Narcan 101: How to Save a Life in an Emergency

Link to Narcan 101 presentation

Articles:

• What is Narcan: History and Uses for the Overdose Reversal Drug

Webinars:

• Why Naloxone is Important and How to Use It

Welcome to the community education series hosted by The Recovery Village and Advanced Recovery Systems.

We really wanted to focus on the necessity of understanding how to utilize Narcan. This a life saving medication that’s available. It’s being highly requested in our communities. We’re continuing, especially through COVID, to see an escalation of overdoses across the country. We have programs in several different states, and no community is immune, unfortunately, right now to this situation. All of us are in this together and I think it’s a really important topic to discuss.

And so I have the honor of introducing Dr. Josey. She is our Medical Director at The Recovery Village Palm Beach at Baptist Health. I wanted to share a little bit more about Dr. Josey as well as our organization. As I mentioned, we’ve got multiple locations across the country, but primarily we provide inpatient services. We’ve also expanded into telehealth recently and really are focused on meeting the needs of our community. Dr. Josey has an incredible career behind her so far, and such a bright future ahead of her.

I am thrilled to be able to introduce you to her. She holds multiple degrees, a true professional. She has a bachelor of science in biology from Atlantic Union College, a master of science in human nutrition from Columbia University, College of Physicians and Surgeons, and a master of public health from the University of Medicine and Dentistry of New Jersey School of Public Health, which is now Rutgers university. She earned her doctorate of medicine from Howard University College of Medicine, and I am honored and privileged to call her a colleague and friend. So, Dr. Josey, I’m going to turn it over to you.

At the end we’ll come back and have questions. If you have questions throughout this presentation, please use the chat function at the bottom and we will address them at the end of the presentation. So, Dr. Josey, it’s all yours. Thank you.

Welcome everyone. I want to thank you all for taking time out of your schedules to spend some time with us today. I would like to get a little more familiar with who our attendees are, just so I know how to best address the population doing the session.

So, if you could chat in the box, whoever might be a physician, physician extender, a nurse, social worker, family member, or concerned community member. If you could just type that in, I’ll get a sense of who is with us today as you proceed.

I see child welfare, social work. Thank you, Carrie. Welcome answers are coming in. School-based prevention education. Perfect, prevention specialist. I love that. As we get… CNA. Okay.

As we get some more answers in, I think this is a perfect time. This is the ideal population, those who work in prevention, and we all should focus on prevention. This is crucial. I have my first board certification as a physician in preventative medicine/public health. At the end of this topic and the presentation, I’ll talk a little bit about how we can prevent overdoses and even prevent addiction. It’s great to be able to treat patients, but to prevent is even better.

Tobacco specialist, prevention specialist. Thank you. Welcome. A therapist for substance use disorder. Fantastic. The therapists are crucial to partner with us in medicine as we work to get the patients as safe as possible upon discharge from certain facilities. Prevention specialist. I’m so glad to see so many preventionists.

Okay. So a little bit about my background. Allison gave me an amazing introduction. Thank you so much. I’m board certified in addiction medicine as well as preventative medicine, public health medicine, and so this topic is near and dear to my heart.

As Allison mentioned, I’m the medical director currently of an inpatient detox, residential intensive outpatient and partial hospital program for those with addictive illness. I worked previously in Tampa at an outpatient addiction medicine treatment program, so we did a lot of MAT as well as partnering with the community to try to keep our patients safe.

We could go on to the first slide. We’ll start here. So one may ask, what’s the public health importance of preventing this at this time? Well, firstly, since April of 2018 our U.S. Surgeon General Dr. Adams has encouraged the public health field and public health advisory to become familiar with Naloxone. He has advised more Americans to carry it with them in order to help prevent opioid overdoses because of the escalation in overdose cases that we’ve seen in the United States. It’s already carried by many first responders and EMT police officers, but the Surgeon General in 2018 particularly recommended that community members and individuals, family members and lay people who are not involved in health care carry this to prevent the risk of overdose in individuals.

As I was asked to present the topic, I was also thinking about our current state of affairs in the past few weeks and months. We are in a time of a pandemic, so there are a lot of aspects of our social lives being disrupted. We know how it is affecting us, but thinking even more of our patients and those with addictive illness. They’re being impacted severely as well. We now have social distancing being implemented, so there’s more isolation, there’s more downtime, there’s more anxiety and stress. In an already vulnerable population of people who have been impacted by abuse, trauma, neglect, we now have this pandemic causing anxiety and fear. And because of the social isolation, a lot of the treatment centers have closed, a lot of the sober homes are no longer accepting any clients, and a lot of the meetings where our clients would go for support, the NA or AA, are also nonfunctional. Now we have a vulnerable population without the access that they might’ve had to support services, even their therapist. This is the perfect time for us to talk about Naloxone and how we can become familiar with its actions, its effects and its ability to save lives.

