What are the best practices for educating patients and their families about naloxone use?

1.

Elsevier ClinicalKey Drug Class Overview

Content last updated: November 5, 2017.

Discuss the availability of naloxone with all patients and consider prescribing it in patients who are at increased risk of opioid overdose, including those also using other CNS depressants, with a history of opioid use disorder (OUD), who have experienced a previous opioid overdose, or with household members or close contacts at risk for accidental ingestion or overdose[65733]. Instruct patients and their caregivers about proper naloxone use[68447].

2.

Elsevier ClinicalKey Drug Monograph

Content last updated: May 2, 2024.

Administration * During cardiopulmonary resuscitation, the same dosage may be given via the intraosseous route when IV access is unsuccessful or not feasible. * Inhalation Administration * Oral Inhalation Administration * NOTE: Naloxone is not FDA-approved for oral inhalation administration. * Dilute 2 mg in 3 mL of 0.9% Sodium Chloride Injection. * Administer through a standard face mask. * Other Administration Route(s) * Intranasal Administration Instructions for Caregivers and Family * Alert others about the presence of naloxone nasal spray, as administration must be performed by someone other than the patient. Family members, caregivers, or other people who may have to use naloxone in an opioid emergency should know the signs and symptoms of opioid overdose, where the nasal spray is stored, and how to administer the drug before an opioid emergency occurs. Once obtained, become familiar with how to use the nasal spray by reading the instructions. * Those who administer naloxone should be aware that its use in patients who are opioid dependent may precipitate opioid withdrawal. In neonates, opioid withdrawal can be life-threatening and must be treated immediately. * Instruct patients and their family members or caregivers that the reversal of respiratory depression caused by partial agonists or mixed agonist/antagonists such as buprenorphine and pentazocine, may be incomplete. Higher doses or repeated administrations of naloxone may be needed. Administration * Administer naloxone nasal spray as quickly as possible if a patient is unresponsive and an opioid overdose is suspected, even when in doubt. Prolonged respiratory depression may result in central nervous system damage or death. * Hold the device with your thumb on the bottom of the plunger and your first and middle fingers on either side of the nozzle. * Place the patient in the supine position. Assure that the device nozzle is inserted into 1 of the patient's nostrils and provide support to the back of the neck to allow the head to tilt back. Both of your fingers on either side of the nozzle should be against the bottom of the patient's nose.

Administration * Inject undiluted solution subcutaneously taking care not to inject intradermally. Subcutaneous Injection with Auto-injector (Zimhi) Instructions for Caregivers and Family * Because treatment of suspected opioid overdose must be performed by someone other than the patient, caregivers and people in close contact with the recipient should be informed of the presence of Zimhi and its instructions for use before the need for the medication arises. * Prior to a medical emergency (during storage), periodically visually inspect Zimhi through the viewing window on the device. If the solution is discolored yellow or brown color, cloudy, or contains particles, replace Zimhi with a new one. * Zimhi is intended to be administered by individuals 12 years of age or older. Younger individuals or those with limited hand strength may find the device difficult to use. * Those who administer Zimhi should be aware that the use of naloxone in patients who are opioid dependent may cause an acute abstinence syndrome. In neonates, opioid withdrawal can be life-threatening and must be treated immediately. * Instruct patients and their family members or caregivers that the reversal of respiratory depression caused by partial agonists or mixed agonist/antagonists such as buprenorphine and pentazocine, may be incomplete. Higher than usual doses of naloxone may be needed. Administration * Remove the needle cap to expose needle; do not attempt to re-cap the needle with the needle cap once it has been removed. * Administer subcutaneously, as quickly as possible, into the anterolateral aspect of the thigh, through clothing if necessary. Ensure the needle is embedded completely before pushing the plunger. Push the plunger firmly all the way down until it clicks and hold in place for 2 seconds. * For neonates and infants: The caregiver should pinch the middle of the outer thigh muscle prior to and during drug administration. Carefully observe the administration site for evidence of residual needle parts and/or signs of infection. * Immediately after the injection, using one hand with fingers behind the needle, slide the safety guard over the needle. Do not use two hands to activate the safety guard.

