1. Approved by the Maine EMS Medical Direction and Practices Board.
Intranasal Naloxone Administration Training Module for Law Enforcement Officers and Firefighters
Approved by the Maine EMS Medical Direction and Practices Board.
Welcome!
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2. Objectives
By the end of this course the participants will learn about intranasal naloxone and will be able to:
Recognize the signs and symptoms of an overdose
Be able to prepare and administer intranasal Naloxone
Identify the possible responses to intranasal Naloxone
Describe how continued support should be provided to the overdose victim
This presentation is going to discuss the use of Intranasal naloxone by law enforcement and firefighters. Naloxone is the generic name while Narcan is the trade name. EMS providers must follow the Maine EMS protocols for their respective license level.
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3. 5 MRSA § (effective 4/29/14)
Law enforcement officers and municipal firefighters, in accordance with their agency/municipality policies, may administer intranasal naloxone as clinically indicated if the officer or firefighter has received medical training as adopted by the Medical Direction and Practices Board. (paraphrased)
The legislation is permissive, not mandatory. The decision about whether a municipality adopt such a policy is a local one.
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4. Agency/Municipal Responsibilities
Establish a policy regarding administration of intranasal naloxone by law enforcement officers / firefighters, including:
Documentation of completion of MDPB approved training
Agency specific supplemental training
Agency specific policies/procedures/general orders
The municipal policy should include at a minimum: maintaining documenting the completion of naloxone administration training; identifying any agency specific training (e.g. practical training), and any other agency specific policies and procedures. Maine EMS has approved this presentation as meeting the requirements for intranasal naloxone, but will not be retaining records regarding course completion.
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5. When is intranasal Naloxone used?
Bystanders should have contacted EMS (Dial 911) or sent for help and provided respiratory support (rescue breathing) to the best of ability.
Use of intranasal Naloxone is for when the person is not responsive to reverse narcotic effects (opiates and opioids).
Narcotics cause respiratory depression (slowed breathing), which causes low oxygen to the brain and may cause brain injury or death.
An unresponsive person whose gag reflex is not fully functioning may vomit, which can then get into the lungs causing aspiration, which can lead to illness and possible death.
Quickly reversing the overdose may save lives.
Definitive treatment for an opioid or opiate overdose is the reversal of hypoventilation. Intranasal naloxone is a possible treatment option for trained law enforcement officers and firefighters.
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6. Opiates and Opioids Chemicals that act in the brain to:
Decrease feeling of pain
Decrease the reaction to pain
Provide comfort
May be used for pain from injury or after having procedures done (surgery) or as part of long term care for cancer or other terminal diseases.
Both opiates and opioids are often misused.
An opioid is a synthetic or semi-synthetic alkaloid that acts on the central nervous system to decrease perception of and reaction to pain. They are also used to increase pain tolerance. They are prescribed for acute, debilitating, chronic pain, or palliative care.
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7. Narcotics (opiates and opioids)
Heroin
Buprenorphine (Suboxone)
Butorphanol (Stadol)
Codeine
Fentanyl (duragesic patch)
Hydrocodone (Vicodin*)
Hydromorphone (Dilaudid)
Meperidine (Demerol)
Morphine
Nalbuphine (Nubain)
Oxycodone (Percocet*/Percodan†)
Oxymorphone
Pentazocine (Talwin)
Paregoric
Propoxyphene (Darvon)
Narcotics are opioids (synthetic – oxycodone, hydrocodone, methadone, suboxone, etc.) and opiates (naturally derived from the poppy plant – heroin, morphine, fentanyl, and codeine).
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8. Use / Misuse / Abuse
After prolonged use of these substances increasing amounts are needed for the same effects.
Common side effects include:
Nausea and vomiting
Drowsiness
Itching
Dry mouth
Small pupils
Long term usage of opioids and opiates is known for creating tolerance and/or addiction that requires increasing doses to maintain the same effect or avoid withdrawal. There are many common side effects, but constriction of the pupils is one that you should be using during your differential diagnosis.