So what is Naloxone exactly? How does it work pharmacologically and who should receive it? So firstly, this medication works as an opioid antagonist, which simply means that it works on the opioid receptor. It travels throughout the body once it’s administered, and it binds to the receptor and blocks it. This is important to know because if someone is taking opioids and suffering from the effects of the opioids (sedation, drowsiness, loss of consciousness) or if you suspect that they may be suffering from it, Naloxone should be administered because it can help prevent central nervous system damage that comes from the person not breathing and losing their respiration.

Opioids work on a small area of the brain with a few hundred cells. Tiny quantities of it, just a few hundred cells in the brain stem. Opioids bind there and, in excessive quantities or with additional sedatives like benzodiazepines, it causes the central nervous system and the brain to signal the person to stop breathing as frequently and stop breathing as deeply.

In order to push those opioids causing this dysfunction off the receptor, Naloxone is excellent in binding and removing those opioids or sedatives from the opioids from the receptor. The sedatives will not be removed, but they’re also problematic. The benzodiazepines may be binding on their receptors as well, sending signals to the brain to slow and stop respiration.

It’s also important to know that Naloxone is really not active when it is swallowed orally. It has no viability practically, which is why when it’s used in combination (the Naloxone buprenorphine as a substance to prevent people from abusing it) there is no effect of it. It is digested and metabolized, and it will not affect the person. When it’s given intravenously or intranasally, that’s when it can get into the bloodstream, travel to the areas of the brain where it needs to be active, and that’s how it will work.That’s a little bit of the pharmacology.

So who should receive Naloxone? In which population will it be appropriate and advised? There are many people in the United States who have chronic pain and who have been taking opioids at high doses for a long time.

If we think about the elderly, it’s not unusual that they may forget that they took a medication that maybe take too much. They may take double doses forgetting that they took it and they may be subject to an overdose. So it’s good for family members and friends, or those who work at a nursing home, still have access to Naloxone for those vulnerable individuals.

People who may have been discharged from an emergency department after an overdose. It is ideal to send these individuals home with Naloxone so that we can prevent a future overdose.
There’s also our patients, the ones that I’m most familiar with who are in treatment with us, either in medication-assisted treatment or in a facility where they’re not receiving MAT, maybe detox or any level of care within the addiction medicine arena. Those individuals should have access to Naloxone as well.

People taking extended release formulations of medications that are opioid-class like fentanyl should have access as well. Now, the important thing to remember is that we can give it to the patients upon discharge. However, it’s most important to advise them to share the prescription as well as the directions with family members.

If you’re overdosing, you will not be able to administer it to yourself. So by sharing the information and the brochure that comes within the package (I’ll go through this later) with the people who live with them, who are close to them, who may be present if god forbid there’s an overdose and familiarizing themselves, those family members with the information ahead of time will be the most effective way to prevent an overdose in our vulnerable patients.

What about pregnant women? That’s a good question. Unfortunately, there have been no randomized double blind placebo controlled studies, which are the gold standards for pregnant women. However, it’s been shown to be relatively safe and one should administer it when the benefit outweighs the risks. If a pregnant woman has been administered Naloxone, she should tell the emergency medical personnel who sees her and treats her thereafter so that the baby can be examined and it could be ensured that there was no damage to the fetus because the fetus may go through withdrawal as well.

Another thing is that in marketing any pharmaceutical substance, the last part of marketing is that community-wide surveillance after it’s been released into the general population. That surveillance is done because the pharmaceutical product has already been approved, so now millions of people are taking that drug. We look for those reactions that may be very rare with that amount of people actively taking the drug. It’s at that time that we’re able to see some very rare side effects because this hasn’t been studied anywhere. Side effects we would not know. So all we can go by is the few studies and the few case reports, small studies, or case reports of pregnant woman who have received it, but once again, it’s the benefits versus the risks and there has not been shown to be a lot of risk. It’s currently class B and C for the pregnancy safety category.

So as I mentioned before (this is a more specific question), you want to have access to and provide this medication in times of an opioid overdose, or if you suspect an overdose. If someone has misused opioids or they have a history of misusing opioids, or if they’re using opioids and benzodiazepines, that is when it will be effective. Now, please note if there are other overdoses to stimulants or benzodiazepines alone, Naloxone will not be effective. It specifically works on the opioid receptor.