Administration * Inhalation Administration * Oral Inhalation Administration * NOTE: Narcan is not FDA-approved for oral inhalation administration. * Dilute 2 mg in 3 mL of 0.9% Sodium Chloride Injection. * Administer through a standard face mask. * Other Administration Route(s) * Intranasal Administration Instructions for Caregivers and Family * Alert others about the presence of narcan nasal spray, as administration must be performed by someone other than the patient. Family members, caregivers, or other people who may have to use narcan in an opioid emergency should know the signs and symptoms of opioid overdose, where the nasal spray is stored, and how to administer the drug before an opioid emergency occurs. Once obtained, become familiar with how to use the nasal spray by reading the instructions. * Those who administer narcan should be aware that its use in patients who are opioid dependent may precipitate opioid withdrawal. In neonates, opioid withdrawal can be life-threatening and must be treated immediately. * Instruct patients and their family members or caregivers that the reversal of respiratory depression caused by partial agonists or mixed agonist/antagonists such as buprenorphine and pentazocine, may be incomplete. Higher doses or repeated administrations of narcan may be needed. Administration * Administer narcan nasal spray as quickly as possible if a patient is unresponsive and an opioid overdose is suspected, even when in doubt. Prolonged respiratory depression may result in central nervous system damage or death. * Hold the device with your thumb on the bottom of the plunger and your first and middle fingers on either side of the nozzle. * Place the patient in the supine position. Assure that the device nozzle is inserted into 1 of the patient's nostrils and provide support to the back of the neck to allow the head to tilt back. Both of your fingers on either side of the nozzle should be against the bottom of the patient's nose. DO NOT prime or test the device prior to administration. * Press firmly on the device plunger to administer the dose. * Remove the device nozzle from the nostril.

Administration Aspirate prior to injection to avoid injection into a blood vessel. Intramuscular Injection with Auto-injector (Zimhi) Instructions for Caregivers and Family * Because treatment of suspected opioid overdose must be performed by someone other than the patient, caregivers and people in close contact with the recipient should be informed of the presence of Zimhi and its instructions for use before the need for the medication arises. * Prior to a medical emergency (during storage), periodically visually inspect Zimhi through the viewing window on the device. If the solution is discolored yellow or brown color, cloudy, or contains particles, replace Zimhi with a new one. * Zimhi is intended to be administered by individuals 12 years of age or older. Younger individuals or those with limited hand strength may find the device difficult to use. * Those who administer Zimhi should be aware that the use of naloxone in patients who are opioid dependent may cause an acute abstinence syndrome. In neonates, opioid withdrawal can be life-threatening and must be treated immediately. * Instruct patients and their family members or caregivers that the reversal of respiratory depression caused by partial agonists or mixed agonist/antagonists such as buprenorphine and pentazocine, may be incomplete. Higher than usual doses of naloxone may be needed. Administration * Remove the needle cap to expose needle; do not attempt to re-cap the needle with the needle cap once it has been removed. * Administer intramuscularly, as quickly as possible, into the anterolateral aspect of the thigh, through clothing if necessary. Ensure the needle is embedded completely before pushing the plunger. Push the plunger firmly all the way down until it clicks and hold in place for 2 seconds. * For neonates and infants: The caregiver should pinch the middle of the outer thigh muscle prior to and during drug administration. Carefully observe the administration site for evidence of residual needle parts and/or signs of infection. * Immediately after the injection, using one hand with fingers behind the needle, slide the safety guard over the needle. Do not use two hands to activate the safety guard. Put the used syringe into the blue case and close the case.

3.

Elsevier ClinicalKey Drug Monograph

Content last updated: May 5, 2024.

