 mg intramuscular vial you use like an EpiPen. That dose is the amount most adults need to for the naloxone to reach half the relevant receptors in their brain, and thus reverse the overdose.
When arriving at the scene of an overdose, it can seem intuitive to hit the person with Narcan a couple of times back-to-back, especially if you don’t know how long they’ve already been unresponsive. The problem is that in most cases, a standard 4 mg Narcan nasal spray already contains a bigger dose than they needed, and multiple doses or higher-potency formulations almost guarantee it. For someone with an opioid tolerance, waking up by way of an unnecessarily large dose of Narcan is extremely painful, and is often the catalyst for overdosing again shortly after an attempt to alleviate that pain.
If you’ve ever revived someone with Narcan who then took a swing at you, chances are it could have been avoided by only giving them the amount that they needed.
Image via San Diego County Sheriff’s Department
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