The opioid epidemic has been ravaging across the United States, leading to overdose deaths from prescription opioids, heroin, and more. In fact, the mortality rate quadrupled since 1999 with an average of 38 deaths each day from overdoses involving prescription opioids in 2019. To combat the epidemic, federal and state legislations have given more resources to health care professionals in the form of an important tool known as naloxone.
What is Narcan?
Naloxone, also known as Narcan®, is an opioid antagonist medication approved by the Food and Drug Administration (FDA) to rapidly reverse an opioid overdose.
Naloxone works by binding highly to opioid receptors, displacing any opioids currently bound and reversing their effects. It is administered when a patient is showing signs of an opioid overdose such as unresponsiveness, very slow or abnormal breathing, limp body, pin-point sized pupils, and cold/clammy skin. Naloxone should be administered to anyone who is either presenting signs of or is suspected of an opioid overdose.
Source: Eastern Idaho Public Health
The onset of action is about 2-15 minutes after exposure. Naloxone is only active in the body for 30 to 90 minutes but the effects of most opioids last longer. This means that the effects of naloxone are likely to wear off before opioids are removed from the body, which can cause an overdose relapse and breathing to stop again. The CDC recommends more than one dose of naloxone may be needed to revive someone who is overdosing and to call 911 so the individual can receive immediate medical attention. To maintain stability, constant attention should be given for 2 hours after the last dose of naloxone is given to make sure breathing does not slow or stop.
Although its effects do not last long, it is a life-saving medication that stabilizes the patient before emergency personnel arrives and from 1996 through June 2014, there have been more than 26,000 opioid overdose reversals in the United States.
Is naloxone safe?
According to National Institute on Drug Abuse, “There is no evidence of significant adverse reactions to naloxone.” People who have a dependency on opioids may exhibit opioid withdrawal effects with naloxone including headaches, changes in blood pressure, rapid heart rate, sweating, nausea, vomiting, and tremors. It is rare to have side effects from naloxone but some people might have an allergic reaction. Naloxone reverses an overdose in people with opioids in their systems and will not reverse overdoses from other drugs like cocaine or methamphetamine.
There were about 50,000 people who died from an opioid-involved overdose in 2019 where a bystander was present in more than one in three overdoses involving opioids. Unintentional drug overdoses are a leading cause of preventable death but bystanders may not call for medical assistance out of fear of criminal charges. As a result, states have created “Good Samaritan” laws to create immunities and legal protections for people who call for help during an event of an overdose. These laws can have broad or comprehensive protection and some states have passed laws that consider providing and seeking medical help for a person as a mitigating factor during sentencing.
A more detailed resource for each state’s Good Samaritan laws can be found on the Prescription Drug Abuse Policy System’s website.
Most states have standing orders to allow pharmacists to fill prescriptions for naloxone. Naloxone has become widely used by emergency medical providers in all 50 states with pharmacists and other health professionals leading education and training.
Source: National Institute on Drug Abuse
Overdose Education and Naloxone Distribution (OEND) has been shown to increase the reversal of potentially fatal overdoses. Studies have shown that pharmacist-provided training has reduced the opioid overdose death rates between 27 to 46 percent lower in communities where OEND was implemented.
Although naloxone has been critical in avoiding opioid overdose-related deaths, the amount of prescriptions filled as a preventive measure is severely lacking in comparison to the number of prescription opioids filled on average. This is mostly due to the stigma around naloxone and substance use disorders in general. Patients may be hesitant to get a prescription and it can often be difficult for pharmacists to recommend it.
What is the best way to counsel patients on this medication?
The best way to combat this is to destigmatize the life-saving medication and educate pharmacists on how best to approach counseling and recommendations.
An example conversation:
Pharmacist: Good evening, I am the pharmacist that will be helping you today. I would like to talk to you about some of the prescriptions that your doctor has sent over to us. Along with your pain medication, your doctor has prescribed naloxone, also known as Narcan.. Have you had a chance to talk to your prescriber about what this medication is used for?
Patient: Yes, I do not remember exactly but I thought that is used for overdoses. I don’t know why he prescribed it to me, I take my medications when I am supposed to as needed.
Pharmacist: It is true that Narcan is used to reverse a breathing emergency caused by effects from opioid pain medications. It is becoming more common for incidents of accidental overdoses of pain medications and it is important to have the right tools in emergency situations. Think of it as similar to an Epi-Pen or a fire extinguisher, you may never need to use it but it’s always a good idea to have it just in case.
Patient: Okay, that makes sense.
Pharmacist: It is important to talk to a trusted family member that will be a bystander on how to administer naloxone. Opioid overdose can be abrupt and a bystander should watch out for the common signs such as shortened or stopped breathing, pinpoint-sized pupils, cold/clammy skin, and unresponsiveness.
Narcan should be administered into the nasal pathway with one spray into one or each nostril, depending on the device. The medicine will take effect within a few minutes after exposure and will last about 30-90 minutes. This will give the bystander enough time to call for medical assistance. But, keep in mind opioids last longer and there is a risk of relapse after the medicine wears off so that’s why there are two devices included.
Patient: Wow, that sounds scary.
Pharmacist: I hear your concern. We want you to stay safe and healthy and by being educated and aware of prescription medicine, we can achieve that! What are some of your expectations for this drug?
Patient: That will help me if I am having an overdose, I feel like it is more important to have this than I thought of before.
Pharmacist: That is correct, naloxone doesn’t have any adverse reactions besides the effects someone might feel after opioid withdrawal. These can include headaches, changes in blood pressure, rapid heart rate, sweating, and nausea. In rare cases, some people might have an allergic reaction that can include hives or swelling in the face, lips, or throat. If anything similar happens to you, let your doctor know right away.