Contraindications And Precautions Buprenorphine is a partial opioid agonist that can be abused in a manner similar to other opioids, legal or illicit. Patients with mental illness (e.g., major depression) or a family history of substance abuse (including alcoholism) have an increased risk of opioid abuse. Prescribe and dispense buprenorphine with appropriate precautions to minimize risk of misuse, abuse, or diversion, and ensure appropriate protection from theft, including in the home. Clinical monitoring appropriate to the patient's level of stability is essential. Do not prescribe multiple refills early in treatment or without appropriate patient follow-up visits. Discuss the availability of naloxone with all patients and strongly consider prescribing it in patients treated for opioid use disorder (OUD) because of the potential for relapse. Consider prescribing naloxone in patients using other CNS depressants or if the patient has household members or other close contacts at risk for accidental ingestion or opioid overdose. Inform patients and caregivers of their options for obtaining naloxone as permitted by individual state naloxone dispensing and prescribing requirements or guidelines (e.g., by prescription, directly from a pharmacist, or as part of a community-based program). Advise patients and caregivers that naloxone may also be administered for a known or suspected overdose with buprenorphine itself. Higher than normal doses and repeated administration of naloxone may be necessary due to the long duration of action of buprenorphine and its affinity for the mu opioid receptor. Consumption of ethanol will result in additive CNS depressant effects. Advise patients to avoid ethanol ingestion and ethanol intoxication, including the ingestion of alcohol contained in prescription or non-prescription medications, during therapy.

4.

Food and Drug Administration (DailyMed).

Publish date: October 3, 2022.

Information For Patients Also discuss the importance of having access to naloxone if there are household members (including children) or other close contacts at risk for accidental ingestion or opioid overdose. Inform patients and caregivers of the options for obtaining naloxone as permitted by individual state naloxone dispensing and prescribing requirements or guidelines (e.g., by prescription, directly from a pharmacist, or as part of a community-based program). Educate patients and caregivers on how to recognize the signs and symptoms of an opioid overdose. Explain to patients and caregivers that naloxone’s effects are temporary, and that they must call 911 or get emergency medical help right away in all cases of known or suspected opioid overdose, even if naloxone is administered. Repeat administration may be necessary, particularly for overdose involving buprenorphine and naloxone sublingual film, because naloxone is often not effective at the doses available for patient access [ Dosage and Administration (2.3) , Warnings and Precautions (5.2) , Overdosage (10) ]. If naloxone is prescribed, also advise patients and caregivers: • How to treat with naloxone in the event of an opioid overdose • To tell family and friends about their naloxone and to keep it in a place where family and friends can easily access it in an emergency • To read the Patient Information (or other educational material) that will come with their naloxone. Emphasize the importance of doing this before an opioid emergency happens, so the patient and caregiver will know what to do. • Advise patients that buprenorphine sublingual tablets contain an opioid that can be a target for people who abuse prescription medications or street drugs, to keep their tablets in a safe place, and to protect them from theft. • Instruct patients to keep buprenorphine sublingual tablets in a secure place, out of the sight and reach of children. Accidental or deliberate ingestion by a child may cause respiratory depression that can result in death. Advise patients to seek medical attention immediately if a child is exposed to buprenorphine sublingual tablets.

5.

Food and Drug Administration (DailyMed).

Publish date: October 4, 2023.

Information For Patients Also discuss the importance of having access to naloxone if there are household members (including children) or other close contacts at risk for accidental ingestion or opioid overdose. Inform patients and caregivers of the options for obtaining naloxone as permitted by individual state naloxone dispensing and prescribing requirements or guidelines (e.g., by prescription, directly from a pharmacist, or as part of a community-based program). Educate patients and caregivers on how to recognize the signs and symptoms of an opioid overdose. Explain to patients and caregivers that naloxone’s effects are temporary, and that they must call 911 or get emergency medical help right away in all cases of known or suspected opioid overdose, even if naloxone is administered. Repeat administration may be necessary, particularly for overdose involving Buprenorphine HCl and Naloxone HCl (buprenorphine and naloxone) Sublingual Tablets, because naloxone is often not effective at the doses available for patient access [Dosage and Administration (2.3), Warnings and Precautions (5.2), Overdosage (10)]. If naloxone is prescribed, also advise patients and caregivers: How to treat with naloxone in the event of an opioid overdose To tell family and friends about their naloxone and to keep it in a place where family and friends can easily access it in an emergency To read the Patient Information (or other educational material) that will come with their naloxone. Emphasize the importance of doing this before an opioid emergency happens, so the patient and caregiver will know what to do. Advise patients that Buprenorphine HCl and Naloxone HCl (buprenorphine and naloxone) Sublingual Tablets contain an opioid that can be a target for people who abuse prescription medications or street drugs, to keep their tablets in a safe place, and to protect them from theft.

