2015 ILCOR and AHA references opioid OD

Physicians most trusted site MedscapeNaloxone for the Reversal of Opioid Adverse Effects
First line quote “All patients considered to have opioid intoxication should have a stable airway and adequate ventilation established before the administration of naloxone.”
Read my moderated comment Medscape  

Marcia L. Buck “Naloxone for the Reversal of Opioid Adverse Effects” Pediatric Pharmacotherapy. 2002;8(8)1-5 See bottom page 1 children kept alive five days respiratory assist. Doctors pumping massive doses Naloxone into children with no affect? Both toddlers probably would have woken up and started breathing on their own in the same time period without all the Naloxone.

Thousands more case reports like this in the medical literature. Women and children Naloxone ineffective kept alive rescue breathing. 

Dr. James R. Roberts  Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions  Emergency Medicine News: October 2011 – Volume 33(10)p 16-18  Quote “… the majority of one’s arsenal to treat cardiorespiratory collapse secondary to a drug overdose is primarily basic support.” Means first aid rescue breaths essential, Naloxone is second line defense.

Annotated medical information Naloxone Read my moderated comments 14-15 Then follow Trackback for more of my moderated comments

Ontario, Canada the only place in the world that teaches chest compression’s only for respiratory emergency.   Dr. Aaron Orkin et al ‘Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario.‘   Can. J. Public Health 2013;104(3):e200-4   My response above article

One of my moderated comments in the 2015 AHA & ILCOR guidelines hyperlink BLS 891 Has been reopened for comment

Correspondence from Dr. Christian Vaillancourt co-author 2015 ILCOR

ILCOR REFERENCES  http://circ.ahajournals.org/content/132/16_suppl_1/S51.full.pdf+html

What was wrong with reference 48 removed by ILCOR after publication 2015?

  1. US Food and Drug Administration. FDA News Release: FDA approves new hand-held auto-injector to reverse opioid overdose. 2015.  Accessed May 11, 2015.

Quote p.1 “It is intended for the emergency treatment of known or suspected opioid overdose, characterized by decreased breathing or heart rates, or loss of consciousness.”

Response: Decreased breathing essential to provide rescue breaths. Rarely decreased heart rate ‘bradycardia’, pushing on the chest is not going to increase heart rate, suppling rescue breathing should increase heart rate.  Cause of bradycardia lack of oxygen has causes your blood chemistry’s calcium levels to go high, this hyper calcium slows the heart rate. 

49. Maxwell S, Bigg D, Stanczykiewicz K, Carlberg-Racich S. Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis. 2006;25:89–96.

Quote p.90 “techniques of rescue breathing, routes of administration and dosing guidelines for Naloxone”

50. Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174  http://www.bmj.com/content/346/bmj.f174

Quote p.1 “providing rescue breathing, and delivering naloxone”

51. Walley AY, Doe-Simkins M, Quinn E, Pierce C, Xuan Z, Ozonoff A. Opioid overdose prevention with intranasal naloxone among people who take methadone. J Subst Abuse Treat. 2013;44:241–247.

Quote p.242“prevent a non-fatal over dose progressing to a fatal overdose by using naloxone, rescue breathing and seeking help”

52. Albert S, Brason FW 2nd, Sanford CK, Dasgupta N, Graham J,
Lovette B. Project Lazarus: community-based overdose prevention
in rural North Carolina. Pain Med. 2011;12 Suppl 2:S77–S85.
doi: 10.1111/j.1526-4637.2011.01128.x.

Quote p.81  “known etiology of opioid-induced respiratory depression” p.83 “One concern with prehospital administration of naloxone is the return of respiratory depression.”
“there is reason to believe that return of opioid depression after an initial administration of naloxone may be different in hospital and community settings”

Response: ‘Return of opioid depression may be different in community setting’ makes sense, paramedics and ED department would tend to be better at airway management.


Correspondence from Dr. Aaron Orkin co-author 2015 AHA toxic ingestions Dr. Aaron Orkin also co-author Ontario’s protocol CJPH 2013;104(3):e200-6 see above

2015 AHA Toxic Ingestions 

61.Centers for Disease Control and Prevention. Injury prevention and control: prescription drug overdose. http://www.cdc.gov/drugoverdose/index.html Accessed March 17, 2015.

Click hyperlink ‘Learn More about the Epidemic’ Quote “Taking too many prescription painkillers can stop a person’s breathing—leading to death.”

62.Hedegaard H, Chen LH, Warner M. Drug-poisoning deaths involving heroin: United States, 2000–2013. http://www.cdc.gov/nchs/data/databriefs/db190.htm Accessed March 17, 2015.

Response: No mention of the cause of death. Common knowledge poisoning drug OD is a respiratory emergency.

63. Centers for Disease Control and Prevention. Fatal injury data. http://www.cdc.gov/injury/wisqars/fatal.html Accessed April 4, 2015.

Response: No mention of the cause of death.  Common knowledge poisoning drug OD is a respiratory emergency.

64.Carter CI, Graham B. Opioid overdose prevention and response in Canada. http://drugpolicy.ca/wp-content/uploads/2014/07/CDPC_OverdosePreventionPolicy_Final_July2014.pdf Accessed March 17, 2015.

Quote p.4 “In the case of overdose, an individual’s breathing drops below 10-12 breaths per minute. Insufficient oxygen levels can result in the lips and/or nails turning blue, strange gurgling/snoring sounds, cool and clammy skin, seizures, and muscle spasms because there is no longer sufficient oxygen in the blood. Without enough oxygen, the heart will stop beating and the individual will die. Though death can occur within minutes of taking an opioid, more often there is a longer period of unresponsiveness lasting up to several hours.”

65. Jones CM, Paulozzi LJ, Mack KA; Centers for Disease Control and Prevention (CDC). Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug related deaths – United States, 2010. MMWR Morb Mortal Wkly Rep.2014;63:881–885.

Quote p. 881 “When taken with opioid pain relievers or benzodiazepines, alcohol increases central nervous system depression and the risk for overdose.”

Response: Naloxone is ineffective against poly drug OD.

66. Madadi P, Hildebrandt D, Lauwers AE, Koren G. Characteristics of opioid-users whose death was related to opioid-toxicity: a population-based study in Ontario, Canada. PLoS One. 2013;8:e60600. doi: 10.1371/journal.pone.0060600.

