Idaho State Board of PharmacyNaloxone Overview

Robert S. ColeAda County Paramedics

Disclaimer

• Nothing to sell• No conflicts of interest.

“I'm just a poor boy, nobody loves me.He's just a poor boy from a poor family,”

Objectives• Background on Naloxone• Opioids on the streets• Naloxone on the Streets• Setting up Naloxone for Lay Persons• Vital Information for the Lay Person

Administering Narcan• Post-Narcan Care

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Background on Naloxone•Patented in 1961, and rapidly adopted in emergency medicine and EMS by the mid 70’s. • Patent Expired• On the WHO list of essential medications•Currently, there are an estimated 16,000 deaths annually in the US attributed to Opoids• Likely under estimated•In 2014, FDA (Fast Tracked) approval for lay public/Non Medical responder formulations• IM: Auto Injector “Evzio”• IN: Narcan Nasal Spray

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Basic information• Pure Opioid Antagonist• Works predominantly on the Mu Opioid receptors in the central

Nervous System– Very little effect on the other opioid receptors

• Clinical effect typically 20-40 minutes. – ½ live 30-80 minutes– Clinical effect shorter than many opioids

• Most effective when administered IV, IM, SQ, SL, and IO.– Wide dose range based on clinical situation for HCP– Limited dose range and routes for lay public (2-4 mg IV, IM)

• Limited inconclusive research on possible use in sepsis, and certain other CNS depressants.

Opioid Toxidrome

• The Opiate Toxidrome consists of:– Altered mental status – Miosis*– Unresponsiveness – Shallow respirations – Slow respiratory rate – Decreased bowel sounds – Hypothermia– Hypotension*

• * these symptoms are very subjective, and may not be present in polypharmacy overdoses.

KEY POINT: Miosis and Hypotension are not definitive for ruling in or ruling out a opioid overdose.

Opioids on the streets

• Shooting• Skin Popping• Muscle Popping• Chasing the dragon• Freebasing• Plugging and Shelving• Transdermal

So why do people overdose?

• IV opioid use• Poly-pharmacy Overdose• Returning to opioid use from abstinence – Jail?– Detox?

• The Weekend Warrior• Using opioids alone • New supply of Drug

According to the CDC

•Misuse of opioids accounts for 1000 ER visits a day in the US•Over 40,000 deaths per year (2014 stats) • Over 16,000 related to prescription opioids•Most common prescription opioid deaths:• Methadone• Oxycodone (such as OxyContin®)• Hydrocodone (such as Vicodin®)

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“Speed Balls”

Poly Pharmacy Opioid Situations

The New Opioid: Poly-Opioid Mixes

Key Points

•Narcan may not be enough• May not be effective• May not be only an opioid• May have been down too long• May need to redose

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Naloxone on the Streets

Target Population

The target population for naloxone is persons who may have overdosed on opioids and whose respiratory drive

is at a depressed life-threatening level.

Naloxone is for depressed respirations, not depressed mental status.

Opiate use alone (without depressed respirations) does not merit the use of naloxone.

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Intranasal Naloxone

• Minimizes risk for blood borne pathogen exposure (no needle)

• May be administered rapidly and painlessly

• Onset of action is 3-5 minutes, peak effect is 12-20 minutes Protect naloxone from light

Avoid temperature extremes

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Intranasal Naloxone

Intranasal Naloxone

Intranasal Naloxone

Intranasal Dose

•2-4 mg•1/2 of dose in each nostril

Intramuscular Naloxone

• Intramuscular likely more reliable– Needle Risk

• Lay Public Dose: 2-4 mg• Locations:– Any large muscle mass– Thigh– Upper Arm– Buttocks

Vital Information for the Lay Person Administering Narcan

•Call 911 first without delay•CPR takes priority OVER Naloxone• “Hands Only CPR is OK if no face mask•Naloxone often causes vomiting• Roll on side if not doing CPR• Keep airway clear•DON’T STOP CPR FOR NARCAN ADMINSITRATION

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Post-Narcan Care• Roll on side if CPR is not

needed• If CPR is needed, do CPR until

the patient wakes up

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In Closing• Narcan does not always work• Dose is 2-4 mg for lay public, IV or IN• Call 911 early as possible• CPR (If needed) as early as possible,

even if Narcan is given• Continue CPR (if needed) until the patient wakes up, or EMS directs otherwise.

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