How Do You Know When To Give Narcan?Anna Ciulla
Opiate overdose is a serious medical emergency responsible for 68 percent of the 70,237 drug overdose deaths in the United States in 2017. The largest increase in opiate deaths involved synthetic opiates, including illicitly manufactured fentanyl. As the opiate epidemic continues to worsen in America, even with potential provisional improvements in 2018 in some drug overdose indicators, there is an urgent need for efforts to prevent and respond to opiate overdose deaths, specifically due to illicitly manufactured fentanyl and other opiates, and prescription opiate drugs. Narcan can and does help to reverse opiate overdose. Yet, how do you know when to give Narcan?
WHAT IS NARCAN?
Naloxone is the life-saving prescription opiate overdose drug approved by the Food and Drug Administration to treat opiate overdoses. Narcan is a brand name for naloxone (another is Evzio). Narcan is a safe medication widely used by police and firefighter first responders and emergency medical personnel, although in many cases, by the time help reaches the overdose victim, it’s administered too late.
According to the FDA, Narcan is easy to use and can be administered by anyone, even those without medical training. It is not, however, a substitute for immediate medical care. Any person administering Narcan should call for emergency medical attention immediately for the overdose victim.
WHO CAN ADMINISTER NARCAN?
As a result of expanded naloxone distribution programs, family members, friends and other bystanders are now able to obtain naloxone kits so they can help save the life of an opiate overdose victim. Currently, 51 states have naloxone access laws. In 50 states, pharmacies are able to distribute naloxone in an outpatient setting without requiring a physician-ordered prescription. The layperson administering naloxone is immune from criminal liability in 38 states. Specifics on who can administer naloxone (Narcan) are available on the Prescription Drug Abuse Policy System website.
HOW DOES NARCAN WORK?
When immediately administered to a person in risk of or in the middle of an opiate overdose, naloxone (Narcan, Evzio) reverses the opiate’s effects, quickly restoring breathing to a normal level. The medication is an antagonist that binds to opiate receptors, which blocks the effects of the narcotic substance. Naloxone can be administered by nasal spray (Narcan nasal spray, approved by the FDA in 2015), auto-injector (Evzio), or injection (professional training required).
Evzio, a pre-filled, auto-injection device, can be injected into the outer thigh. Once activated, the device gives instruction on how to use it.
Narcan, a pre-filled, needle-free device, is sprayed into one nostril while the opiate-overdose victim is in a prone position (lays on back). No assembly is required for the device.
The Harm Reduction Coalition provides clear instructions on how to administer Narcan for an overdose response.
WHAT TO DO IMMEDIATELY AFTER ADMINISTERING NARCAN?
As soon as Narcan is administered to a person known or suspected to be in opiate overdose, call for emergency medical help by dialing 911. That’s because Narcan only remains active in the body for 30 to 90 minutes, after which its effects wear off before those of the opiate involved in the overdose and the drug user may stop breathing again.
You, or another bystander, may need to perform cardio-pulmonary resuscitation (CPR) or rescue breathing prior to the arrival of medical help. Be aware that if breathing again stops before emergency help arrives, you, or someone else who is willing and able, should administer another dose of Narcan and closely watch the overdose individual until responders come on the scene.
FENTANYL OVERDOSES MAY REQUIRE MULTIPLE NARCAN DOSES
Fentanyl is 50 to 100 times more potent than morphine, and can quickly enter brain tissue. This makes overdose due to fentanyl use an extremely life-threatening possibility. Can Narcan help reverse fentanyl overdose? Yes, although it likely will require repeat Narcan doses to do so.
Research published in Substance Abuse Treatment and Prevention examining the pharmacology of the highly-potent synthetic opioid fentanyl, along with data on number of repeat naloxone (Narcan) doses used to treat the fentanyl overdoses, found that multiple sequential doses may be required in certain percentages of overdose victims. Researchers said that because fentanyl, different from other opioids, has “a very rapid onset with high systemic levels found in overdose victims,” naloxone requires a rapid competition to “out-compete large numbers of opioid receptors occupied by fentanyl” in the central nervous system. In view of the findings, researchers proposed that higher naloxone doses are necessary to effectively deal with “the new era of overdoses” involving fentanyl and other highly-potent synthetic opioids.
Other research published in Substance Abuse revealed that even though illicitly manufactured fentanyl is more potent than heroin and is contributes to a rapidly-increasing number of drug overdose deaths in Allegheny County, the average dose administered during fentanyl-related overdose cases remains unchanged. Researchers said their findings differ from other areas also experiencing increased illicitly-manufactured fentanyl prevalence, and they called for further investigations to clarify how much naloxone is necessary to reverse opiate overdoses due to new synthetic opiates.
As stated in a research letter published in the Journal of the American Medical Association (JAMA), nearly half of all opiate-related overdose deaths in 2016 involved fentanyl. Thus, synthetic opiate drugs eclipsed prescription opiates as the most common drug involved in overdose deaths in the U.S. in 2016. Findings highlight the quickly increasing involvement of fentanyl and other synthetic opiates in the opiate overdose epidemic – and the increasing number of overdose deaths involved with illicit and psychotherapeutic drugs.
HOW DO YOU KNOW SOMEONE IS HAVING AN OVERDOSE?
If a loved one, family member or friend has a history of drug use, or has been treated for substance use disorder (SUD), and has experienced relapses or overdose situations before, you likely know what to look for when an overdose is imminent or happening now. Being prepared to take immediate action in such occurrences by administering Narcan means having the life-saving drug on hand.