Quote p. 1 “Evidence and insight on how and why opioid-related deaths occur”

Response: No mention in article cause of death. Humankind has known since the invent of opium (5,500 years ago) cause of death Acute Respiratory Failure.  It’s in the Old and New Testaments of the Bible

67. Webster LR, Cochella S, Dasgupta N, Fakata KL, Fine PG, Fishman SM, Grey T, Johnson EM, Lee LK, Passik SD, Peppin J, Porucznik CA, Ray A, Schnoll SH, Stieg RL, Wakeland W. An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011;12suppl 2:S26–S35. doi: 10.1111/j.1526-4637.2011.01134.x.

Quote p. 26 “Other likely contributors to all opioid-related deaths were the presence of additional central nervous system-depressant drugs (e.g., alcohol, benzodiazepines, and antidepressants) and sleep-disordered breathing.”  p. 30 “overestimating the tolerance to respiratory depression conferred by prior opioid use in patients with chronic pain.” p.32 “When patients with presumed opioid tolerance and no apparent substance use disorder die of respiratory depression…”

Response:  Don’t push on a beating heart that’s murder, patient needs air.  0.5 liters of air every 5 seconds to stay alive.  Less than 12-10 breaths per minute you are dying lack of oxygen

68. Paulozzi LJ, Logan JE, Hall AJ, McKinstry E, Kaplan JA, Crosby AE. A comparison of drug overdose deaths involving methadone and other opioid analgesics in West Virginia. Addiction. 2009;104:1541–1548. doi:10.1111/j.1360-0443.2009.02650.x.

Quote p. 1542 “Unlike addictions specialists, however, primary care providers using methadone for pain may have been unfamiliar with its prolonged depressant effects on the central nervous system.”

69. Krantz MJ, Kutinsky IB, Robertson AD, Mehler PS. Dose-related effects of methadone on QT prolongation in a series of patients with torsade de pointes. Pharmacotherapy. 2003;23:802–805.

Response: Don’t give chest compressions for an irregular heart beat, you will just make it worse (common knowledge).  Case reports Methadone OD.  Respiratory assist then Naloxone more rescue breathing.  Naloxone can be in effective  Naloxone ineffective

70.Eap CB, Crettol S, Rougier JS, Schläpfer J, Sintra Grilo L, Déglon JJ, Besson J, Croquette-Krokar M, Carrupt PA, Abriel H. Stereoselective block of hERG channel by (S)-methadone and QT interval prolongation in CYP2B6 slow metabolizers. Clin Pharmacol Ther. 2007;81:719–728. doi:10.1038/sj.clpt.6100120.

See case reports Methadone OD ref 69 above

71.Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MC. QTc interval screening in methadone treatment. Ann Intern Med.2009;150:387–395.

Quote p. 388 “Because fewer than half of the physicians surveyed among accredited opioid treatment programs in the United States were aware of the association between methadone and QTc interval prolongation (20), the panel believed a consensus document was warranted.”

Quote p. 390 “…these series cannot distinguish the cause of death as arrhythmic or attributable to respiratory depression from overdose.”

Response: It has long been known that Methadone is toxic and cumulative (ref. 1 & 2)  See case reports Methadone OD ref 69 above. Methadone overdose causes death acute respiratory failure.

Ref 1. ‘Methadone: A 3-in-1 Medical Reference’ Ed. James N. Parker; Philip M. Parker ICON Health Publications 2003

Ref 2. ‘Methadone and Pregnancy: An annotated guide to the literature’ Journal of Psychoactive Drugs Volume 6,  Issue 1, 1974 pp. 101-124  DOI:10.1080/02791072.1974.10471512

72.Stallvik M, Nordstrand B, Kristensen Ø, Bathen J, Skogvoll E, Spigset O. Corrected QT interval during treatment with methadone and buprenorphine–relation to doses and serum concentrations. Drug Alcohol Depend.2013;129:88–93. doi:10.1016/j.drugalcdep.2012.09.016.

See case reports Methadone OD ref 69 above

73. Chou R, Weimer MB, Dana T. Methadone overdose and cardiac arrhythmia potential: findings from a review of the evidence for an American Pain Society and College on Problems of Drug Dependence clinical practice guideline. J Pain. 2014;15:338–365. doi:10.1016/j.jpain.2014.01.495.

See case reports Methadone OD ref 69 above

74. Lipski J, Stimmel B, Donoso E. The effect of heroin and multiple drug abuse on the electrocardiogram. Am Heart J. 1973;86:663–668.

Quote p. 666 “Anoxia and increased vagal tone caused by the drug was postulated as the etiologic mechanism.” p. 667 “respiratory depression produced by methadone”

Response:  ‘Anoxia’ means sever hypoxia organ and cell death. Less than 0.5 liters of air every five seconds for an adult you are dying hypoxia.

75. Labi M. Paroxysmal atrial fibrillation in heroin intoxication. Ann Intern Med. 1969;71:951–959.

Quote p. 951 “The major medical complications of heroin intoxication include respiratory depression…” “All patients were comatose and five had severe respiratory depression manifested by slow and shallow respiration”

76. Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid pulse. Resuscitation. 1997;35:23–26.

Response: No need to check for pulse Public Health Ontario’s signs of overdose proves the heart is beating, patient is dying respiratory failure. https://vimeo.com/68067103 Listen 9:20 secs signs of respiratory emergency.

77. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation. 1996;33:107–116.

See above response ref 76  Cardiac arrest happens after you are brain dead lack of oxygen.  Chest compressions only just makes sure you stay dead.

78. Leach M. Naloxone: a new therapeutic and diagnostic agent for emergency use. JACEP. 1973;2:21–23.

Quote p. 71 “Narcotic overdosage can lead to central nervous system and respiratory depression, a medical emergency demanding immediate attention”

Response:  Every second you delay rescue breathing every cell, tissue and organ is dying lack of oxygen, especially the brain.

79. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med. 1996;3:660–667.

Quote p. 660 “Those patients with at least 3 of 5 objective criteria of an opioid overdose [respiratory rate<6/min, pinpoint pupils, evidence of IV drug use, Glasgow Coma Scale (GCS) score <12, or cyanosis] were included.”

Response: Any coma patient needs rescue breathing it’s not a cardiac arrest.  Coma proves the heart is beating.

80. Robertson TM, Hendey GW, Stroh G, Shalit M. Intranasal naloxone is a viable alternative to intravenous naloxone for prehospital narcotic overdose. Prehosp Emerg Care. 2009;13:512–515. doi:10.1080/10903120903144866. Quote p. 512 “Clinical response was defined as an increase in respiratory rate (breaths/min)…”

Response: Stabilize the patient first with rescue breaths, then Naloxone, continue rescue breaths, until transported to emergency department.

