NaloxoneNaloxoneTraining ProgramTraining Program

EMR/EMTEMR/EMTMay 27, 2014May 27, 2014

State of Connecticut Department of Public Health/OEMS

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GoalGoalTo reduce mortality and morbidity from

opioid overdose by instructing EMS Responders (EMT and EMR) in the

administration of naloxone.

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ObjectivesObjectivesBy 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

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Objectives Objectives • 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

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HistoryHistory• 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.

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Treatment HistoryTreatment 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

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OpioidsOpioidsSynthetic 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”https://www.youtube.com/watch?v=IhfZ7ZPPRQA

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Opioids, continuedOpioids, 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

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OpioidsOpioidsOpioids may include:

BuprenorphineButorphanol (Stadol®)CodeineFentanyl (Duragesic® patch)Hydrocodone (Vicodin®)Hydromorphone (Dilaudid®)Meperidine (Demerol®) Methadone

MorphineNalbuphine (Nubain®)Oxycodone (Percocet®/Percodan®)OxymorphonePentazocine (Talwin®)ParegoricPropoxyphene (Darvon®)

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Opioid Addiction Opioid Addiction Treatment DrugsTreatment 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”)

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• Chase the Dragon (1st high)• Need another high after running out of prescription

painkillers like Vicodin and OxyContin• Use of other drugs• Cheap ($10 per dime bag)• Peer pressure• Experiment• To escape reality

Why Use It?Why Use It?

On SceneOn 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?

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On SceneOn 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

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On SceneOn Scene

Drug Kit “Packaged” Drugs (Heroin)

Drug use clues

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• Most used methods

• Intravenously

• Tar is heated and drawn up in syringe

• Cotton swab technique

• Quick way to get high

• Track Marks

• Prone to HIV/AIDS and hepatitiso Syringes are shared and reused

IV injection

Routes- InjectionRoutes- Injection

• Cuts down on overdose.

• “saves your veins.”

• Heroin is usually place on aluminum foil then heated from underneath.

• Heroin is boiled and users use a tube like object to inhale fumes.

• People who use heroin tend to crave sweet foods, increase the risk of tooth decay if dental hygiene is neglected.

• Heroin can also cause dry mouth and tooth grinding

Routes- InhalationRoutes- Inhalation Smoking Smoking

• Least used method

• Pure white heroin

• usually snorted by using a straw or rolled up paper

• Takes a lot longer than other methods to feel the effects of the heroin when snorted, users sometimes continue snorting until they obtain a high, which leads to over dose

• Asthma attacks, nosebleeds, breathing problems, and damage and irritation to the sinuses and cartilage of the nose

Routes- InhalationRoutes- Inhalation “Snorting” “Snorting”

• Eatingo GI track instead of blood streamo Less effective higho Poorly absorbedo Stomach breaks it down to a morphine compound

• Stuffingo Absorbed in the rectumo Via needless syringeo Quick higho No evidence of drug use

Routes- OtherRoutes- Other

Signs and Symptoms of Signs and Symptoms of

Opioid/Toxidrome:Opioid/Toxidrome:

• Unresponsive or minimally responsive, with a pulse

• Depressed respiratory rate

• Agonal respirations

• Respiratory arrest

• Cyanosis

• Miosis (constricted pupils) 19

Naloxone (NarcanNaloxone (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.

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CAUTION!!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

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Indications for Naloxone UseIndications 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

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“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

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• Naloxone is for depressed respirations, not depressed mental status.

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

ContraindicationsContraindications

Known hypersensitivity (rare)

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Naloxone DosageNaloxone Dosage• Common intramuscular (IM) dosage:

o 0.4 mg autoinjector

• Common intranasal (IN) dosage:oAdults and children: 2 mg (2 mL) divided as 1mg (1 mL) per nostriloInfant 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

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Naloxone UseNaloxone Use1. Ensure scene safety!2. Maintain appropriate Body Substance Isolation

(BSI)3. Assess level of consciousness and vital signs4. Maintain open airway and provide tactile

stimulation5. Assist ventilations 6. Ensure appropriate resources are responding7. Administer naloxone when indicated8. Initiate transport as soon as possible (don’t wait on

scene for paramedic)

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Naloxone Use,Naloxone Use, continuedcontinued The “Eight Rights” for Medication Administration:

•Right Patient•Right Reason•Right Time•Right Dose•Right Route•Right Drug•Right Response•Right Documentation

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Naloxone Use, Naloxone Use, continuedcontinued

• 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.

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Intranasal NaloxoneIntranasal 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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Why Intranasal?Why Intranasal?Works almost as quickly as IV route since nasal mucosa is highly vascularized and absorbs drugs directly into the blood stream

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Why an Atomizer?Why an Atomizer?Briskly compressing thesyringe converts the liquiddrug to a fine atomizedmist.

This results in broadermucosal coverage andbetter chance of

absorptioninto the blood stream thandrops that can run straightback into the throat.

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Intranasal NaloxoneIntranasal NaloxonePreparation Step 1Preparation Step 1

You will need:

•One Luer-Jet needle-free syringe

•One ampule of naloxone 2.0 mg

•One atomizer

Dosage indicator

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One Luer-Attached AtomizerOne Luer-Attached Atomizer

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Intranasal NaloxoneIntranasal NaloxoneAdministrationAdministration

•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

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Intranasal NaloxoneIntranasal NaloxoneAdministration, Administration, continuedcontinued

•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

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Intramuscular NaloxoneIntramuscular Naloxone

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Why Intramuscular?Why Intramuscular?

• Consistent delivery of medication

• Simple and fast acting

• Similar to other auto-injectors used by EMS

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Intramuscular Naloxone Intramuscular Naloxone AdministrationAdministration

• Ventilate patient with BVM

• Pull naloxone auto-injector from caseo Device will now provide voice-

prompt guidance

• Grasp firmly and pull off red safety guard

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Intramuscular Naloxone AdministrationIntramuscular Naloxone Administration, continued, continued

• Place black end against patient’s outer thigh

• Press firmly against patient’s outer thigh and hold in place for five seconds.

• Auto injector Administers 0.4 mg of naloxone

• Remove auto-injector and dispose of in sharps container

• Continue to ventilate patient with BVM

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Critical ReminderCritical Reminder• Do NOT get distracted by drug administration• Be sure to ventilate properly as needed

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Avoid “Tunnel Vision”Avoid “Tunnel Vision”• If respirations do not improve after five minutes,

consider what else could be going on?

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Other PossibilitiesOther 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?

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Adverse Reactions 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!

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Adverse Reactions, Adverse Reactions, continuedcontinued

Rapid opiate withdrawal may also cause:•Runny nose•Diaphoresis (excessive sweating)•Tachycardia•Tremulousness•Hypertension (high blood pressure)•Hypotension•Cardiac disturbances, including cardiac arrest•Epistaxis

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Adverse Reactions, Adverse Reactions, continuedcontinued

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

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Paramedic RoleParamedic 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:o Other medications/drugs they have received (polypharmacia)

o Additional care if no response to BLS care or if patient relapses

o Other conditions (head Injury, stroke, hypoxia, etc.)

• Do not delay transport

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DocumentationDocumentationAs 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”

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Patient RefusalsPatient Refusals• Do not “treat & release”

• Having a physician speak with the patient may assist in encouraging transport.

• Request police assistance if needed

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ReviewReviewWhat 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.

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ReferencesReferences

• 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)

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