Naloxone: A Critical Tool to Fight the Opioid Crisis

Overview

Naloxone

This presentation is provided for pharmacists and providers who wish to learn more about factors that increase an individuals' risk of opioid overdose, identify signs and symptoms of opioid overdose, and understand the pros and cons of different naloxone formulations. The presentation will review resources patients may use to access naloxone, describe legal considerations for prescribing and dispensing of naloxone in Minnesota, and discuss available naloxone and opioid resources for healthcare providers and patients.

Presentation Resources

This presentation on naloxone can be viewed by clicking the play button within the video frame below. Additional resources and references related to this topic have been provided in the tabs beneath the video. 

Naloxone: A Critical Tool to Fight the Opioid Crisis

Learning Objectives

  • State some factors that may increase risk of opioid overdose
  • Identify signs and symptoms of opioid toxicity
  • List pros and cons of different naloxone formulations
  • Review resources patients may use to access naloxone
  • Describe legal considerations for prescribing and dispensing of naloxone in Minnesota
  • Discuss available naloxone and opioid resources for healthcare providers and patients

Faculty

Laura Palombi, PharmD, MPH, MAT
Assistant Professor, Department of Pharmacy Practice and Pharmaceutical Sciences
Affiliate Assistant Professor, Division of Environmental Health Sciences, School of Public Health

Dr. Palombi is a faculty member in the University of Minnesota College of Pharmacy and School of Public Health. She has worked for four years to address substance use disorder, including Drug Court, in part by organizing this presentation. She has presented variations of this presentation to many different audiences, including health care professionals and community members, using her understanding of the challenges that come with opioid prescribing and naloxone distribution.

Heather Blue, PharmD, BCPS, BCGP
Assistant Professor of Clinical Pharmacy, Department of Pharmacy Practice and Pharmaceutical Sciences

Dr. Heather Blue is an Assistant Professor at the University of Minnesota College of Pharmacy- Duluth campus. She completed her PharmD at the University of Minnesota and completed a PGY-1 residency at Allina Health Mercy and Unity hospitals. After residency, she worked as clinical pharmacist at Mercy Hospital. Her current research is based on her clinical practice in the emergency department at St. Luke’s Hospital Duluth, with an emphasis in opioid overdose reduction strategies.

Lauren Hanson, PharmD
Essentia Health – Duluth

Dr. Hanson completed her PharmD at the University of Wisconsin with a Patient Safety Certificate. Her background in this topic includes serving on the Chronic Opioid Analgesic Treatment Steering Committee at Essentia Health during 2016-2017 and presenting on Naloxone to pharmacists and health providers in the Duluth, Minn., area. Dr. Hanson has also worked with St. Louis and Carlton Counties of Minnesota developing action plans and education opportunities with the Pharmacy and Public Health Partnership for Naloxone as well as the Opioid Abuse Response Strategies Group. 

Elisabeth Bilden, MD
St. Louis County Public Health, Essentia Health – Duluth

Dr. Bilden is a hospital-based medical toxicologist for Esentia Health and a consultant for the Minnesota Poison Control System. Her background as a physician with specialized training in toxicology, as well as her past role as medical consultant for St. Louis county, give her experience and specialized skills related to naloxone and appropriate opioid prescribing. She is connected to networks across the state and has an excellent working knowledge of trends in medical toxicology and public health initiatives related to substance use.

Disclosure Statements

The University of Minnesota has a conflict of interest policy that requires course faculty to disclose whether they have financial interests or affiliations with organizations with a direct substantial interest in the subject matter of their programs. The following information was received from Drs. Palombi, Blue, Hanson, and Bilden.

Laura Palombi, PharmD, MPH, MAT
No relationships to disclose. Dr. Palombi will not discuss off-label or investigational uses of commercial products.

Heather Blue, PharmD, BCPS, BCGP
No relationships to disclose. Dr. Blue will not discuss off-label or investigational uses of commercial products.

Lauren Hanson, PharmD
No relationships to disclose. Dr. Hanson will not discuss off-label or investigational uses of commercial products.

Elisabeth Bilden, MD
No relationships to disclose. Dr. Bilden will not discuss off-label or investigational uses of commercial products.

Administering Naloxone

The following is a short summary on how to administer naloxone in an opioid overdose situation. For more complete information and instructions, watch the presentation above.