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9. Naloxone is only effective with opiates and opioids
Naloxone will not reverse the effects of other medications/drugs, such as: benzodiazepines (Valium/Versed), cocaine, LSD, ecstasy, bath salts, tranquilizers, methamphetamines, and marijuana.
Remember, Narcan is specific to opiate and opioid overdoses! It will NOT reverse the effects of other drugs/medications, such as benzodiazepine (e.g. Valium and Versed), alcohol, marijuana, sedatives, bath salts, PCP, methamphetamine, cocaine, etc.
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10. Addiction and Treatment Drugs
Methadone is an opioid which may be used as a pain reliever, but is also commonly prescribed in addiction treatment.
Suboxone and Subutex are brand names for the opioid buprenorphine, which may be used as a pain reliever, but is also commonly prescribed in addiction treatment. Suboxone comes in film strips and tablet form.
These drugs last a long time and can help reduce the craving for opiate and opioids.
Methadone and buprenorphine are never used alone as the sole plan for treatment of addiction, but are used in combination with counseling and skill learning efforts.
There are two common opioid/opiate addiction treatment drugs: methadone and suboxone. Vivitrol is another that is gaining popularity among some medical providers.
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11. Who’s at High Risk for Overdose?
Individuals abusing medical visits and care from multiple doctors who are not following instructions about prescription use
Users of prescriptions that should belong to others
Users who inject drugs for greater effects
Former users who are recently released from prison or who are entering and exiting from drug treatment programs
Who is at a high risk for an opioid or opiate overdose? As you can see by the list, there are many risk groups.
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12. Who else is at risk?
Elderly patients using opiates or opioids for pain
Patients using pain relieving patches incorrectly
Patients co-prescribed opioids and benzodiazepines
Patients co-prescribed opioids and anti-depressants
Patients on opioids who consume alcohol
Children who accidentally take pain-killers in their homes or the homes of others
In addition the elderly, children, and people using pain relieving patches are also at risk for an opioid or opiate overdose. Common benzodiazepines include diazepam (Valium), and midazolam (Versed).
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13. Intranasal Naloxone
Naloxone (Narcan) is an antidote that can reverse overdose of opioids/opiates.
Naloxone is NOT effective against respiratory depression due to non-opioid drugs (or other causes).
Naloxone can reverse central nervous system and respiratory depression due to an overdose of opioids opiates. It is not effective against respiratory depression due to non-opioid drugs. Thus, it is important to recognize the signs and symptoms of an opioid or opiate overdose and use naloxone appropriately.
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14. Why Intranasal Naloxone?
Very low risk of exposure to blood (no needle)
Can be administered quickly and with little training
Onset of action is quick
Very effective when used
There are many reasons to administer intranasal naloxone. It minimizes the risk for blood borne pathogen exposure. It can be rapidly administered and naloxone has a rapid onset with peak effect within a few minutes.
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15. Intranasal Naloxone
Works quickly since the nose has a large area for absorbing drugs directly into the blood stream.
The medication is sprayed in a large area and rapidly absorbed.
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16. Why is it used with an Atomizer?
Squirting the liquid drug as a fine mist covering more of the surface, like spray paint or hair spray increases entry into the bloodstream.
The atomizer helps spread the distribution of the medication.
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17. What does an overdose look like?
The person is:
Not responsive when shaken
Possibly not breathing well or not breathing at all
Possibly breathing less than 6 breaths per minute
Snoring deeply/gurgling sounds
Possibly having a bluish color of the skin, nails or lips
Small pupils
There are many signs and symptoms of an opioid or opiate overdose, but intranasal naloxone is indicated for a patient with respiratory arrest or hypoventilation.
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18. When to use intranasal Naloxone?
If a person is not responding to you.
If bystanders report drug use and the person is not responding to you.
If there are drug bottles, or signs of injection of drugs on the skin (“track marks”) and the person is not responding to you.
