This document provides training for EMTs and EMRs on administering the opioid antagonist naloxone. It aims to reduce deaths from opioid overdose by instructing first responders. The training covers recognizing and treating opioid overdose, indications and contraindications for naloxone use, possible adverse reactions, and how to prepare and administer naloxone via intramuscular autoinjector or intranasal spray. Responders learn to identify overdose, administer naloxone, manage adverse reactions, and ensure transportation to definitive care.

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

2. GoalGoal
To reduce mortality and morbidity from
opioid overdose by instructing EMS
Responders (EMT and EMR) in the
administration of naloxone.
2

3. ObjectivesObjectives
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
3

4. 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.
4

5. Rate* of unintentional drugRate* of unintentional drug
OD deaths US 1970–2007OD deaths US 1970–2007
* Per 100,000 population
5

6. 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
• 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
6

7. 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.
7

8. 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
8

9. OpioidsOpioids
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”
9

10. 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
10

11. OpioidsOpioids
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®
)
11

12. OpioidsOpioids
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
12

13. Opioid AddictionOpioid 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”)
13

14. Target PopulationTarget 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.
14

15. 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?
15

16. 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
16

17. On SceneOn Scene
Drug Kit “Packaged” Drugs (Heroin)
Drug use clues
17

18. On SceneOn Scene
Drug use clues
“Track Marks”
18

19. Signs and Symptoms ofSigns 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

20. 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
20

21. “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
21
• Naloxone is for depressed respirations, not
depressed mental status.
• Opiate use alone (without depressed respirations)
does not merit the use of naloxone.

22. ContraindicationsContraindications
Known hypersensitivity (rare)
22

23. Naloxone DosageNaloxone Dosage
• Naloxone dosage will be specified by the agency’s
EMS sponsor hospital
• Common intramuscular (IM) dosage:
o 0.4 mg autoinjector
• Common intranasal (IN) dosage:
o Adults and children: 2 mg (2 mL) divided as 1mg (1 mL) per nostril
o 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
23

24. Naloxone UseNaloxone 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)
24

25. 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
25

26. • Administer naloxone via approved route at
specified dose
• Continue ventilating patient as needed
• Consider contacting poison control if poly-
substance use is suspected: (800) 222-1222
26
Naloxone Use,Naloxone Use, continuedcontinued

27. 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.
27

28. Methods of AdministrationMethods 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.
28

29. 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
29

30. 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
30

31. Why an Atomizer?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.
31

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

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

34. Intranasal NaloxoneIntranasal Naloxone
Preparation Step 3Preparation 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
34

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

36. One Luer-Attached AtomizerOne Luer-Attached Atomizer
36

37. Intranasal NaloxoneIntranasal Naloxone
AdministrationAdministration
•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
37

38. Intranasal NaloxoneIntranasal Naloxone
Administration,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
38

39. Intramuscular NaloxoneIntramuscular Naloxone
39

40. Why Intramuscular?Why Intramuscular?
• Consistent delivery of medication
• Simple and fast acting
• Similar to other auto-injectors used by EMS
40

41. Intramuscular NaloxoneIntramuscular Naloxone
AdministrationAdministration
• Ventilate patient with BVM
• Pull naloxone auto-injector
from case
o Device will now provide voice-
prompt guidance
• Grasp firmly and pull off
red safety guard
41

42. 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.
• Remove auto-injector and dispose of in sharps
container
• Continue to ventilate patient with BVM
42

43. Critical ReminderCritical Reminder
• Do NOT get distracted by drug administration
• Be sure to ventilate properly as needed
43

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

45. 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?
45

46. Adverse ReactionsAdverse 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!
46

47. 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
47

48. 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
48

49. 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
49

50. DocumentationDocumentation
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”
50

51. Patient RefusalsPatient 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
51

52. NotesNotes
• 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.
52

53. ReviewReview
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.
53

54. Thank youThank 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
54

55. 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)
55

56. Skills Practice &Skills Practice &
AssessmentAssessment
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
56

57. Student EvaluationStudent Evaluation
57