  • Short video presentation from the MN Department of Health on what to do when someone overdoses on opioids: https://www.youtube.com/watch?v=GPbqPDOol14
  • Steps to take when someone overdoses on opioids:
    1. Elicit a pain response by rubbing fist on the sternum; if there is no response, follow these steps…
    2. Call 911
    3. Get your naloxone
    4. Give 2 rescue breaths
    5. Administer a dose of naloxone
    6. Continue giving rescue breaths
    7. If little to no response after 2 minutes, provide another dose of naloxone (can continue providing doses as they are available every 2 minutes until help arrives or patient responds)
    8. Continue giving rescue breaths until help arrives

Reading Materials

Naloxone Resources

PDF icon Strategies and policies to address the opioid epidemic

PDF icon Opioid safety and how to use naloxone

Opioid Prescribing Resources

PDF icon Guideline for Prescribing Opioids for Chronic Pain (CDC, 2016)

PDF icon Prescribing Opioids Fact Sheet (CDC)

PDF icon Prescription Opioid Usages and Abuse Relationships (Substance Abuse: Research and Treatment article)

PDF icon Minnesota Prescription Monitoring Program

PDF icon Opioid Prescribing Improvement Program (Minnesota Dept of Human Services)

PDF icon Opioid Risk Tool

PDF icon Prescriber Role in Preventing Diversion of Prescription Drugs (US Dept of Health & Human Services)

PDF icon Regulating Opioid Prescribing Through Prescription Monitoring Programs (Pain Medicine article)

PDF icon Methadone in Primary Care (New England Journal of Medicine article)

PDF icon Moving Addiction Care to the Mainstream - Improving the Quality of Buprenorphine Treatment (New England Journal of Medicine article)

PDF icon Primary Care and the Opioid-Overdose Crisis - Buprenorphine Myths and Realities (New England Journal of Medicine article)

Pharmacist Resources

PDF icon 2017 Legislation Affecting the Practice of Pharmacy (Minnesota Legislature)

PDF icon Collecting Pharmaceuticals from Households and Long Term Care Facilities (Minnesota Pollution Control Agency)

PDF icon Opiate Antagonist Protocol (Minnesota Board of Pharmacy)

PDF icon Opiate Antagonist Protocol implementation message (Minnesota Dept of Health)

PDF icon Naloxone Access: A Practical Guideline for Pharmacists (College of Psychiatric & Neurologic Pharmacists)

PDF icon Naloxone Dispensing and Consultation Checklist

Addiction and Abuse Prevention Resources

PDF icon Over the Counter Medicine Safety - community leader resource (Scholastic)

PDF icon Prescription Drug Abuse: Teens in Danger - teacher resource (Scholastic)

PDF icon Straight Talk on Prescription Drugs - teacher resource (Scholastic)

PDF icon Straight Talk on Prescription Drugs - student resource (Scholastic)

Syringe Services Information

PDF icon Effect of Legal Status of Syringe Sales on Syringe Purchases (Int Journal of Drug Policy article)

PDF icon Guide to Establishing Syringe Services Programs in Rural, At-Risk Areas (Comer Family Foundation)

PDF icon Ideological Anachronism Involving Needle and Syringe Exchange Programs (JAMA article)

PDF icon Impact Evaluation of a Policy Intervention for HIV Prevention (AIDS and Behavior article)

PDF icon Minnesota HIV/AIDS Epidemiologic Profile - December 2015

PDF icon Ongoing Battle for Syringe Exchange (Journal of AIDS and HIV Infections article)

PDF icon Safe Disposal Options for Needles and Syringes (Minnesota Pollution Control Agency)

Online Resources

Administer Naloxone Overdose Response.” Harm Reduction Coalition

"Calculating Total Shareholder Return." Centers for Disease Control and Prevention

Drug label information for naloxone hydrochloride 

Earth911, Minnesota safe medications disposal locator

Fast-Tracker, an online mental health and substance use disorder resources hub

Minnesota Medical Association's Pain, Opioids, and Addiction Lecture Series

Minnesota Pharmacy Syringe/Needle Access Initiative website

Minnesota Poison Control Center Training Course; Module 5, Units 3 and 4

Minnesota Prescription Monitoring Program website

"NALOXONE ACCESS: A Practical Guideline for Pharmacists." College of Psychiatric and Neurologic Pharmacists

"Naloxone at Pharmacies." British Columbia Centre for Disease Control

"Naloxone Prescribing and Dispensing Questions." Minnesota Board of Pharmacy

Opioid Dashboard from the MN Department of Health

"Overdose Death Rates." National Institute on Drug Abuse (NIDA)

"The Opioid Epidemic: By the Numbers." Department of Health & Human Services

Prescribe to Prevent Naloxone Product Chart

"S.F. No. 1900 - Administration of Opiate Angagonists." Minnesota Senate

Shatterproof website

"Treatment Statistics." National Institute on Drug Abuse (login required)

"Understanding Naloxone." Harm Reduction Coalition

Drug-Specific Resources

"EVZIO: Highlights of Prescribing Information." kaleo, Inc.