81. Evans LE, Swainson CP, Roscoe P, Prescott LF. Treatment of drug overdosage with naloxone, a specific narcotic antagonist. Lancet.1973;1:452–455. Quote p. 452 “Accidental and deliberate overdosage with narcotic analgesics is an increasingly common problem, and is especially dangerous because of severe respiratory depression” p. 454 “Large doses of Naloxone were sometimes needed to obtain an adequate response in patients with severe intoxication, and a patient who had taken dipipanone single doses of 0.4 mg. produced only minor transient increases in respiration which were not at first recognised as a response to Naloxone. The subsequent injection of 1.2 mg. produced an immediate return to consciousness and a striking increase in respiration-rate and minute volume.” “There was no significant change in the level of consciousness, respiration rate, minute volumn, blood pressure, pulse rate, or pupil size after injection of Naloxone in the patients intoxicated with hypnotics, tranquillisers, and antidepressants.”

Response: Naloxone does not always work, keep the poisoned patient alive rescue breaths till the drugs wear off, transport to emergency department.

82. Kelly AM, Kerr D, Dietze P, Patrick I, Walker T, Koutsogiannis Z. Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose. Med J Aust. 2005;182:24–27. Quote p. 182 “treatment of respiratory depression due to suspected opiate overdose in the prehospital setting” “Response time to regain a respiratory rate greater than 10 per minute”

Response: Every second you delay respiratory assist every cell, tissue and organ is dying, especially the brain.

83. Barton ED, Colwell CB, Wolfe T, Fosnocht D, Gravitz C, Bryan T, Dunn W, Benson J, Bailey J. Efficacy of intranasal naloxone as a needleless alternative for treatment of opioid overdose in the prehospital setting. J Emerg Med. 2005;29:265–271. doi: 10.1016/j.jemermed.2005.03.007. Quote p. 265 “All adult patients encountered in the pre hospital setting as suspected opiate overdose (OD), found down (FD), or with altered mental status (AMS)”  “Patients were then treated by EMS protocol”  “Seven patients (16%) in this group required further doses of i.v. naloxone”  p. 267 “Immediately after i.n. Naloxone, the standard protocol including airway management”  “… care for life threatening illnesses such as respiratory arrest from opiate overdose”

Response: EMS protocol same as for lay responders rescue breathing ASAP.

84. Wolfe TR, Braude DA. Intranasal medication delivery for children: a brief review and update. Pediatrics. 2010;126:532–537. doi: 10.1542/peds.2010-0616. Quote p. 533 “Other potential uses for intranasal medication delivery that are not included in this review include the treatment of reversal of …….narcotic overdose with naloxone”

85. Loimer N, Hofmann P, Chaudhry HR. Nasal administration of naloxone is as effective as the intravenous route in opiate addicts. Int J Addict. 1994;29:819–827. Quote p. 819 “Initial and final unassisted respiratory rates (RR) and GCS, recorded by paramedics, were used as indicators of naloxone effectiveness. The median changes in RR and GCS were determined.” “Additionally, we demonstrated that GCS is correlated with RR in opioid intoxication”

Response: Glasgow coma scale patient in coma heart is beating.

86. Doe-Simkins M, Walley AY, Epstein A, Moyer P. Saved by the nose: bystander-administered intranasal naloxone hydrochloride for opioid overdose. Am J Public Health. 2009;99:788–791. doi: 10.2105/AJPH.2008.146647. Quote p. 789 “1 [person] did not administer naloxone, but delivered rescue breathing” p. 790 “Thus, there was some peer-to-peer overdose knowledge and skill transfer beyond the program”

Response: Toronto ‘POINT’ program is transferring contraindicated skills”

87. Wanger K, Brough L, Macmillan I, Goulding J, MacPhail I, Christenson JM. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med. 1998;5:293–299. Quote p. 293 “cohort study of 196 consecutive patients with suspected opioid overdose was conducted in an out-of-hospital setting, comparing time intervals from arrival at the patient’s side to development of a respiratory rate >10 breaths/min, and durations of bag-valve-mask ventilation.”

Response: bag-valve-mask ventilation same as rescue breathing for lay responders.

88. Baumann BM, Patterson RA, Parone DA, Jones MK, Glaspey LJ,Thompson NM, Stauss MP, Haroz R. Use and efficacy of nebulized naloxone in patients with suspected opioid intoxication. Am J Emerg Med. 2013;31:585–588. doi: 10.1016/j.ajem.2012.10.004.

Quote p. 585 “Need for supplemental oxygen”

Response: No mention of chest compressions only.

89. Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB. Can nebulized naloxone be used safely and effectively by emergency medical services for suspected opioid overdose? Prehosp Emerg Care. 2012;16:289–292. doi: 10.3109/10903127.2011.640763.

Quote p. 289 “Included were cases of suspected opioid overdose, altered mental status, and respiratory depression” “…need for rescue naloxone (IV or intramuscular), need for assisted ventilation”

p. 291 “twenty three(22%) had complete response, 62(59%) had partial response, and 20(19%) had no response to nebulized naloxone”

90. Greenberg MI, Roberts JR, Baskin SI. Endotracheal naloxone reversal of morphine-induced respiratory depression in rabbits. Ann Emerg Med. 1980;9:289–292.  http://www.annemergmed.com/article/S0196-0644(80)80060-6/abstract

Quote p. 289 “Our study was performed to determine if naloxone could be efficacious in reversing morphine-induced respiratory depression”

Response: Respiratory depression is not a sudden witnessed cardiac arrest.

91. Posner J, Burke CA. The effects of naloxone on opiate and placebo analgesia in healthy volunteers. Psychopharmacology (Berl).1985;87:468–472.

Quote p. 468 “The results do not support the involvement of endogenous opioids in ischemic limb pain or placebo analgesia”

92. Borras MC, Becerra L, Ploghaus A, Gostic JM, DaSilva A, Gonzalez RG, Borsook D. fMRI measurement of CNS responses to naloxone infusion and subsequent mild noxious thermal stimuli in healthy volunteers. J Neurophysiol. 2004;91:2723–2733. doi:10.1152/jn.00249.2003.

Response This paper is not dealing with opioid overdose.