So, signs of opioid overdose: how would you be alerted to the fact that someone may be suffering from an opioid overdose? The first thing is that they will be difficult to arouse. When I used to teach CPR for the American Heart Association, you always have this presentation of a person down. And then you would go to the person; shake and shout, they would say. So if you see someone that’s difficult to rouse, they’re not responding to vocal commands to their name, do a sternal rub. You can use your knuckles and rub on the sternum, which is the bone in the middle of the chest. That is a sensation that’s very uncomfortable and that will wake most people up, and alert them to the fact that their attention is being called. If the person is not arousable, that is a time that you can suspect that they may be suffering from an overdose. Their breathing also will be shallow or irregular or slow. The loss of consciousness I somewhat alluded to, unresponsive.

You may also notice choking sounds or gurgling sounds from the back of the throat where fluid may be accumulating. Pulmonary edema may be happening because of the lack of consciousness, or there may be some vomiting. and aspiration of the vomit is when you may get some of the vomit and fluids drawn into your lungs, which is very serious. So you may actually see the vomit as well.

The muscles and their extremities will be very limp. You may notice that as well. If you feel the areas where they’ll have a pulse in the carotid area or the radial area, if you press here instead of feeling a pulse, you may feel nothing or a very faint pulse.

Those are the signs you want to look out for. A lot of times it’s easy to assume the person’s just sleeping. If there’s any reason that an overdose is suspected or you know the person is taking opioids or even if you don’t know, it doesn’t hurt to still give them the Naloxone in order to save that life.

Now, there are certain steps. You want to call 911 as well. You do not want to rely only on the Naloxone; the reason being the Naloxone is very short-acting. Once you administer it, you have to continue administering it every two to three minutes because the person can revert back into respiratory depression. So you definitely want to get the emergency medical personnel on the way.

Next slide. Now we’ll go into exactly how it may be given. This slide shows some of the different formulations. I’ll talk most about the Naloxone hydrochloride in the center. These are all FDA-approved, but I’ll talk most about the four milligram Naloxone nasal spray, because that’s what we administer- well, discharge our patients with, rather. We discharge it for administration if necessary, and we use that one just simply because of the ease of use. It’s been shown to be one of the easiest to administer.

The one on the left is also another formulation of a nasal spray, and I have a picture that will go through exactly how that one is administered in the case that you come across that, your location offers it, or a patient or family member that you may know has been administered any of these.

The one on the right, the Naloxone hydrochloride, that one, the purple and gold, is a self-directed injection. Once you pull the tab, it will tell you, step-by-step with verbal prompts, what to do to administer it. It’s a needle that you can administer intramuscularly into the thigh. You can use it through the clothes, you don’t have to move the clothes and it will be effective. I don’t have a physical device to show you how to use it, but I do have one of the Naloxone in the middle.

So as I alluded to, it can be injected into the muscles subcutaneous under the skin, which is the one on the right or into a vein through an IV. We won’t discuss that at all, as that formulation is used exclusively by health care providers or emergency medical personnel. They always will come with information that will instruct ahead of time on the specifics of how to use and administer those medications.

It’s good to practice. Not with the device itself because if you use it, you won’t be able to use it in an emergency. Just be familiar even with how to handle it, how to hold it, and definitely with the steps in the directions to administer. The purple and gold. I already talked about that. There’s verbal instructions. It’s similar to a defibrillator how the defibrillator will walk you through the steps.

We could go to the next slide. I think I talked about everything there. Okay, so let’s get into what you would notice and what are the steps to take. I will say that there are some differences in opinion on what is the first step. I will talk about that one: the steps that Narcan and the Naloxone hydrochloride, the brand name, Naloxone advises. It would describe most of those, which would be to administer it first before calling 911. They say to do that because at least you can get the purse and get some of those openers off the receptor and get some of the breathing started and reduce some of the damage to the central nervous system.

If someone else is there, like I used to teach in CPR, as soon as you find a person down, if anyone else is there, you could tell them to call 911. That’s the best thing. And then you can deal with the person then.

So as it relates to what you will notice, we talked about that, but it will be in these slides as well. You’re shaking and shouting at them and shouting their name. You can do the sternal rub, calling 911 and then this is what Naloxone looks for, which I’ll go through in detail.

That is what’s being shown in this picture. How to administer this type of the Naloxone nasal spray, the Narcan. You’re going to get one spray in the nostril, which will be a four milligram dose. You’ll peel the label off first. Peall-place-press, which means you will peel the label off the back, place it in one of the nostrils and press. If the person is on their back, you do want them on their back to do this. You do want to support their neck with the back of your hand so that it will be more likely to not run out of their nose, but go deeply into their nose. I’ll show you specifically later on with this package. I’ll pull it out. This is just an overview of the different formulations and how to use them.