NARCAN® Administration training video

"NARCAN: Package Insert and Label Information." DrugInserts.com

NARCAN Quick Start Guide

References

Belz, D., Lieb, J., Rea, T., and Eisenberg, M. (2006) Naloxone use in a tiered-response emergency medical services system. Prehosp Emerg Care 10: 468-471.

Bird SM, Fischbacher CM, Graham L, Fraser A. Impact of Opioid Substitution Therapy for Scotland’s prisoners on drug-related deaths soon after prisoner release. (2015) Addiction. 1617-1624.

Buajordet, I.m Naess, A., Jacobsen, D. and Brors, O. (2004) Adverse events after naloxone treatment of episodes of suspected acute opioid overdose. Eur J Emerg Med 11: 19-23.

Coffin PO, Behar R, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med 2016. DOI: 10.7326/M15-2771.

Doe-Simkins M, Quinn E, Ziming X, Sorensen-Alawad A, Hackman H, Ozonoff A, Walley A. Overdose rescuers by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health 14: 297 (2014).

Dowell, Deborah, MD, Tamara Haegerich M., PhD, and Roger Chou, MD. "CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016." JAMA 315.15 (2016): 1624

Dowling, Jonathonm, Geoffrey Isbister K., Carl Kirkpatrick M J, Daya Naidoo, and Andis Graudins. "Population Pharmacokinetics of Intravenous, Intramuscular, and Intranasal Naloxone in Human Volunteers." Therapeutic Drug Monitoring PAP (2008)

Dunn, Kate M., KW Saunders, CM Rutter, CJ Banta-Green, JO Merrill, MD Sullivan, CM Weisner, MJ Silverberg, CI Campbell, BM Psaty, and M. Von Korff. "Opioid Prescriptions for Chronic Pain and Overdose." Annals of Internal Medicine Ann Intern Med 152.2 (2010): 85

Jones, Jermaine, Campbell, Aimee, Metz, Verna, Comer, Sandra. No evidence of compensatory drug use risk behavior among heroin users after receiving take-home naloxone. Addictive Behaviors 71 (2017): 104106.

MacArthur GJ, van Velzen E, Palmateer N, Kimber J, Pharris A, Hope V, et al. "Interventions to prevent HIV and hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness." International Journal of Drug Policy. 2014;25(1):34–52.

McDonald, Rebecca, and John Strang. "Are Take-home Naloxone Programmes Effective? Systematic Review Utilizing Application of the Bradford Hill Criteria." Addiction 111.7 (2016): 1177-187

Park, T. W., R. Saitz, D. Ganoczy, M. Ilgen A., and A. Bohnert S. B. "Benzodiazepine Prescribing Patterns and Deaths from Drug Overdose among US Veterans Receiving Opioid Analgesics: Case-cohort Study." BMJ 350.Jun10 9 (2015)

Venner KL, Donovan DM, Campbell ANC, Wendt DC, Rieckmann T, Radin SM, Momper SL, Rosa CL. Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives. Addictive Behaviors. 86 (2018): 111-117.

Wagne K, Valente TW, Casanova M, Partovi S, Mendenhall BM, Hundley JH, Bonzalez M, Unger J. Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles, CA. International Journal of Drug Policy. 21 (2010): 186-193.

Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 2013;346:f174. DOI: 10.1136/bmj.f174.

Wermeling, D. P. "Review of Naloxone Safety for Opioid Overdose: Practical Considerations for New Technology and Expanded Public Access." Therapeutic Advances in Drug Safety 6.1 (2015)

Williams, Jess. "Drug Overdose in Our Backyard Is Breeding Home-Grown Solutions." IRETA. Institute for Research, Education & Training in Addictions, 03 Dec. 2015

Wodak A., and A. Cooney. "Do Needle Syringe Programs Reduce HIV Infection Among Injecting Drug Users: A Comprehensive Review of the International Evidence." Substance Use & Misuse. 41 (2006): 777-813.

Wolfe, Susan, PhD, Dennis Bouffard L., PhD, and Vania Modesto-Lowe, MD, MPH. "The Opioid Crisis and the Physician's Role in Contributing to Its Resolution: Step One - Prevention of Overdoses." Connecticut Medicine 80.6 (2016)