93. Clarke SF, Dargan PI, Jones AL. Naloxone in opioid poisoning: walking the tightrope. Emerg Med J. 2005;22:612–616. doi: 10.1136/emj.2003.009613.  https://www.researchgate.net/publication/7647917_Naloxone_in_opioid_poisoning_Walking_the_tightrope

Quote p. 612 “instances have been reported where over 20 times the recommended doses of naloxone have been needed to counteract massive opioid overdoses, and even more in body packers. Numerous case histories have revealed a 13-fold variation in rate of naloxone infusions given for prolonged overdoses.” “the respiratory depression. Seizures and arrhythmias have also been noted, but could have been caused by hypoxia [oxygen depravation], the opioids themselves, their coingestants (most notably cocaine)”

94. Walley AY, Doe-Simkins M, Quinn E, Pierce C, Xuan Z, Ozonoff A. Opioid overdose prevention with intranasal naloxone among people who take methadone. J Subst Abuse Treat. 2013;44:241–247. doi: 10.1016/j.jsat.2012.07.004.

Quote p.242 “educate potential overdose victims and bystanders how to prevent an overdose from occurring, recognize and overdose when it occurs and prevent a non-fatal overdose from progressing to a fatal overdose by using naloxone, rescue breathing, and seeking help.”

Response: If you don’t give rescue breathing they will probably wind up with a fatal overdose. Chest compressions only just quickens the patients death.

95. Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med. 2014;8:153–163. doi:10.1097/ADM.0000000000000034.

Quote p. 155 “Three studies were primarily descriptive but  included outcome information based on spontaneous self-report of OOPP participants  (Leece et al., Can. J. Public Health 2013;104(3):e200-4)” “Sixteen articles reported an OOPP curriculum that included appropriate responses to overdose events…instructions on rescue breathing”

Response: This article states Leece et al., Can. J. Public Health 2013;104(3):e200-4 the only program that teaches chest compressions only.

96. Lagu T, Anderson BJ, Stein M. Overdoses among friends: drug users are willing to administer naloxone to others. J Subst Abuse Treat.2006;30:129–133. doi: 10.1016/j.jsat.2005.05.010.

Quote p. 129 “Overdose of drugs such as heroin and morphine causes death by respiratory depression”  “The addition of other central nervous system depressants such as alcohol and benzodiazepine seems to increase risk for life-threatening  respiratory depression..” “Unfortunately, most injection drug users will witness an overdose at least once, and although at least one study indicates the desire of drug users to intervene, the best interventions are often not used and emergency services are frequently not notified”

Response:  There are hundreds of causes of respiratory emergency all can be misdiagnosed as a drug OD.

97. Tracy M, Piper TM, Ompad D, Bucciarelli A, Coffin PO, Vlahov D, Galea S. Circumstances of witnessed drug overdose in New York City:implications for intervention. Drug Alcohol Depend. 2005;79:181–190. doi: 10.1016/j.drugalcdep.2005.01.010.

Quote p. 181 “opportunities for those present to reduce potential morbidity and mortality through timely intervention.  More than 90% of heroin overdoses victims who receive emergency medical care still exhibiting pulse and blood pressure survive, although neurological and other physical effects of overdose become more severe if hypoxia [oxygen depletion] is prolonged”

Response: Any respiratory emergency case that does not receive prompt rescue breathing they are dying lack of oxygen.

98. US Food and Drug Administration. FDA News Release: FDA approves new hand-held auto-injector to reverse opioid overdose. 2015. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm Accessed May 11, 2015.

Quote “It is intended for the emergency treatment of known or suspected opioid overdose, characterized by decreased breathing or heart rates, or loss of consciousness.”
“Because naloxone may not work as long as opioids, repeat doses may be needed. Evzio is not a substitute for immediate medical care, and the person administering Evzio should seek further, immediate medical attention on the patient’s behalf.”

Response:  ‘immediate medical attention’  rescue breathing essential, for all respiratory emergencies.

99. Tataris KL, Weber JM, Stein-Spencer L, Aks SE. The effect of prehospital nebulized naloxone on suspected heroin-induced bronchospasm. Am J Emerg Med. 2013;31:717–718. doi:10.1016/j.ajem.2012.11.025.

Quote p. 717 “Snorting or smoking heroin is a known trigger of acute asthma exacerbation”

Response: ‘Acute asthma’ another reason to  supply rescue breathing.

100. Aaron M Orkin, Katherine Bingham, Michelle Klaiman, Pamela Leece, Jason E Buick, Fiona Kouyoumdjian, Laurie J Morrison, Howard Hu.  ‘An Agenda for Naloxone Distribution Research and practice: Meeting report of the Surviving Opioid Overdose with Naloxone (SOON) International Working Group.’ J Addict Res Ther. 2015;6:212

Quote p.3 “Existing basic life (BLS) support guidelines provide little specific guidance regarding bystander or layperson best practices in the management of suspected opioid related emergencies.”  p.5  Figure 1 ‘BLS & Bystander resuscitation guidelines’ “No consensus on the role of ventilations”

Response: Correspondence Dr. Laurie Morrison above  Nonsense we have known for five thousand years eat to much opium (any poisoning ad fin item) you stop breathing. Certificate CPR baby sitter program, rescue breathing for poisoning drug OD.  Heart finally stops brain dead lack of oxygen, chest compression’s only just makes sure you stay dead. Note highlighted authors also part of this live human study ‘Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario.’  Can. J. Public Health 2013;104(3):e200-4 

101. Kerr D, Kelly AM, Dietze P, Jolley D, Barger B. Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction. 2009;104:2067–2074. doi: 10.1111/j.1360-0443.2009.02724.x.

Quote p. 2068 “Supportive care (primarily breathing support) was administered simultaneously , in accordance with ambulance clinical practice guidelines for this condition.”

Response: Lay responders for any respiratory emergency rescue breathing.

102. Boyd JJ, Kuisma MJ, Alaspää AO, Vuori E, Repo JV, Randell TT. Recurrent opioid toxicity after pre-hospital care of presumed heroin overdose patients. Acta Anaesthesiol Scand. 2006;50:1266–1270.  doi:10.1111/j.1399-6576.2006.01172.x.

Quote p. 1276 “For the purpose of this study, we considered patients with a Glasgow Coma Scale (GCS) of eight or less to be overdose cases, even if signs of respiratory depression were not recorded.  Signs of respiratory depression were considered to be a respiratory rate of less than 12 breaths/min, a peripheral oxygen saturation of less than 90% without supplemental oxygen (or less than 95% with supplemental oxygen) or cyanosis on arrival of the first responding unit.”   “Eight patients recovered by ventilator assistance alone and five patients recovered spontaneously.”

