1. Naloxone Training Program EMR/EMT May 27, 2014
State of Connecticut
Department of Public Health/OEMS

2. Goal
To reduce mortality and morbidity from opioid overdose by instructing EMS Responders (EMT and EMR) in the administration of naloxone.
Naloxone may be administered intranasal or by autoinjector as per local medical control

3. Objectives By the end of this course the EMT/EMR will:
Recognize the signs and symptoms of an opiate overdose
Identify the indications and contraindications of naloxone
Explain the possible adverse reactions of naloxone
Describe how to manage adverse reactions
Prepare and administer naloxone via approved route
Describe the on-going patient management after the administration of naloxone
Appreciate the place of naloxone in the management of opioid overdose

4. History
In 2010, approximately 38, 329 drug overdose deaths occurred in the United States, one death every 7 minutes.
About 75% of these deaths involved prescription opioid analgesics.
In 2009 alone, there were 257 million opioid prescriptions written.
Source: Federal Drug Administration
Most Common Drugs involved in Overdoses
In 2010, of the 38,329 drug overdose deaths in the United States, 22,134 (60%) were related to pharmaceuticals.6
Of the 22,134 deaths relating to prescription drug overdose in 2010, 16,651 (75%) involved opioid analgesics (also called opioid pain relievers or prescription painkillers), and 6,497 (30%) involved benzodiazepines.6
In 2011, about 1.4 million ED visits involved the nonmedical use of pharmaceuticals. Among those ED visits, 501,207 visits were related to anti-anxiety and insomnia medications, and 420,040 visits were related to opioid analgesics.2
Benzodiazepines are frequently found among people treated in EDs for misusing or abusing drugs.2  People who died of drug overdoses often had a combination of benzodiazepines and opioid analgesics in their bodies.6

5. Rate* of unintentional drug OD deaths US 1970–2007
Source: National Vital Statistics System. Available at
IN CT, rural areas have experienced an especially high OD rate per capita.
Connecticut Heroin Deaths
2012 – 174
* Per 100,000 population

6. Treatment History
Opiates kill because they cause people to stop breathing
EMTs and EMRs have been limited to providing ventilatory support as a means to reverse hypoxia
Reversal of the cause of hypoventilation allows for return of spontaneous respiration and limits the continued need for ventilatory support
Prolonged hypoventilation complications include hypercarbia, hypoxia, aspiration, respiratory arrest and death
Hypercarbia: abnormally high levels of carbon dioxide concentrations in the blood.

7. Naloxone (Narcan®)
Naloxone (Narcan®) is an opioid (narcotic) antagonist that may reverse central nervous system and respiratory depression secondary to an overdose of opioids.
Naloxone is not effective against respiratory depression due to non-opioid drugs.
Photo Source: MDPH Opioid Overdose Prevention & Reversal Information Sheet (1/25/12)
What is naloxone (Narcan®)?
A. It is a prescription medicine that reverses an opioid overdose. It cannot be used to get high and is not addictive.
Naloxone is safe and effective; emergency medical professionals have used it for decades. For more information, see:

8. CAUTION!!
Naloxone works for a shorter period of time than most opioids
Without additional treatment, patients may experience a relapse of respiratory arrest that may lead to death
The half- life of naloxone is 1 hour and the duration of action ranges from 30 minutes to four hours.
From MicroMedex: Absorption
■Tmax, subQ or IM: 15 minutes (Evzio(R) auto-injector); 20 minutes (standard syringe) [6]Distribution
■Protein binding, Albumin: relatively weak [6][12]Metabolism
■Liver: extensive [6][12]■Naloxone-3-glucoronide (major): inactive [6][12]Excretion
■Renal: 25% to 40% as metabolites (within 6 hours), about 50% (in 24 hours), 60% to 70% (in 72 hours) [6][12]Elimination Half Life
■Adults: 1.28 hours (Evzio(R) auto-injector); 30 min to 81 min (standard injection) [6][12]
■Neonates: 3.1 hours +/- 0.5 hours [6][12]