Call 911 to activate Emergency Services
What are the indications of an opioid or opiate overdose? 1. Respiratory arrest or hypoventilation with evidence of use by bystander report, drug paraphernalia, prescription bottles, or track marks – and/or 2. recognition of the opiate/opioid toxidrome.
Naloxone has a half life (falls to half its original value) of about 30 minutes, but opioids have a half life of many hours. It is essential to call EMS for additional treatment and for transportation to the emergency department. Be sure that EMS has been called and is enroute.
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19. Option 1: Adult Nasal Atomizer Use
Administer Naloxone 1.0mg (1/2 tube) nasally with the atomizer. Wait 1 minute to see if this is effective. If not, administer the second half in the other nostril.
EMS Providers: follow Maine EMS protocols for your license level.
If you know how and have the appropriate equipment, you may provide rescue breathing for the person
Consider contacting poison control if other poisons are suspected : (800)
Each tube of naloxone contains 2 mg of naloxone. For intranasal administration, this is 1mg of Naloxone per nostril. Administer ½ tube in one nostril and wait a minute to see if this is effective. If the patient is still not adequately breathing, administer the second ½ of the tube into the other nostril. Also consider contacting poison control ( ) if more than one drug use is suspected. EMS Providers: follow the Maine EMS protocols for your respective license level.
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20. Nasal Atomizer Use
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21. Preparation: Step 1
For equipment, you will need one luer-jet needle free syringe, one vial of naloxone, and one atomizer.
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22. Preparation: Step 2
Remove the caps from both ends of the luer-jet needle free syringe.
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23. Preparation: Step 3
Remove the red cap from the naloxone vial. Screw the now open end of the vial into the syringe. It will become difficult to turn when it is threaded enough.
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24. Preparation: Step 4 Attach the nasal atomizer to the opposite end.
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25. One Luer Attached Atomizer
This is what your final product should look like!
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26. Administration (non-EMS)
Assemble kit
Gently, but firmly, place the atomizer in one side of the nose and spray half the medication
Wait one minute. If the patient is still not breathing adequately, spray the other half in the other side.
If only one side of the nose is available, put all of the medication on that side
The administration will take some choreographing of your team members. Continue to ventilate your patient, assess the nares and suction as needed. Control your patient’s head and place the atomizer in one nare while carefully occluding the opposite nostril.
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27. Option 2: NARCAN NASAL SPRAY
FDA Approved
Set single dose
No Assembly
High concentration
Approved by The Maine EMS Medical Direction and Practices Board(MDPB) February, 2016
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28. Administration
Remove NARCAN Nasal Spray from the box. Peel back the tab with the circle to open the NARCAN Nasal Spray.
Hold the NARCAN nasal spray with your thumb on the bottom of the plunger and your first and middle fingers on either side of the nozzle.
Gently insert the tip of the nozzle into either nostril.
Tilt the person’s head back and provide support under the neck with your hand. Gently insert the tip of the nozzle into one nostril, until your fingers on either side of the nozzle are against the bottom of the person’s nose.
Press the plunger firmly to give the dose of NARCAN Nasal Spray.
Remove the NARCAN Nasal Spray from the nostril after giving the dose.
If additional NARCAN Nasal Sprays are available, repeat every 2 to 3 minutes until the person responds or emergency medical help is received.
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29. 06/24/2014 Update 02/2016

30. EMS providers Follow Maine EMS Prehospital Treatment Protocols
EMS providers will follow the protocol for their respective license level.
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31. Administration
Aim slightly upwards and toward the ear on the same side of the nostril. Briskly compress the syringe to administer up to 1mg of atomized spray. Repeat in the other nostril. Remember that using both nostrils doubles the surface area available for absorption. Continue ventilating your patient with a bag valve mask.
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32. What happens next?
Naloxone works by temporarily withdrawing the affect of the opiate.
The goal is to have the patient able to breath on their own.
The withdrawal of the opiate effect may cause sweating, sneezing, confusion.
