A novel naloxone training compared with current recommended training in an overdose simulation

Tiffany Cheng, Pharm.D., Fairview Pharmacy Services

Background: With the growing concern of deaths caused by opioid overdose, naloxone education has emerged as a topic of interest. Currently, there is no standardized naloxone training or mandate for pharmacists on a federal level and can vary on a state level; Minnesota does not require naloxone training for pharmacists. Naloxone is available as three delivery systems with distinct administration techniques - nasal atomizer, nasal spray, and autoinjector. The American Society of Addiction Medicine (ASAM) recommends all clinicians who provide care to people with substance use disorders have naloxone readily available and be trained on appropriate response to an overdose. The Pennsylvania Act 139 (2014) states all first responders, including family and friends, are allowed to administer naloxone if an opioid overdose is suspected. The Act strongly advises that the person administering the agent complete a state approved training program. Currently, the state has approved an online training program for the general public, but it does not include education on the naloxone atomizer and stress management during an emergency situation.

Objective: The purpose of the study was to determine if a novel naloxone training program that addresses stress management has better results compared to current training in a simulated overdose response.

Study Design: This was a randomized prospective trial including pharmacy students in their third professional year during a substance use disorder series of the clinical laboratory course. Each student was randomized to either the state online training program or a novel training program created by the Wilkes University Nesbitt School of Pharmacy. The state training program is computer based with online voice-over modules covering signs and symptoms of overdose, use of naloxone intranasal spray, and use of the autoinjector. The novel training program is a voice-over Powerpoint that covers the same topics in addition to an overview of the opioid crisis, use of naloxone atomizer, laws of naloxone administration, tools to reduce misuse, and stress management during emergencies. After the training, students completed a simulated overdose response scenario with a panicked bystander. The simulation was timed and evaluated with a checklist. Results from the checklist were compared between groups. Students were aware their score would not impact their course grade. The study was approved by the Wilkes University Institutional Review Board and completed over two academic years. 

Results: Of the 139 eligible students, 135 students completed the simulation. The median time to complete the simulation in the state training program was two minutes and ten seconds compared to two minutes for the novel training program (P=0.31). The following tasks from the checklist demonstrated a significant difference between the simulations of the state training and novel training groups, respectively:  pulse was checked in 25% vs 90% of simulations; breathing was checked in 34% vs 68% of simulations; head was appropriately titled for exposure of nasal passage in 11% vs 68% of simulations; and naloxone was properly administered in 47% vs 97% (P<0.0001 for all). Average scores from the checklist for the state training and novel training groups were 64% and 89% (P=<0.0001), respectively.

Conclusions: The novel naloxone training program provided better training to pharmacy students for a live overdose simulation. The results of the simulation checklist were similar in many areas; however,there were significant differences in checking pulse and breathing, and properly administering naloxone. Missing pulse and breathing can be detrimental in a real-life emergency situation.

Key Point: Pharmacy students who completed the novel naloxone training program were able to respond to a live simulated opioid overdose more appropriately compared to the online state training program. Institutions should consider a more robust training program for naloxone and overdose response that includes assessing for pulse and breathing as well as stress management tactics. 


  1. Franko TS, Distefano D, Lewis L. A novel naloxone training compared with current recommended training in an overdose simulation. J Am Pharm Assoc. 2019;59(3):375-378. doi: 10.1016/j.japh.2018.12.022. 

  2. Pennsylvania Department of Drug and Alcohol Programs. Naloxone. https://www.ddap.pa.gov/overdose/pages/naloxone_reversal.aspx. Accessed May 13, 2019. 

  3. Roberts AW, Carpenter DM, Smith A, Look KA. Reviewing state-mandated training requirements for naloxone-dispensing pharmacists. Research in Social and Administrative Pharmacy: RSAP. 2019;15(2), 222-225. doi: 10.1016/j.sapharm.2018.04.002.