9. Opioids
Synthetic or semi-synthetic alkaloids act on the Central Nervous System as a depressant to:
decrease the perception of pain
decrease the reaction to pain
increase pain tolerance
May be prescribed for acute pain, debilitating pain, or chronic pain as part of palliative care (e.g., cancer)
May be abused to induce euphoria or “high”
Trivia: Opiates are an alkaloid derived from the opium poppy plant (non-synthetic)
Reversal by naloxone of opioids in patients with pain may result in acute return of pain. Emphasize use of tactile stimulation and respiratory support in this population.

10. Opioids, continued
Tolerance and/or addiction may occur, requiring increasing doses for the same effect
Common side effects include:
-respiratory depression
-drowsiness
-itching
-nausea and vomiting
-dry mouth
-miosis (constricted pupils)
-constipation

11. Opioids Opioids may include: Buprenorphine Butorphanol (Stadol®)
Codeine
Fentanyl (Duragesic® patch)
Hydrocodone (Vicodin®)
Hydromorphone (Dilaudid®)
Meperidine (Demerol®) Methadone
Morphine
Nalbuphine (Nubain®)
Oxycodone (Percocet®/Percodan®)
Oxymorphone
Pentazocine (Talwin®)
Paregoric
Propoxyphene (Darvon®)
For a more complete list, see NIDA's page on commonly abused prescription drugs:
For pictures of opioids and other commonly abused drugs, see:

12. Opioids
Heroin is an illegal opioid which may be injected, snorted, or smoked. Street names include:
Big H Boy Capital H China white Chiva Dead on arrival Diesel Dope Eighth Good HH
Hell dust Horse Junk Mexican horse Mud Poppy Smack Thunder Train White junk

13. Opioid Addiction Treatment Drugs
Methadone
Opioid which may be used as a pain reliever, but commonly prescribed to minimize the effects of opioid withdrawal
Suboxone
Opioid (buprenorphine) and naloxone combined to both minimize effects of opioid withdrawal while blocking the effects of euphoria (“high”)

14. 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.
Is naloxone just a "safety net" that allows users to use even more?
A. Research studies have investigated this common concern and found that making naloxone available does NOT encourage people to use opiates more.  The goal of distributing naloxone and educating people about how to prevent, recognize and intervene in overdoses is to prevent deaths.  Other goals, such as decreasing drug use, can only be accomplished if the user is alive. 
High Risk Populations for opioid overdose:
Individuals demonstrating drug-seeking behavior (e.g., frequent ED visits, or accessing care from multiple doctors)
High dose users
Prescription pain-killer users (often not own prescription)
IV drug users
Over-medicated elderly patients
Patients with pain relieving patches
Children with access to prescription pain-killers

15. On Scene
You may know you’re responding to a suspected overdose, or you may be told upon arrival
Scene Safety/BSI is a top priority
Do you have appropriate resources present or responding?
Remain non-judgmental and non-confrontational
Ask bystander(s) what and when the patient injected, ingested, or inhaled (or if a transdermal patch has been used)
Was more than one substance used?
Police necessary as patient may become agitated, uncooperative and/or violent after naloxone. Advanced life support should be activated.

16. On Scene
Multiple bottles of the same prescription medication
Multiple bottles of the same prescription medication that don’t belong to the patient or anyone else at that residence
Drug use clues
Discuss other situations such as child overdoses, medically frail patients, etc.

