Key Considerations for Providing Naloxone

The opioid overdose death toll has been steadily increasing for more than a decade, making it a leading cause of accidental death in the United States.

In an effort to help reduce opioid-related death, the FDA approved naloxone auto-injector (Evzio) and naloxone nasal spray (Narcan) for take-home use for the emergency treatment of opioid overdose (Table). Both products can reverse the effects of opioids, including respiratory depression, sedation, and hypotension.

Table: Evzio and Narcan Comparison

Evzio

Narcan

Administration

Auto-injector

Intranasal

Key Attributes

· Audio directions guide caregivers on proper administration

· Trainer device accompanies each carton

· Manufacturer has offered a free carton to all US high schools

· Ease of administration + low cost

Potential Disadvantages

· Audio directions only available in English

· High cost

· Intranasal adverse effects

· Potential absorption concern in users whose nasal mucosa may be damaged from drug snorting, obstructed by vomit during overdose, or experiencing severe rhinitis

Notably, naloxone has been used for more than 40 years to reverse respiratory depression during opioid-related emergencies. Prior to the approval of Evzio and Narcan, the medication had to be administered as an intravenous (IV) injection, which was problematic for 2 reasons: 1) peripheral venous access may be difficult to obtain in IV drug abusers, making the medication difficult to administer, and 2) exposure to the affected patient’s blood could mean exposure to a blood-borne disease like hepatitis or HIV.

All forms of naloxone carry a warning of causing withdrawal in opioid-dependent patients, but as Juliana Zschoche, PharmD, emergency medicine clinical pharmacy specialist at Johns Hopkins Hospital, put it during PAINWeek 2016, “I would rather a patient be in withdrawal than not breathing.”

Naloxone Needs Assessment

Pharmacists can use validated risk assessment tools, such as the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD), to identify patients who may be at risk for opioid overdose and could benefit from keeping naloxone handy. They could also access their state’s Prescription Drug Monitoring Program to check whether patients are obtaining opioid prescriptions from multiple prescribers or pharmacies, and then consult with the patients’ providers to determine whether they’re good candidates for naloxone.

“The pharmacist [should be] willing to have a conversation with a provider, and if they’re noticing anything odd, to alert the prescriber and maybe recommend that they think the patient is at risk [for opioid overdose] and may benefit from [naloxone] intervention,” Dr. Zschoche told Pharmacy Times.

Naloxone Administration

When providing patients with naloxone—which, depending on state laws, could be accomplished without a prescription or through collaborative practice agreements with physicians or standing orders—pharmacists should make a point to demonstrate how to administer the product.

“Some [naloxone products] require assembly, and some patients may not feel comfortable in an emergency situation to have to flip a top off a vial or…put a needle or whatever else is necessarily prior to administration,” Dr. Zschoche explained. “So, walking a patient through the exact type [of naloxone] that they’re going to get is really important to patient education.”

Dr. Zschoche has also found that patients are sometimes reluctant to administer naloxone when they’re unsure whether the affected individual has overdosed on heroin, opioids, or something else entirely. Therefore, it’s important for pharmacists to assure patients that the benefits of naloxone greatly outweigh its risks, so patients should still administer the product even if they’re not sure what the individual took because it could potentially save a life.