David Yaffe-Bellany Photo
A kit for administering nasal Narcan.
When 16 New Haveners overdosed in six hours from a bad batch of drugs, two of them died. The opioid antidote Narcan — an easy-to-use, fast-acting cure that has been around since the 1970s — was widely credited with keeping those numbers down.
Since that episode last month and amid an ongoing opioid crisis, city officials have launched a renewed effort to make Narcan more accessible to emergency responders and average citizens.
Meanwhile, officials and others have been asking: How much Narcan does an overdose victim need? How is the antidote administered? And who is allowed to use it?
A team of doctors, first responders, and emergency management officials met with the Independent at the headquarters of New Haven’s American Medical Response team to answer those questions.
How Narcan Is Administered
First Responder: AMR Paramedic Justin Merchant.
Naloxone — an anti-opioid drug sold as a nasal spray under the label Narcan by the company Adapt Pharma — functions as a cellular “antagonist,” binding to receptors in the brain in order to block opioids from latching on.
It can be administered to overdose victims three different ways: intravenously, intramuscularly, or nasally, in the form of Narcan. In recent years, the intramuscular method, which involves a needle similar to an EpiPen, has become increasingly expensive, so first responders typically deliver the antidote through either a nasal spray or an IV line, before providing respiratory support, in accordance with state rules.
AMR Paramedic Justin Merchant told the Independent that a number of factors shape that initial choice, including the severity of the overdose, the condition of the victim, and the hostility of the surrounding environment.
“It’s all based on our interpretation of what’s going on,” he said.
An IV line can deliver naloxone to the bloodstream a few second faster than either alternative — but without significant manpower, it takes much longer to set up. And in a dangerous environment, first responders tend to quickly administer the spray, then transport the victim to safety.
A single dose of the spray shoots one milligram of Narcan into each nostril. It never hurts to administer too much of the antidote, a benign chemical that does not negatively affect patients who don’t actually need it.
“We can give it to a diabetic person who we thought was an overdose, and they won’t get hurt,” said Charles Babson, AMR’s general manager.
But that doesn’t mean emergency responders are unconcerned with precision. One of the primary advantages of the IV method is that it can regulate the amount of naloxone delivered into the bloodstream. The goal is to get victims breathing again without making them jump to their feet in a burst of violent energy.
“When we revive them, sometimes they will become combative, because they don’t remember what happened, and now there are 12 people standing over them,” Merchant said.
“They’re up — and it’s, ‘I’m good, I’m good, I didn’t do anything,’” said city emergency services chief Rick Fontana.
Ed Badamo, the operations manager at AMR, smiled wryly.
“‘I didn’t do anything’ is the key,” he said.
More Narcan Needed
Fontana.
Since January, the AMR team and the Fire Department have responded to a total of 210 overdoses across the city. One hundred-twenty-one of those, around 58 percent, have required Narcan.
A dose of nasal spray is usually enough to revive an unconscious victim within two or three minutes.
But last month’s overdoses were different.
Many of the victims had taken fentanyl, a dangerous opioid that is 80 to 100 times more potent than heroin. In the most severe cases, it took up to eight doses of Narcan to revive the victims, creating shortages that forced the AMR team to borrow kits from other cities in the area.
“We depleted all of our resources of Narcan in eight hours,” said Babson. “We always had it on the street, but our shelf was bare.”
It often takes repeated doses of Narcan to fully revive an overdose victim, because the antidote doesn’t last nearly as long as drugs like heroin.
That’s another way last month’s crisis was different: although it is far more powerful than heroin, fentanyl survives in the body for a much shorter period of time.
“It required more Narcan to revive [the victims] initially, but it did not require many repeat doses,” said Sandy Bogucki, a doctor at Yale who specializes in emergency medicine.
Narcan used to be cheap. But over the past few years, the cost of nasal kits — which contain a bag, gloves, two milligrams of the antidote, and the equipment needed to spray it — has skyrocketed, and now comes out to roughly $100 per kit. Earlier this month, the city requested funding for more Narcan from the federal government.
“We found out that we need more,” Fontana said. “We need more Narcan.”
Lessons from the Crisis
A syringe used to apply Narcan to a victim’s nostrils.
At the moment, only the AMR team and the Fire Department are qualified to administer Narcan in New Haven.
The Fire Department’s emergency medical technicians (EMTs) are trained to apply nasal Narcan and perform respiratory support using ventilation equipment. And AMR paramedics, who train longer than EMTs and are qualified to do more at the scene of an overdose, can administer both nasal Narcan and intravenous naloxone.
Over the last few weeks, still reeling from the overdose crisis in June, the city has embarked on a new effort to increase the number of emergency responders qualified to administer Narcan.
An initiative to put the nasal spray in the hands of police officers has provoked safety concerns as well as impassioned debate over the budgetary wisdom of investing heavily in an expansion that might not save any lives.
Opponents of the expansion point out that state protocol would force cops to give rescue breaths as well as administer the spray — a requirement that might leave police weapons exposed at a crime scene.
An obvious solution to that problem — providing cops with the ventilation equipment used by firefighters — could prove prohibitively expensive, especially given the numerous other costs associated with the project.
“One of the most important things is after administering Narcan to a victim, you have to provide ventilator support,” Fontana said.
He added, however, that ordinary people can administer the antidote without any background in emergency medicine. Only trained emergency responders are required by law to provide ventilation at the scene of an overdose.
“For us in the field, this is a prescribed algorithm,” Fontana said.
Alfred Dellaville, a regional vice-president at AMR, said the primary takeaway from last month’s crisis was that “what was put in place works.”
Dellaville carried Narcan as an emergency responder in the 1980s. He has watched with interest as the antidote has become increasingly important over the last couple years. He said that any long-lasting solution to the narcotics problem would have to involve education and other societal measures designed to keep young people away from drugs.
Babson, a veteran of the trade who has worked at AMR for more than three decades, nodded in agreement.
And, he added, the string of overdoses in June might not be a one-time crisis.
“Could that happen again?” he said. “It could happen today.”