Response Cardiac arrest patients were excluded, reason chance of  survival very slim patient in cardiac arrest, more than likely brain dead hypoxia (lack of oxygen).

103: Buajordet I, Naess AC, Jacobsen D, Brørs O. Adverse events after naloxone treatment of episodes of suspected acute opioid overdose. Eur J Emerg Med. 2004;11:19–23.

Quote p. 19 “Initially, patients with life-threatening opioid overdose were artificially ventilated”

Response: Rescue breathing for lay responder.

104. Cantwell K, Dietze P, Flander L. The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting. Resuscitation. 2005;65:315–319. doi: 10.1016/j.resuscitation.2004.12.012.

Quote p. 316 “The CPGs (clinical practice guidelines) specify  that all suspected narcotic overdose patients be treated with 100% oxygen and ventilator support and be administered a standard dose of naloxone (1.6-2.0 mg IMI)”

Response Rescue breathing for lay responder.

105. Cetrullo C, Di Nino GF, Melloni C, Pieri C, Zanoni A. [Naloxone antagonism toward opiate analgesic drugs. Clinical experimental study]. Minerva Anestesiol. 1983;49:199–204. [Article in Italian]


Bologna,September 16th,2014: Dear friend,the article you requested goes back to 1983 and I do not possess any other copy in my archives.Moreover the article is in italian and I am sure you can find more interesting and moreup to date articles on Pubmed.Sorry for the delay,Claudio Melloni,Md,PhD.

106. Nielsen K, Nielsen SL, Siersma V, Rasmussen LS. Treatment of opioid overdose in a physician-based prehospital EMS: frequency and longterm prognosis. Resuscitation. 2011;82:1410–1413. doi: 10.1016/j.resuscitation.2011.05.027.

Quote p. 1410 “Treatment consists of basic life support, including bag-valve ventilation, and the administration of the opioid antagonist naloxone.”

Response Bag- valve ventilation same as rescue breathing for lay responder.

107. Osterwalder JJ. Naloxone–for intoxications with intravenous heroin and heroin mixtures–harmless or hazardous? A prospective clinical study. J Toxicol Clin Toxicol. 1996;34:409–416.

Quote p.409 “The short time between naloxone administration and the occurrence of complications, as well as the type of complications, are strong evidence of a causal link. In 1,000 clinically diagnosed intoxications with heroin or heroin mixtures, from 4 to 30 serious complications can be expected. Such a high incidence of complications is unacceptable and could theoretically be reduced by artificial respiration with a bag valve device (hyperventilation) as well as by administering naloxone in minimal divided doses, injected slowly.”

Response: Of course you need to stabilize the patient with rescue breathing before naloxone, and continue rescue breathing.

108. Stokland O, Hansen TB, Nilsen JE. [Prehospital treatment of heroin intoxication in Oslo in 1996]. Tidsskr Nor Laegeforen. 1998;118:3144–3146.  http://www.ncbi.nlm.nih.gov/pubmed/9760858

The number of heroin overdoses among drug addicts in Oslo is increasing. In 1996 overdoses counted for 1,248 (12%) of all emergency call-outs by the ambulance service. Heroin can cause fatal respiratory insufficiency, and in 1996 a total of 104 deaths related to heroin overdoses were reported in Oslo. Heroin overdoses are treated on site by ambulance personnel. Advanced cardiopulmonary resuscitation was started on 18 of the 79 addicts who were found unconscious, and 11 persons were treated successfully. A total of 846 drug addicts had to be given the antidote naloxone, and among these 678 (80%) persons were found in a coma. Only 29 persons had to be transported to hospital. Early treatment probably prevented both morbidity and mortality, no time being wasted transporting the patients to hospital. Ambulance personnel treat all drug addicts with the same respect as they do other patients. They have no police escort; they are familiar with the addicts and their environment and they have gained their confidence. Prehospital treatment saves on health services resources, and should, in our experience, be carried out in collaboration with a hospital or other health institutions for mutual and optimal benefit.

109. Wampler DA, Molina DK, McManus J, Laws P, Manifold CA. No deaths associated with patient refusal of transport after naloxone reversed opioid overdose. Prehosp Emerg Care. 2011;15:320–324. doi:10.3109/10903127.2011.569854.

Quote p. 321 “management of suspected narcotic overdose consists of standing orders for immediate ventilator support and 2 mg. of Naloxone administered intramuscularly (IM).”

110. Saybolt MD, Alter SM, Dos Santos F, Calello DP, Rynn KO, Nelson DA, Merlin MA. Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation. 2010;81:42–46. doi: 10.1016/j.resuscitation.2009.09.016.

Quote p. 42 “Due to low rates of return of spontaneous circulation and survival during cardiac arrest…”

Response:  Naloxone in cardiac arrest with suspected opioid overdose
Lay responders better find the patient before cardiac arrest, patient is probably brain dead lack of oxygen.

111. Stoové MA, Dietze PM, Jolley D. Overdose deaths following previous non-fatal heroin overdose: record linkage of ambulance attendance and death registry data. Drug Alcohol Rev. 2009;28:347–352. doi:10.1111/j.1465-3362.2009.00057.x.

Quote p. 347 “Non-fatal overdose results in significant morbidity”

Response: Morbidity happens because prompt rescue breathing not applied.

112. Chan GM, Stajic M, Marker EK, Hoffman RS, Nelson LS. Testing positive for methadone and either a tricyclic antidepressant or a benzodiazepine is associated with an accidental overdose death: analysis of medical examiner data. Acad Emerg Med. 2006;13:543–547. doi: 10.1197/j.aem.2005.12.011.

Quote p. 543 “Methadone can cause life-threatening respiratory and central nervous system depression when the dose is excessive or when combined BZD [benzodiazepines]. Respiratory depression may also result in respiratory acidosis that potentiates the cardiotocicity of TCAs [tricylic antidepressants]”

Response: Respiratory acidosis, blood has become toxic lack of oxygen.

113. Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2010: national estimates of drug-related emergency department visits. 2010. http://archive.samhsa.gov/data/2k13/DAWN2k10ED/DAWN2k10ED.pdf Accessed May 13, 2013.

Quote p.15 “When population size and sampling error were taken into account, women had notably more visits than men (909.3 and 590.2 visits per 100,000 population, respectively) involving drug-related adverse reactions. For children aged 5 and under, the rate of ED visits for adverse reactions was 736.0 visits per 100,000 population.”

Response:  No mention of treatment.  Poisoning drug OD is happening to your women and children.

114. Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, Koepsell TD. Release from prison–a high risk of death for former inmates. N Engl J Med. 2007;356:157–165. doi: 10.1056/NEJMsa064115.

Response: No statement on the etiology of overdose.

115. Davoli M, Bargagli AM, Perucci CA, Schifano P, Belleudi V, Hickman M, Salamina G, Diecidue R, Vigna-Taglianti F, Faggiano F; VEdeTTE Study Group. Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multisite prospective cohort study. Addiction. 2007;102:1954–1959. doi:10.1111/j.1360-0443.2007.02025.x.

Quote p. 1955 ‘Cause of death was coded according to the International Classification of Diseases (ICD) (IX revision). The following ICD codes were selected: 292;  304.0–.9; 305.2–.9; 965.0–.9; 969.0–.9; E850–E858; E980.0–.5–.9; E950.0–.5–.9; E962. According to the European Monitoring Centre for Drugs and Drug Addiction protocol for drug-related deaths [18], these codes  correspond mainly to the causes of death ‘drug dependence’ and ‘poisoning’.

Response: The only info on cause of death.  Any poisoning is a respiratory emergency

116. Caplehorn JR. Deaths in the first two weeks of maintenance treatment in NSW in 1994: identifying cases of iatrogenic methadone toxicity. Drug Alcohol Rev. 1998;17:9–17. doi: 10.1080/09595239800187551.

Quote p.10 “As the lungs of people dying of methadone toxicity are often under-ventilated for prolonged periods, bacteria have time to invade the lower airways and the body [NO] time to mount an immune response”

Response: Side affect of any respiratory emergency patient that does not receive prompt rescue breathing.

117. Woody GE, Kane V, Lewis K, Thompson R. Premature deaths after discharge from methadone maintenance: a replication. J Addict Med.2007;1:180–185. doi: 10.1097/ADM.0b013e318155980e.

Quote p.183 “produces fatal respiratory depression”

118. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171:686–691. doi:10.1001/archinternmed.2011.117.

Quote p. 690 “…bears reiterating that the outcome is mortality, and preventing any number of avoidable deaths should be a major public health priority.”

Response Article does not mention the cause of death.

119. Degenhardt L, Bucello C, Mathers B, Briegleb C, Ali H, Hickman M, McLaren J. Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction. 2011;106:32–51. doi: 10.1111/j.1360-0443.2010.03140.x.

Quote p.32 “opioid overdose which, if not fatal, can require resuscitation”

120. Vilke GM, Sloane C, Smith AM, Chan TC. Assessment for deaths in outof-hospital heroin overdose patients treated with naloxone who refuse transport. Acad Emerg Med. 2003;10:893–896.

Response Article makes no statement about protocol used.  See reference number 1. EMT-Paramedic Program Adult Medication List.  San Diego County Division of Emergency Medical Services Policy/ Procedure/Protocol, P-115, 2001.

121. Rudolph SS, Jehu G, Nielsen SL, Nielsen K, Siersma V, Rasmussen LS. Prehospital treatment of opioid overdose in Copenhagen–is it safe to discharge on-scene? Resuscitation. 2011;82:1414–1418. doi: 10.1016/j.resuscitation.2011.06.027.

Quote p. 1415 “Basic treatment for the unresponsive patient is administration of supplemental oxygen, ventilation by bag-valve mask and intravenous injection of 0.8 mg naloxone.”

Response Bag-valve mask same as rescue breathing for lay responder.

122. Moss ST, Chan TC, Buchanan J, Dunford JV, Vilke GM. Outcome study of prehospital patients signed out against medical advice by field paramedics. Ann Emerg Med. 1998;31:247–250.

Quote p. 247 “Study objective: To describe the incidence and demographic data of prehospital patients who contact paramedics by way of the 911 system, refuse transport against medical advice.
Of 6,512 total 911 responses reviewed, 12 received Naloxone”

Response This is not an article dealing specifically with opioid overdose.

123. Christenson J, Etherington J, Grafstein E, Innes G, Pennington S, Wanger K, Fernandes C, Spinelli JJ, Gao M. Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule. Acad Emerg Med. 2000;7:1110–1118.

Quote p. 1110 “Clinical findings from 573 patients allowed us to develop a clinical prediction rule with a sensitivity of 99% (95% CI = 96% to 100%) and a specificity of 40% (95% CI = 36% to 45%). Patients with presumed opioid overdose can be safely discharged one hour after naloxone administration if they: 1) can mobilize as usual; 2) have oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and 35.0 degrees C and 50 beats/min and

Response Respiratory rate and Glasgow coma scale.  Not dealing with cardiac arrest, caused secondary to respiratory arrest.

124. Etherington J, Christenson J, Innes G, Grafstein E, Pennington S, Spinelli JJ, Gao M, Lahiffe B, Wanger K, Fernandes C. Is early discharge safe after naloxone reversal of presumed opioid overdose? CJEM. 2000;2:156–162.

Quote p. 156 “required a critical intervention, including supplemental oxygen for hypoxia, repeat Naloxone”

125. Zuckerman M, Weisberg SN, Boyer EW. Pitfalls of intranasal naloxone. Prehosp Emerg Care. 2014;18:550–554. doi: 10.3109/10903127.2014.896961.

Quote p. 550 “In order to contribute to our understanding of the strengths and limitations of IN administration of naloxone, we present a case where it failed to restore ventilation”

Response:  Rescue breathing until drugs wear off and patient breaths adequately on their own.

END OF 2015 References more found below 

Hundreds of millions of references can be found in the medical textbooks and data bases all say rescue breathing then Naloxone continue rescue breathing until patient breaths adequately on their own.

World Health Organization 2013 Page 7  http://www.unodc.org/docs/treatment/overdose.pdf “In the case of suspected opioid overdose, any respiratory arrest should be managed with assisted breathing and/or oxygen while waiting for naloxone to be administered and take effect.” “If naloxone is not available, overdose can be treated with respiratory support, either mouth-to-mouth, with a bag and mask, or with pressure-controlled ventilation.”

Naloxone Hydrochloride Monograph 2015 “Administration should be accompanied by other resuscitive measures such as administration of oxygen, mechanical ventilation, or artificial respiration.”

International Programme on Chemical Safety ” Since many of these patients suffer from impaired respiration or respiratory arrest, it is extremely important to give oxygen and to support ventilation immediately while waiting for naloxone to beavailable for injection. If ventilation is under control and cyanosis is regressing”   “adequate ventilatory support must be given.”