17. On Scene Drug use clues Drug Kit “Packaged” Drugs (Heroin)
Photo Source “Packaged” Drugs (Heroin): Central MA EMS Corp; Holden, MA
Drug Kit
“Packaged” Drugs (Heroin)

18. On Scene Drug use clues “Track Marks”
Photo Source “Track Marks”: Central MA EMS Corp; Holden, MA
“Track Marks”

19. Signs and Symptoms of Opioid/Toxidrome:
Unresponsive or minimally responsive, with a pulse
Depressed respiratory rate
Agonal respirations
Respiratory arrest
Cyanosis
Miosis (constricted pupils)

20. Indications for Naloxone Use
Respiratory arrest or hypoventilation in addition to:
Evidence of opioid/opiate use
Bystander report
Drug paraphernalia
Opioid prescription bottles/patches
“Track marks”
Opiate/opioid toxidrome

21. Naloxone is for depressed respirations, not depressed mental status.
“Addicts take opiates and other sedatives specifically to induce a pleasant stupor. If they’re lethargic and hard to arouse, but still breathing effectively, it’s not an overdose. It’s a dose.” –Boston paramedic
Naloxone is for depressed respirations, not depressed mental status.
Opiate use alone (without depressed respirations) does not merit the use of naloxone.

22. Known hypersensitivity (rare)
Contraindications
Known hypersensitivity (rare)
Abnormal breath sounds may indicate opiate induced noncardiogenic pulmonary edema or aspiration.
Cautions:
Abnormal breath sounds on auscultation (wheezing, unequal breath sounds, rale or rhonchi)
Recent seizure (by report or signs)
Head/Facial trauma
Nasal trauma (obstruction and/or epistaxis)

23. Naloxone Dosage
Naloxone dosage will be specified by the agency’s EMS sponsor hospital
Common intramuscular (IM) dosage:
0.4 mg autoinjector
Common intranasal (IN) dosage:
Adults and children: 2 mg (2 mL) divided as 1mg (1 mL) per nostril
Infant and toddler: naloxone 1 (1 mL) mg divided as 0.5 mg (0.5 mL) per nostril
Physician oversight may direct different dosing to improve therapy or decrease adverse effects

24. Naloxone Use Ensure scene safety!
Maintain appropriate Body Substance Isolation (BSI)
Assess level of consciousness and vital signs
Maintain open airway and provide tactile stimulation
Assist ventilations
Ensure appropriate resources are responding
Administer naloxone when indicated
Initiate transport as soon as possible (don’t wait on scene for paramedic)
Suction as needed
Paramedics should be dispatched
Police should be dispatched

25. Naloxone Use, continued
The “Eight Rights” for Medication Administration:
Right Patient
Right Reason
Right Time
Right Dose
Right Route
Right Drug
Right Response
Right Documentation

26. Naloxone Use, continued
Administer naloxone via approved route at specified dose
Continue ventilating patient as needed
Consider contacting poison control if poly-substance use is suspected: (800)
Photo Source Denver Paramedics Administering naloxone:
If NPA in place, remove prior to administration and then reinsert.
Local medical control will determine appropriate dose. This will commonly be 2mg (1mg per nostril)
Auto injector contains 0.4mg for IM use

27. Naloxone Use, continued
The effects of naloxone may not last as long as the effects of the opioid; be prepared for a return of overdose signs & symptoms!
Every effort should be made to encourage patient be transported to definitive care.
Physician or police speaking with the patient may assist in eliciting transport.

28. Methods of Administration
The following slides address the preparation and administration of both intranasal and intramuscular (via autoinjector) administration of naloxone.
Providers may only administer naloxone via the route(s) authorized by their EMS sponsor hospital.

