When Naloxone Isn’t Enough: Could Chest Compressions Save More Lives?
Most doctors have never heard of carfentanil, a lethal narcotic that has killed more than 75 people in Akron, OH, since July. That’s because it’s not a human medicine. The opiate, used by veterinarians for sedating large animals like elephants, is 10,000 times stronger than morphine.
Akron medical examiner Lisa Kohler, MD, first noticed a spike in drug-related deaths at the beginning of July, and initial tests pointed to fentanyl, a pain medication, in the urine—but subsequent analysis found it was actually carfentanil.
All over the United States and Canada, communities like Akron are handing out free antidote kits containing the reversal drug naloxone to the public, empowering people to reverse the effects of drugs like heroin, morphine and fentanyl.
But when it comes to carfentanil, naloxone may not be strong enough to restore breathing. That’s led some emergency doctors to call for everyone who receives a naloxone kit to be trained in chest compressions—but most public health teams, including Akron’s, only teach rescue breathing because of fears adding chest compressions could complicate training, discourage people from helping and make the situation worse.
Douglas Smith, MD, is the medical director of the Alcohol, Drug Addiction and Mental Health Services Board in Akron, where antidote kit training includes teaching rescue breathing but doesn’t mention chest compressions. “The breathing stops first,” he explains, which is why Akron encourages people to give mouth-to-mouth rescue breaths until the naloxone kicks in.
But front-line responders are worried that more potent narcotics like carfentanil are killing people who get naloxone but don’t start breathing. The problem, says Akron District Fire Chief Joseph Natko, is that bystanders “often don’t want to get involved.” Surveys indicate that people are not willing to do rescue breathing, even though every kit handed out has a face mask.
“Every day our paramedics start CPR on someone surrounded by empty naloxone vials…people give the naloxone and walk away,” says Vancouver paramedic Bronwyn Barter. Like Ohio, Vancouver is battling an opioid epidemic.
Del Dorscheid, MD, PhD, is an ICU doctor at St. Paul’s Hospital in downtown Vancouver. Many of his patients are brain-damaged despite having fentanyl-antidote naloxone injected by their friends. “Fentanyl is highly potent—you may not get any recovery from naloxone,” he says. Dorscheid is concerned that people are counting on naloxone to work. He believes that if chest compressions were started right away, more people would survive.
Several large studies show the odds of survival double when bystanders start chest compressions on someone who isn’t breathing. That’s why the American Heart Association recommends chest compressions be delivered to unconscious overdose patients who are not breathing normally.
Resuscitation experts like Christian Vaillancourt, MD, agree. The research chair in emergency cardiac resuscitation at the University of Ottawa says, “Chest compressions are easier than rescue breathing and don’t cause harm.” They also draw air into the lungs so rescue breaths aren’t required, he says.
“When the heart stops, chest compressions are the only reasonable chance of survival,” says emergency and public health doctor Aaron Orkin, MD. He helped create the take-home naloxone program for Toronto, Canada, where people are taught to start chest compressions after giving naloxone. That’s a good thing, he believes, partly because rescue breathing is more difficult to teach and perform than chest compressions.
But there is controversy even beyond Ohio’s borders. Sharon Stancliff, MD, says “the room was split” when experts recently converged to discuss the matter. Stancliff, medical director of the New York-based Harm Reduction Coalition, says the meeting ended in a consensus that there wasn’t enough evidence to recommend for or against training targeted bystanders in chest compressions.
Adam Lund, MD, an emergency doctor and harm-reduction specialist at the University of British Columbia in Vancouver, tries to bridge the divide between public health doctors and emergency doctors. “There’s a gap between giving naloxone and naloxone working,” he says. “Chest compressions fill that gap.”
Blair Bigham, MD, MSC, ACPF, is a flight paramedic and resident physician in Hamilton, Canada. He is a fellow in Global Journalism at the University of Toronto’s Munk School for Global Affairs. E-mail him at blair.bigham@medportal.ca; follow on Twitter @BlairBigham.