6.

Food and Drug Administration (DailyMed).

Publish date: March 3, 2024.

Information For Patients Also discuss the importance of having access to naloxone if there are household members (including children) or other close contacts at risk for accidental ingestion or opioid overdose. Inform patients and caregivers of the options for obtaining naloxone as permitted by individual state naloxone dispensing and prescribing requirements or guidelines (e.g., by prescription, directly from a pharmacist, or as part of a community-based program). Educate patients and caregivers on how to recognize the signs and symptoms of an opioid overdose. Explain to patients and caregivers that naloxone’s effects are temporary, and that they must call 911 or get emergency medical help right away in all cases of known or suspected opioid overdose, even if naloxone is administered. Repeat administration may be necessary, particularly for overdose involving buprenorphine and naloxone sublingual tablet, because naloxone is often not effective at the doses available for patient access [See Dosage and Administration ( 2.2 ), Warnings and Precautions ( 5.2 ), Overdosage ( 10 )] . If naloxone is prescribed, also advise patients and caregivers: How to treat with naloxone in the event of an opioid overdose To tell family and friends about their naloxone and to keep it in a place where family and friends can easily access it in an emergency To read the Patient Information (or other educational material) that will come with their naloxone. Emphasize the importance of doing this before an opioid emergency happens, so the patient and caregiver will know what to do. Advise patients that Buprenorphine Sublingual Tablet contains an opioid that can be a target for people who abuse prescription medications or street drugs, to keep their tablets in a safe place, and to protect them from theft. Instruct patients to keep Buprenorphine Sublingual Tablet in a secure place, out of the sight and reach of children. Accidental or deliberate ingestion by a child may cause respiratory depression that can result in death. Advise patients to seek medical attention immediately if a child is exposed to Buprenorphine Sublingual Tablets.

7.

Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports. 2022;71(3):1-95. doi:10.15585/mmwr.rr7103a1. Copyright License: CC0

Publish date: November 5, 2022.

g., patients undergoing tapering or recently released from prison). Practices should educate patients on overdose prevention and naloxone use and offer to provide education to members of their households. Naloxone coprescribing can be facilitated by clinics or practices with resources to provide naloxone training, by collaborative practice models with pharmacists, or through statewide protocols or standing orders for naloxone at pharmacies. In part because of concerns about cost of naloxone and access for some patients and reports that purchasing of naloxone has in some cases been required to fill opioid prescriptions, including for patients without a way to afford naloxone, this recommendation specifies that naloxone should be offered to patients. To that end, clinicians, health systems, and payers can work to ensure patients can obtain naloxone, a potentially lifesaving treatment. Clinicians should avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing when possible to minimize risk for respiratory depression. When making decisions about whether to initiate opioid therapy for pain during pregnancy, clinicians and patients together should carefully weigh benefits and risks. For pregnant persons already receiving opioids, clinicians should access appropriate expertise if tapering is being considered because of possible risks to the pregnant patient and the fetus if the patient goes into withdrawal (see Recommendation 5). For pregnant persons with opioid use disorder, medication for opioid use disorder (buprenorphine or methadone) is the recommended therapy and should be offered as early as possible in pregnancy to prevent harms to both the patient and the fetus (see Recommendation 12). Clinicians should use additional caution and increased monitoring (see Recommendation 7) to minimize risks of opioids prescribed for patients with renal or hepatic insufficiency and for patients aged ≥65 years. Clinicians should implement interventions to mitigate common risks of opioid therapy among older adults, such as exercise or bowel regimens to prevent constipation, risk assessment for falls, and patient monitoring for cognitive impairment. For patients with jobs that involve potentially hazardous tasks and who are receiving opioids or other medications that can negatively affect sleep, cognition, balance, or coordination, clinicians should assess patients’ abilities to safely perform the potentially hazardous tasks (e.g.