29. 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 minutes
Photo Source: MDPH Opioid Overdose Prevention & Reversal Information Sheet (1/25/12)
How does naloxone help?
Naloxone is an antidote to opioid drugs. Opioids can slow or stop a person's breathing, which causes death. Naloxone helps the person wake up and keeps them breathing.  An overdose death may happen hours after taking drugs. If EMS acts when they first notice a person's breathing has slowed, or when they can't awaken a user, start rescue breathing (if needed) and give naloxone.
Can naloxone harm someone?
A. No. If you suspect an opioid overdose, it is safe to give naloxone.  People who used opioids will then wake up and go into withdrawal. Withdrawal is miserable but better than dying.
Naloxone does not prevent deaths caused by other drugs such as benzodiazepines (e.g. Xanax®, Klonopin® and Valium®), bath salts, cocaine, methamphetamine or alcohol.
Participants should be directed to store medication in compliance with labeled storage requirements.
Protect naloxone from light
Avoid temperature extremes

30. Why Intranasal?
Works almost as quickly as IV route since nasal mucosa is highly vascularized and absorbs drugs directly into the blood stream
IM administration may be more reliable (less variable)
Mechanism of Action
Competitive opioid antagonist; synthetic congener of oxymorphone
Absorption
Onset: 2 min (IV); 2-5 min (IM/SC)
Duration: Depends on route of administration; generally 1-2 hr
Elimination
Half-life: min (adults); 3-4 hr (neonates)
Excretion: Urine

31. Why an Atomizer? Briskly compressing the syringe converts the liquid
drug to a fine atomized
mist.
This results in broader
mucosal coverage and
better chance of absorption
into the blood stream than
drops that can run straight
back into the throat.
Wolfe-Tory Mucosal Atomizer Device MAD available at:

32. Intranasal Naloxone Preparation Step 1
You will need:
One Luer-Jet needle-free syringe
One ampule of naloxone 2.0 mg
One atomizer
Dosage indicator
Photo Source:

33. Intranasal Naloxone Preparation Step 2
Remove the caps from both ends of the Luer-Jet needle-free syringe
Source:

34. Intranasal Naloxone 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
Source:

35. Intranasal Naloxone Preparation Step 4
Attach the nasal atomizer to the opposite end.
Source:

36. One Luer-Attached Atomizer
Photo Source:

37. Intranasal Naloxone Administration
Ventilate patient with BVM
Assess the patient to ensure their nasal cavity is free of blood or mucous (suction if needed)
Control patient’s head with one hand
Gently but firmly place atomizer within one nostril, carefully occluding the opposite nostril

38. Intranasal Naloxone Administration, continued
Aim slightly upwards and toward ear on same side as the nostril
Briskly compress syringe to administer ½ of total dose (up to 1.0 mg of atomized spray per local medical control)
Repeat in other nostril (using both nostrils doubles the surface area available for absorption)
Continue ventilating patient with BVM

39. Intramuscular Naloxone

40. Why Intramuscular? Consistent delivery of medication
Simple and fast acting
Similar to other auto-injectors used by EMS
Mechanism of Action
Competitive opioid antagonist; synthetic congener of oxymorphone
Absorption
Onset: 2 min (IV); 2-5 min (IM/SC)
Duration: Depends on route of administration; generally 1-2 hr
Elimination
Half-life: min (adults); 3-4 hr (neonates)
Excretion: Urine

41. Intramuscular Naloxone Administration
Ventilate patient with BVM
Pull naloxone auto-injector from case
Device will now provide voice-prompt guidance
Grasp firmly and pull off red safety guard
Instructions are specific to EVZIO naloxone autoinjector. Minor variations may be required for other devices (such as time held against thigh or location of safety guard)
If battery fails or voice prompts are not delivered, auto-injector should still function.
After injection is complete and autoinjector removed from patient, device should shield needle.

42. Intramuscular Naloxone Administration, continued
Place black end against patient’s outer thigh
Press firmly against patient’s outer thigh and hold in place for five seconds.
Remove auto-injector and dispose of in sharps container
Continue to ventilate patient with BVM

43. Critical Reminder Do NOT get distracted by drug administration
Be sure to ventilate properly as needed
Photo Source Bag-Valve-Mask: Central MA EMS Corp; Holden, MA

44. Avoid “Tunnel Vision”
If respirations do not improve after five minutes, consider what else could be going on?

45. Other Possibilities
The patient has taken an amount of opioids that is more than the naloxone is able to counter
Maybe it’s not an overdose!
What other conditions may have similar signs & symptoms?
Discuss how each changes the treatment plan.