Harm Reduction Coalition Page 60 http://harmreduction.org/wp-content/uploads/2012/11/od-manual-final-links.pdf “When someone has extremely shallow and intermittent breathing (around one breath every 5-10 seconds) or has stopped breathing and is unresponsive, rescue breathing should be done as soon as possible; it is the quickest way of getting oxygen to someone who has stopped breathing. If you are performing rescue breathing, you are getting much needed air into someone’s body who will die without it; the difference between survival and death in an opioid overdose depends on how quickly enough oxygen gets into the person’s body.”

2011 Poisoning and Toxicology Handbook pages 35:(83) & 85:(132)  https://ilmufarmasis.files.wordpress.com/2011/07/toxicology-and-poisoning-handbook.pdf “In this manner, the  initial approach to the poisoned patient should be essentially similar in every case, irrespective of the toxin ingested, just as the initial approach to the trauma patient is the same irrespective of the mechanism of injury. This approach, which can be termed as routine poison management, essentially includes the following aspects: Stabilization: ABCs (airway, breathing, circulation); administration of glucose, thiamine, oxygen, and naloxone”  [More accurate ABCD (airway, breathing, circulation, drugs); if no heart beat, no use giving Naloxone.  Chest compressions only is just making sure you stay dead.  Cardiac arrest patient needs ACLS methods: vasopressors, open chest cardiac massage, electro-shock paddles etc. brain dead lack of oxygen] “Initial measures include airway protection, vital sign monitoring, and administration of naloxone, an opiate antagonist.”

Ontario Poison Centre  50,000 Ontarian’s are poisoned each year 28,000 children

Ontario Poison Centre Step 2 BVM = rescue breathing continue breaths all times. Start low dose naloxone  ‘Street Opioid Resuscitation Recommendations’ For Pre-Hospital and Hospital Care  Accessed March 12, 2017

Compressions only CPR AHA Guidelines 2010 Part 4 http://circ.ahajournals.org/content/122/18_suppl_3/S676.full.pdf+html “Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the chance of survival following cardiac arrest.”  “Immediate recognition of cardiac arrest”  [signs of cardiac arrest totally different than respiratory emergency: No pallor; huge pupils; agonal gasps; seizure]

Sudden cardiac arrest Agonal Breathing  Video different signs than respiratory emergency

Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions  Emergency Medicine News: 2011;33(10)p.16-8 2011 – Volume 33(10)p. 16-8  “cardiac arrest and severe drug toxicity in the pre- and post-arrest phase are different scenarios. Don’t confuse post- or pre–arrest toxicologic interventions with the actual cardiac arrest event.”  “there is no drug, antidote, or intervention that alters the outcome of cardiac arrest from a toxin”

CARDIAC ARREST IS SECONDARY TO RESPIRATORY ARREST A COMPLETLY DIFFERENT ANIMAL THAN A SIMPLE CARDIAC ARREST 2010 American Heart Association Guidelines for Cardio pulmonary Resuscitation and Emergency Cardiovascular Care Field JM, et al Circulation 2010;122(18 Suppl 3):S639  “Severe poisonings alter cellular receptors, ion channels, and chemical pathways in a manner different from cardiac arrest secondary to coronary disease or other more common entities. Although managing cardiac arrest after toxic exposures similarly begins with airway, breathing, and circulation, cardiac arrest due to a medication overdose or toxin conjures up interventions of a special nature. Although a few antidotes have the potential to rapidly neutralize or reverse the toxic effects of drugs in the still living, the majority of one’s arsenal to treat cardiorespiratory collapse secondary to a drug overdose is primarily basic support.”  [rescue breathing]

Canadian Red Cross CC only “Compression-only CPR should not be used when the oxygen in the victim’s body has likely been used up, such as with a drowning victim or when a [any] respiratory emergency may have caused the cardiac arrest.”  “When an infant or child’s heart stops, it’s usually because of a respiratory emergency, such as choking or asthma, which uses up their body’s oxygen.”

Baby suffering a seizure, respiratory emergency PR only (rescue breathing), not CR only, nor CPR  http://youtu.be/mSe2LUysxcg

Suspected Opioid Overdose Management Protocol using Naloxone. Manitoba 2008 http://www.gov.mb.ca/health/ems/protocols/docs/opioid_overdose_naloxone.10.08.pdf  Step 4.”Initiate basic life support treatment measures, including supplemental oxygen [rescue breathing].- these take precedence over management using this protocol” Step 8. “If the patient is not hypoglycemic and the patient has a respiratory rate less than 12 per minute, administer naloxone.”

Decision Support Tool (DST) for the use of naloxone HCl (Narcan) in the management of suspected opioid overdose in outreach and harm reduction settings. British Columbia, May 2013  http://www.bccdc.ca/NR/rdonlyres/43016F4A-FA31-4717-90E0-553A09A5945C/0/NaloxoneDSTBCCDCMay302013.pdf  Step 1. “Apply O2 mask [rescue breathing] according to agency policy/availability. Step 2. Administer naloxone 0.4 mg to 0.8mg IM or SC. Step 3. Repeat dose of 0.4mg every 3-5 min up to a maximum of 2-5 mg and until RR > 10-12/min [continue rescue breathing] Step 4. Monitor respiratory rate every 5 min for 15 min then every 10 min [rescue breathing]”

Guidelines for Administration of Naloxone (Narcan) for Opioid induced Respiratory Depression.  NHS Foundation Trust   http://www.dbh.nhs.uk/Library/Pharmacy_Medicines_Management/Formulary/Formulary_S4/Guidelines%20for%20Administration%20of%20Naloxone-1.pdf   Step 3. “Administer 100% oxygen via a non re-breathing mask. Step 4. Seek urgent assistance from on-call anaesthetist/outreach team/pain team. Step 5. If respiratory arrest has occurred ring 2222. Step 5. Support ventilation by face mask or Ambu-bag if rate declines further or if respiratory depression persists. Step 6. Administer 100-200 micrograms naloxone IV immediately.”

NALOXONE ACCESS:A Practical Guideline for Pharmacists.  College of Psychiatric and Neurologic Pharmacists 2015 Nebraska  https://cpnp.org/_docs/guideline/naloxone/naloxone-access.pdf “Rescue breathing involves essentially breathing for someone else. By providing rescue breathing during an opioid overdose, the rescuer can potentially prevent the patient from developing organ damage.”