On the other hand, you may not have witnessed a drug overdose before, and even if you do have Narcan available because a treatment professional advised that loved ones, family members and/or friends of someone who’s experienced problems with drugs, particularly opiates, advised you to do so, you still may be unclear when you should give Narcan.
Signs of a drug overdose to watch for include the following:
- Onset of changes to vital signs – These can precipitate an overdose and include changes in heart rate, blood pressure, respiration, and body temperature. Prior to an overdose, they may suddenly rise dramatically, or not be present.
- Breathing problems – Rapid or slow breathing, shallow breathing, or shortness of breath may coincide with overdose.
- Chest pain – This is another warning sign of an impending overdose, although in the absence of other symptoms, it could be some other heart-related condition.
- Cold, clammy skin – If the person’s skin is cool, cold or clammy to the touch, it could mean an overdose is occurring.
- Blue or purple fingernails or fingertips – This is a tell-tale sign of drug overdose.
- Excessive sleepiness, confusion, inability to be roused (maybe indicating a coma) – These are signs of potential life-threatening overdose. If accompanied by vomiting, the vomit could be breathed into the lungs.
- Nausea, vomiting, abdominal pain, diarrhea – These are symptoms that require emergency medical treatment.
Narcan quickly restores normal breathing function, which is critical in the event of a drug overdose. The Narcan nasal spray was developed by the National Institute on Drug Abuse (NIDA), which designed and conducted the clinical trials necessary to determine that the intranasal formulation delivered naloxone both as quickly and effectively as the injectable Narcan. NIDA then worked with private partners to obtain FDA approval, and subsequently, the quick-acting, easy-to-use Narcan nasal spray was available to save lives in the event of drug overdose.
WHAT SHOULD HAPPEN AFTER A DRUG OVERDOSE
Following a drug overdose, immediate medical attention having been successfully administered and the overdose victim is out of life-threatening danger, further evaluation and treatment at a drug rehab facility is the best course of action. Unfortunately, unless the drug user, who may be a chronic drug abuser or even be addicted to substances of abuse, including alcohol and drugs, is ready to accept treatment, getting on the path to recovery is likely not going to happen.
Those who are closest to the drug user may have some influence with respect to taking proactive steps to encourage the individual to enter treatment. If nothing else, talking about making important lifestyle changes may spur the drug user to consider getting help, if not actually going into treatment at that time.
Be vigilant in observing potential return to drug use, and have Narcan handy in the event of further overdose events. Be supportive of the individual, making clear that you’ll be there for him or her on the recovery journey – and back up your words with actions. Getting clean from drugs is a long process, and it extends beyond detox and formal treatment into ongoing counseling, 12-step or community self-help groups, aftercare and alumni services. Consider getting help yourself by participating in family therapy and attending family self-help groups.
Drug addiction is a chronic, relapsing brain disease. This means there may be multiple treatment stays, recurring relapse, and a long road to sobriety. Addiction recovery is not a one-and-done attempt, but rather a lifelong journey.
For more about Narcan, drug overdose, addiction and recovery, check out these articles:
- Centers for Disease Control and Prevention. “Opioid Overdose.” “Reverse Overdose to Prevent Death.” Retrieved from https://www.cdc.gov/drugoverdose/prevention/reverse-od.html
- Clinical Toxicology (Philadelphia, PA). “Do heroin overdose patients require observation after receiving naloxone?” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27849133
- Food and Drug Administration. “FDA moves quickly to approve easy-to-use nasal spray to treat opioid overdose.” Retrieved from https://wayback.archive-it.org/7993/20180125101447/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm473505.htm
- Harm Reduction Coalition. “Administer Naloxone.” Retrieved from https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/responding-to-opioid-overdose/administer-naloxone/
- JAMA Network. “Changes in Synthetic Opioid Involvement in Drug Overdose Deaths in the United States, 2010-2016.” Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2679931
- Journal of Community Health. “Descriptive Epidemiology for Community-wide Naloxone Administration b Police Officers and Firefighters Responding to Opioid Overdose.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28852906
- Morbidity and Mortality Weekly Report. “Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30605448
- National Institute on Drug Abuse. “Naloxone for Opioid Overdose: Life-Saving Science.” Retrieved from https://www.drugabuse.gov/publications/naloxone-opioid-overdose-life-saving-science/naloxone-opioid-overdose-life-saving-science
- National Institute on Drug Abuse. “NARCAN Nasal Spray: Life-Saving Science at NIDA.” Retrieved from https://www.drugabuse.gov/about-nida/noras-blog/2015/11/narcan-nasal-spray-life-saving-science-nida
- National Institute on Drug Abuse. “Nearly half of opioid-related overdose deaths involve fentanyl.” Retrieved from https://www.drugabuse.gov/news-events/news-releases/2018/05/nearly-half-opioid-related-overdose-deaths-involve-fentanyl
- National Institute on Drug Abuse. “Opioid Overdose Reversal with Naloxone (Narcan, Evzio).” Retrieved from https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio
- National Institute on Drug Abuse. “The True, Deadly Scope of America’s Fentanyl Problem.” Retrieved from https://www.drugabuse.gov/about-nida/noras-blog/2018/05/true-deadly-scope-americas-fentanyl-problem
- Prescription Drug Abuse Policy System. “Expanded Access to Naloxone.” Retrieved from http://www.pdaps.org/
- Substance Abuse. “Amount of naloxone used to reverse opioid overdoses outside of medical practice in a city with increasing illicitly manufactured fentanyl in illicit drug supply.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29558283
- Substance Abuse Treatment Prevention and Policy. “Higher doses of naloxone are needed in the synthetic opioid era.” Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/30777088