Putting the person in the recovery position like you would with CPR is helpful too, so that if they do vomit, they won’t swallow it, choke or what we call aspirate, and if they’re not breathing and there’s no pulse, then you would want to give chest compressions and rescue breathing, like we all know from CPR.

Once again, it’s two to three minutes that you want to be checking the person, you can’t walk away. You have to watch them because even if there is a positive response, the opioids that they take (especially with fentanyl being so prevalent and carfentanil and morphine), those are long-acting opioids, so they will bind back to the receptor. The Naloxone will go on the opioid receptor, pull the other opiods off, but then it’s released from the receptor. The other opioids are still in the bloodstream, so they will bind back to the receptor. The person may succumb again to respiratory depression.

So you give a second dose. And the good thing is that in this packet there are two doses. I’ll pull it out and show you. If you need to give a second dose, you alternate the nostril. Okay. Peel-place-press to the alternate nostril, and if they’re not breathing, continue chest compressions and CPR, that’s why you want the emergency personnel there quickly so that they can help and take over and give it through the IV.

With the Naloxone administered through IV it works more quickly. Getting them to the hospital is the most important thing. Even if they do recover, you still want them to be treated at the hospital recovering, meaning waking up.

We could go to the next slide. This is, again, a different picture of the nasal spray. I like this one because it actually shows the picture of the notes. Unfortunately, I don’t have a dummy to show you like we did in our CP, a mannequin kid or dummy like we had in our CPR classes. So, call 911, lie the person on their back, or you could then support the neck and the head. Tilt the head back. That’s important. Peel it off, place it in the nostril and press. I’ll take it out and show you how to hold it and how to press it up the nose and it will work even if the person isn’t breathing.

Once again, the recovery position, and… monitor, next slide. This shows how to use that left in that other side where we had three different formulations. This is just another type of nasal spray and how to use it. You again, try to wake the person up, shaking, shout, no response. I know this is redundant, but just like with CPR, the more you hear it, the more you practice, the more will stick. So I liked all of these pictures for different reasons. They show different things, not just the different formulations.

So we’ll go through them. And this one shows calling 911 after. You could send someone to do it, or you call themselves and then you administer this Naloxone. You assemble it, you spray half into each nostril. This one you would just do half and you repeat after two to five minutes. If they don’t regain consciousness, you want to check for breathing again, give CPR. We have been trained to do so by tilting the head back to open the airway and start to breathe into the mouth every two to five seconds. The rescue breaths. And if they need chest compressions, you do that too. And again, to stay with the person cause it wears off in about 30 minutes or less depending on which opioid they took. If they wake up, you explain what happened and if you need to leave, turn the person, leave to call 911, turn them on their side to prevent choking. Okay.

And this question is, doesn’t Naloxone have any side effects, and if so, what are they? I wanted to go over that quickly before we go into the actual demonstration. Talk about the other types, there are some side effects. The main ones would be the side effects of opioid withdrawal. The lacrimation, the dysphoria, the agitation, the sweating, the goosebumps. The lacrimation means runny eyes, sorry, the runny nose. There might be nausea, vomiting, all of those you would see, because the Naloxone will push them into opioid withdrawal.

Another thing that’s important, one side effect is actually some cardiac effects. So if the person has a history of heart disease, with this reversal of the opioid effects, they may suffer from some negative cardiovascular effects. The heart will have some abnormality or heart illness. So it’s important if someone has heart disease and has received Naloxone that they tell the doctor after they have been given it.

This is another formulation. This is very similar to the side we went over before. I liked this because it was a step-by-step guide. It started with the rescue breaths as a person put the person on their back. And then this shows you how exactly. I chose this slide because in steps two and three it shows you exactly how to assemble this type of device that we saw in that far left picture where we have the three different devices.

So this one has a yellow cap on top and you would remove it. It has a syringe and then there’s a red and purple cap that has the Naloxone in it. So you attach that yellow tip in place, and once that’s assembled, you screw the Naloxone capsule into the barrel with the syringe. It’s not a needle syringe, it’s a different type of syringe. Then you tilt the head back and put it into the nose and administer. The other steps are the same but I wanted you to see step two and three on how to assemble that little cap. Again, if someone did have that device, there will be an instruction guide, an information sheet with the directions in the packet.

Thank you for watching this video. We hope you enjoyed the presentation.