Patient: Okay, I understand.
Pharmacist: Also quick question, where do you think you will store the medication?
Patient: Would it be okay to carry in my purse?
Pharmacist: Yes, I would recommend having it near you for quick access and to let someone you trust about where you keep it too. Be careful about having moisture near prescription medicines, we want to keep them away from moisture as best as we can.
Patient: Okay, I understand.
Pharmacist: So I know we’ve reviewed a lot, but give me a quick summary of what we talked about so I can help further.
Patient: Well, naloxone is used to stop the effect of an opioid overdose. Signs I should watch for are cold skin, tiny pupils, and feeling shortness of breath. It should be administered into one or each nostril and I should call for help as there is a risk for relapse. I will make sure to share this with my family.
Pharmacist: Perfect! Naloxone has some stigma and I would want you to feel comfortable. It is a preventive medicine, try to think of it as a fire extinguisher in your house, you may never use it but it’s always a good idea to have it just in case.
If you have any questions, don’t be afraid to call the pharmacy. It was a pleasure to talk to you.
End of example.
Naloxone is covered by most insurances at no cost to the patient. The most common delivery system is the nasal spray. There are three versions of this medication:
Table 1: Different brands of naloxone:
| Brand | Narcan® | Evzio® | Generic naloxone atomizer |
| Dosage | Two 4 mg/0.1 mL nasal spray | 2 mg/0.4mL Auto Injection | 1 mg/mL |
| Administration | Nasal spray | Injection (Similar to Epi-pen) | Nasal spray |
| Cost (Good Rx) | About $130 | About $140 | About $50 |
| Pros | No specialized training | Recorded message to talk you through giving the medication. | Cheapest- Most used by first responders |
| Cons | Co-pay about $40 for some insurances | Syringe and most expensive | Complex assembly |
An additional guide sheet can be found here.
Source: National Harm Reduction Coalition
While we know naloxone saves lives, the challenge comes in getting it to the patient. Pharmacists must take the extra step of destigmatizing the medication, educating others, and recommending naloxone to patients where indicated. Going above and beyond in this manner benefits patients, combating the epidemic and making the world safer, one nasal spray at a time.
Resources for Pharmacists
- From Surgeon General: Advisory on Naloxone
- From APhA: Opioid Use And Misuse Resource Center
- From CDC: Opioid Prescribing: Where You Live Matters
- Narcan: website
- Evzio: website
References
1. Johnson M. Drug Overdose Prevention Program Main. Eiph.idaho.gov. https://eiph.idaho.gov/Health%20Education/Drug%20and%20Alcohol/Drug%20Overdose%20Prevention%20Program%20Main.html. Published 2019. Accessed March 27, 2022.
2. Understanding the Opioid Overdose Epidemic. Centers for Disease Control and Prevention. https://www.cdc.gov/opioids/basics/epidemic.html. Published 2021. Accessed March 27, 2022.
3. Help Save Lives: Co-Prescribe Naloxone To Patients At Risk Of Overdose. 1st ed. New York: American Medical Association; 2017. https://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/co-branded-naloxone.pdf. Accessed March 27, 2022.
4. Naloxone for Opioid Overdose: Life-Saving Science | National Institute on Drug Abuse. National Institute on Drug Abuse. https://nida.nih.gov/publications/naloxone-opioid-overdose-life-saving-science#ref. Published 2022. Accessed March 27, 2022.
5. Overdose Death Rates | National Institute on Drug Abuse. National Institute on Drug Abuse. https://nida.nih.gov/drug-topics/trends-statistics/overdose-death-rates. Published 2022. Accessed March 27, 2022.
6. Is naloxone accessible? | National Institute on Drug Abuse. National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/naloxone-accessible. Published 2022. Accessed March 27, 2022.
7. Crocker A, Bloodworth L, Ballou J, Liles A, Fleming L. First Responder knowledge, perception and confidence in administering naloxone: Impact of a pharmacist-provided educational program in rural Mississippi. Journal of the American Pharmacists Association. 2019;59(4):S117-S121.e2. doi:10.1016/j.japh.2019.04.011
8. Responding to Opioid Overdose – National Harm Reduction Coalition. National Harm Reduction Coalition. https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/responding-to-opioid-overdose/. Published 2020. Accessed March 27, 2022.
9. Naloxone. SAMHSA. https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/naloxone. Published 2022. Accessed March 27, 2022.
10. SAMHSA Opioid Overdose Prevention TOOLKIT. 18th ed. New York: SAMHSA; 2013. https://store.samhsa.gov/sites/default/files/d7/priv/sma18-4742.pdf. Accessed March 27, 2022.
11. Good Samaritan Overdose Prevention Laws. Pdaps.org. https://www.pdaps.org/datasets/good-samaritan-overdose-laws-1501695153. Published 2022. Accessed March 27, 2022.
12. Lifesaving Naloxone. Center for Disease Control and Prevention. https://www.cdc.gov/stopoverdose/naloxone/index.html. Published 2020. Accessed March 27, 2022.
13. Overdose Death Rates | National Institute on Drug Abuse. National Institute on Drug Abuse. https://nida.nih.gov/drug-topics/trends-statistics/overdose-death-rates. Published 2022. Accessed March 27, 2022.
Faizan Ali is a P1 student pharmacist with an interest in community, managed care, and critical care pharmacy. In his free time, Faizan enjoys participating as a student researcher for a research project entitled, Assessment of Analgesics and Sedatives in Ventilated Patients with COVID-19, staying involved in professional pharmacy organizations, and learning as much about the world of pharmacy as he can. Faizan is a proud student pharmacist in the Doctor of Pharmacy (PharmD) program at the Wilkes University Nesbitt School of Pharmacy.
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