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33. Safety Considerations
The adverse effects following naloxone administration, particularly in chronic opioid users and abusers, may place the patient and bystanders at risk.
Consider moving sharp/heavy objects and physically restraining patient in anticipation of combative behavior.
Keep bystanders at a safe distance.
All patients should be assessed for other causes of altered mental status or respiratory depression that include, but are not limited to hypoxia, hypoglycemia, head injury, shock, and stroke. The adverse effects following naloxone administration, particularly in chronic opioid users and abusers, may place the patient, EMS providers and bystanders at risk of physical injury. Prior to the administration of naloxone, individuals should consider moving sharp or heavy objects out of the patient’s reach. Ensure that bystanders are kept at a safe distance.
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34. Safety Considerations
Naloxone’s duration of action is relatively brief (as short as 30 minutes)
The duration of action for narcotics can be very long (as long as a day)
All patients who receive naloxone must be monitored closely for recurrent symptoms, including altered mental status, respiratory depression, and circulatory compromise
Patients may need another dose of naloxone
Once naloxone has been administered, it is vital to continue to monitor the patient. The half-life of naloxone is brief and can be as short as 30 minutes. As the effect of the naloxone fades, the signs and symptoms of an opioid overdose can return. Recurrent altered mental status, respiratory depression, or circulatory compromise can follow quickly; therefore, constant patient monitoring and frequent reassessment is essential.
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35. Adverse Reactions In some cases intranasal naloxone may cause:
Withdrawal symptoms
Agitation / violent behavior
Fast heart rate
“Goose bumps”
Yawning
Nausea / Vomiting / Seizures
High blood pressure or Low blood pressure
Fear of causing withdrawal should not prevent use when the person is unresponsive
Naloxone works by creating narcotic withdrawal, which may also cause the above signs and symptoms. These are common in the chronic narcotic user who has been administered naloxone. Nevertheless, if a patient is in respiratory arrest secondary to an narcotic overdose, the administration of naloxone is a life-saving time-critical action.
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36. Children can also overdose:
When an opioid overdose is suspected in a child use less of the liquid and repeat if needed:
Very small child: use one quarter in each side of the nose and consider using the other half in five minutes if the ambulance has not arrived and the child is still unresponsive
Pediatric patients are less likely to be suffering from an intentional overdose, but children can still be victims of an opioid or opiate overdose, usually inadvertently from ingestion of non-secured medications. Treatment doses for pediatric patients are as follows:
Infant: 0.5mg per nostril (total 1mg)
Child: 1mg per nostril (total 2mg)
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37. Children
Remember, children have smaller noses and some of the drug may run out of the nose and down the back of the throat. This will not do any harm.
Remember to suction the child’s nose prior to the administration of naloxone.
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38. Skills Practice Given a scenario:
Prepare a intranasal Naloxone atomizer using the required equipment
Demonstrate administration of intranasal Naloxone on an adult intubation head
Demonstrate as well as explain how you would provide continued support
Always request Emergency Medical Services, dial 911
If your agency develops a skills practice session, consider using a scenario that incorporates preparing the atomizer, demonstrating how to administer intranasal naloxone, and describing what else you would provide to the patient.
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39. Course Summary What we learned:
Why intranasal Naloxone is available as an option for bystanders who witness overdose
What an opioid overdose looks like
The reasons that justify use of intranasal Naloxone
How to prepare an intranasal Atomizer
How and when to use the intranasal Atomizer
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40. Credits and Acknowledgements
Northern New England Poison Center
MaineGeneral Medical Center
VT EMS/VDH/DPS
Ohio DPS/EMS
Central MA EMS Corp.
Northwestern Medical Center
Thank you to Northern New England Poison Center, MaineGeneral Medical Center, Vermont EMS, Ohio EMS, Central Massachusetts EMS Corporation and everyone else that helped develop and review this presentation. If you have questions, please contact Maine EMS
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41. References Federal Drug Administration www.fda.gov
US Centers for Disease Control
Northern New England Poison Center
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