Naloxone: Vermont Statewide EMS protocol  2013 Slide 47  Critical Reminder “Be sure to ventilate properly as needed”

Winnipeg Regional Health Authority July 2010   http://www.virtualhospice.ca/Assets/Narcan%20protocol_20120110163651.pdf  “Administer oxygen [rescue breathing] 5 liters/min. nasal prongs (if available).  Administer naloxone…. until patient rouses and respiratory rate greater than 10 breathes/min”

Intranasal naloxone protocol for opiate overdoses.    http://intranasal.net/Treatmentprotocols/Naloxoneprotocol/Naloxoneprotocol.htm  “1.Assess ABC’s – Airway, Breathing, Circulation 2.For pulseless patients, proceed to ACLS guidelines [beyond the scope of laypersons; trauma team – probably brain dead lack of oxygen]. 3.Apnea with pulse – Establish oral airway and begin bag ventilation with 100% oxygen 4.Load syringe with 2 mg (2 ml) of naloxone and attach nasal atomizer 5.Place atomizer within the nostril 6.Briskly compress syringe to administer 1 ml of atomized spray. 7.Remove and repeat in other nostril, so all 2 ml (2 mg) of medication are administered 8.Continue ventilating patient as needed”

Jason M. White and Rodney J. Irvine ‘Mechanisms of Fatal Opioid Overdose’ Addiction 1999; (7) 961-72  Quote p. 961 “The dangers of opioid overdose have been recognised for as long as the use of opium itself”  p. 962 “the primary mechanism responsible is opioid-induced depression of respiration with resulting hypoxia and death.”

Compendium of Pharmaceuticals and Specialties 2015 page 2143 “Establish adequate respiratory exchange through the provision of a patient airway and institution of assisted or controlled ventilation.”   “Naloxone should not be administered in the absence of clinically significant respiratory or cardiovascular depression.  Oxygen, iv fluids, vasopressors and other supportive measures should be used as indicated.” [ACLS methods, all cells tissues and organs have suffered sever damage hypoxia, prognosis poor]

2016 Compendium of Pharmacuticals and Specialties https://jgarythompson.wordpress.com/2016/06/29/monographs-naloxone-opioid-od/

2016 other Canadian Provincial Training teaches rescue breathing only https://jgarythompson.wordpress.com/2016/08/15/canadian-provincial-naloxone/

Physicians Desk Reference 2015 page 2105 “In case of overdose, priorities are the re-establishment of a patent and protected airway and institution of assisted or controlled ventilation if needed….Cardiac arrest or arrhythmias will require advanced life support [ALS] techniques.”  ALS is beyond the scope of laypersons  “Naloxone may not be effective in reversing any respiratory depression produced by buprenorphine.”

Goldfrank’s ‘Toxicologic Emergencies’ [electronic resource] 2015 Chapter 38 page 559 “The consequential effects of acute opioid poisoning are CNS and respiratory depression.  Although early support of ventilation and oxygenation is generally sufficient to prevent death, prolonged use of bag-valve-mask ventilation and endotracheal intubation may be avoided by cautious administration of an opioid antagonist.”  “Differentiating acute opioid poisoning from other etiologies with similar clinical presentations may be challenging.” [doctors have trouble diagnosing one respiratory emergency from another]


Haddad & Winchester ‘Clinical Management of Poisoning & Drug Overdose’ 3rd Ed. Chapter 36 p512 “The initial evaluation and management of opioid overdose focuses on stabilization.  Priorities include assessment and establishment of effective ventilation and oxygenation.  Ventilatory support can usually be safely provided with a BVM device while awaiting the reversal of respiratory depression by an opioid antagonist.”

Martindale ‘The Complete Drug Reference’ 35th Ed pages 87-8 & 1309  “Death may occur from respiratory failure…The triad of coma, pinpoint pupils, and respiratory depression is considered indicative of opioid overdoseage.” “Intensive supportive therapy may be required to correct respiratory failure” “It is used to reverse opioid central depression, including respiratory depression…”

Lange “Poisoning and Drug Overdose”  Opioids pages 1 ad fin item  “many steps may be performed simultaneously (e.g. airway management, naloxone..)” “The most common factor contributing to death from drug overdose or poisoning is a loss of airway-protective reflexes with subsequent airway obstruction caused by the flaccid tongue, pulmonary aspiration of gastric contents, or respiratory arrest.  All poisoned patients should be suspected of having a potentially compromised airway.”   “…causing sedation and respiratory depression.  Death results from respiratory failure, usually as a result of apnea or pumonary aspiration of gastric contents.”   “Maintain an open airway and assist ventilation if necessary. Administer supplemental oxygen.”
Current edition ‘Lange’

Dr.Gabor Mate’s quote June 8, 2013 Toronto ‘All Saints Church’ http://www.medicaldaily.com/pulse/addiction-specialist-dr-gabor-mate-explains-why-punishing-addict-ineffective-330456

Some punishing of the OD patient and anyone else that suffers any respiratory emergency. G.M. Quote “Vancouver 2004 the RCMP tried to stop an overdose resuscitation program. Dr. Mate taught the RCMP some wisdom, these disenfranchised will not only save each other but anyone else that suffers any respiratory emergency.  Program was allowed to continue.”  In Toronto and other parts of the province Public Health is teaching not only how to maim and kill the poisoned (drug OD) but anyone else that suffers any respiratory emergency.

Moderated comment Canadian Association Of Emergency Physicians  Airway Intervention and Management in Emergencies Public Health Ontario needs some training on basic airway management [rescue breathing]. Training tens of thousands of laypersons all the signs of respiratory emergency, then teaching them chest compressions only.

Live human study Leece P et al. ‘Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario.’  http://journal.cpha.ca/index.php/cjph/article/view/3788  Emergency physicians and families are dealing with the needless complications and needless suffering from this live human study.

Agnotology is the study of culturally induced ignorance or doubt, particularly the publication of inaccurate or misleading scientific [medical] data. Agnotology focuses on the deliberate fomenting of ignorance or doubt in society.  https://www.linkedin.com/pulse/agnotology-gary-thompson

Correspondence from Public Health https://jgarythompson.wordpress.com/2015/10/15/some-correspondence-from-public-health-et-al/

A favored response from professors etc. “…our experts…” when they can’t substantiate a claim.

Don’t Forget to Breathe @GaryCPR

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EMN 2015; 37(12):31 http://journals.lww.com/em-news/Fulltext/2015/12000/Letter__Flaws_in_Toronto_s_Opioid_Overdose.14.aspx Article in the 2015 AHA & ILCOR guidelines 'Opioid OD' https://youtu.be/PX0HQuaNS_I

20 thoughts on “2015 ILCOR and AHA references opioid OD”

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