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

Strategies and policies to address the opioid epidemic (PDF)

Opioid safety and how to use naloxone (PDF)

Opioid Prescribing Resources

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

Prescribing Opioids Fact Sheet (PDF) (CDC)

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

Minnesota Prescription Monitoring Program (PDF)

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

Opioid Risk Tool (PDF)

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

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

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

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

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

Pharmacist Resources

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

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

Opiate Antagonist Protocol (PDF) (Minnesota Board of Pharmacy)

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

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

Naloxone Dispensing and Consultation Checklist (PDF)

Addiction and Abuse Prevention Resources

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

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

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

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

Syringe Services Information

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

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

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

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

Minnesota HIV/AIDS Epidemiologic Profile (PDF) - December 2015

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

Safe Disposal Options for Needles and Syringes (PDF) (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

NARCAN® Administration training video

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

NARCAN Quick Start Guide

References

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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

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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)

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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)

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