46. Adverse Reactions
Use caution when administering naloxone to narcotic dependent patients!
Rapid opiate withdrawal may cause nausea & vomiting.
Keep airway clear and be prepared to suction!
Portable Suction Unit available at:
Patients receiving opioids for pain control may have an acute return of pain

47. Adverse Reactions, continued
Rapid opiate withdrawal may also cause:
Runny nose
Diaphoresis (excessive sweating)
Tachycardia
Tremulousness
Hypertension (high blood pressure)
Hypotension
Cardiac disturbances, including cardiac arrest
Epistaxis
Adverse reactions may be the result of a co-ingestant (stimulant, cocaine, etc.)

48. Adverse Reactions, continued
Rapid opiate withdrawal may also cause:
Agitation, irritability, and violent behavior
Restlessness and nervousness
Be prepared to deal with agitated patient
Maintain the safety of yourself, your partner and patient
May need to consider physical restraint

49. Paramedic Role Call for Paramedic if available
Paramedic may titrate naloxone dosing to reverse respiratory depression without full return to consciousness
Patient may require care for:
Other medications/drugs they have received (polypharmacia)
Additional care if no response to BLS care or if patient relapses
Other conditions (head Injury, stroke, hypoxia, etc.)
Do not delay transport
Polypharmacia is the co-ingestion/administration of multiple drugs or medications. These may have additive or opposing effects.

50. Documentation As always, carefully document, including:
Patient presentation (neuro, respiratory, cardiac)
Signs and symptoms (before & after treatment)
Vital signs (before & after treatment)
naloxone administration prior to EMS arrival
Clinical response
Any use of physical restraint
Record time drug was administrated, amount, and route, for example:
“19:21, naloxone 2.0 mg intranasal”
“02:32, naloxone 2.0 mg intramuscular (IM), right thigh”

51. Patient Refusals Do not “treat & release”
A refusal must be signed by a patient who can reasonably be determined to be competent to make an informed decision to refuse further care
Having a physician speak with the patient may assist in encouraging transport.
Request police assistance if needed

52. Notes Continue to provide respiratory assistance as needed.
If no pulse, with or without agonal breathing, begin CPR.
Do not administer naloxone to patients in cardiac arrest.
If respirations adequate, provide supportive care.
Naloxone is not effective against overdose from non-opiate drugs.
Review your Sponsor Hospital Policies and Procedures.

53. Review What have we learned:
Why naloxone was added as an option for BLS.
What an opioid overdose presents like.
What the signs and symptoms of an opioid overdose are.
The indications for administering naloxone.
The contraindications to administering naloxone.
The possible adverse reactions of naloxone.
How to manage adverse reactions.
How to prepare a naloxone atomizer or to administer naloxone via autoinjector.

54. Thank you
Special thanks to those who have shared their training materials with us to help develop this program:
To Central Massachusetts EMS for use of much of their BLS naloxone program and slides
Peter Canning RN, Paramedic, EMS Coordinator at John Dempsey Hospital
State of CT EMS Advisory Board, Education and Training Committee

55. References Centers for Disease Control Drugs.com
Federal Drug Administration
CT DPH Bureau of Substance Abuse Services
N.O.M.A.D. (Not One More Anonymous Death Overdose Prevention Project)

56. Skills Practice & Assessment
Given a scenario by your instructor:
Prepare a naloxone atomizer and/or autoinjector using the required equipment
Demonstrate administration of intranasal and/or intramuscular naloxone on an adult manikin
Demonstrate as well as explain how you will provide continued patient care support
In addition to intranasal and/ or autoinjector naloxone supplies, the instructor should also have related equipment (e.g., nasal airway, BVM) for students to demonstrate treatment.

57. Student Evaluation