How to Use Narcan

Narcotic painkillers are now responsible for more deaths in the U.S. than cocaine and heroin put together. Overdose deaths caused by opioid prescription pain medications are increasing every year. By some estimates, prescription painkiller overdoses tripled between 2000 and 2014.

Heroin use is on the rise as well and is thought to have doubled since 2007. As many as 669,000 Americans now use heroin. According to the 2012 National Survey on Drug Use and Health, heroin overdoses quadrupled between 2002 and 2013.

One reason for the increase in heroin use is that those who abuse prescription painkillers are finding that street heroin is easier to get and costs less. To reduce the number of overdose deaths by opioids, a drug called naloxone, also known as Narcan, is being used by paramedics and emergency room doctors on the front lines as an overdose treatment to help save lives.

What Is Naloxone?

Naloxone is a medicine that’s been on the market since 1971. It reverses the effects of opiates within minutes. Sold under the brand name Narcan, this FDA-approved medicine is available as a nasal spray or as an injection.

How Does Naloxone Work?

Opioids connect to certain brain receptors. When that happens, the perception of pain by the body is reduced, and this can create feelings of bliss and euphoria. Opioids also affect blood pressure, mood and autonomic processes like breathing and heart rate. During an overdose, opioid drugs can completely stop the breathing process.

Naloxone connects to the same receptors as opioids; the medication pushes its way onto these receptors and displaces the opioid drugs. In the process, the effects of the opioids are blocked. By blocking the effects of opioids, someone who has overdosed can resume breathing within minutes.

When Should You Administer Naloxone?

If someone has overdosed on opioids, they could stop breathing within three hours. The sooner naloxone is administered, the more likely it will be to reverse the effects of opioids so that a person can resume normal breathing. However, the effects of a dose of naloxone only last for 30 to 90 minutes. While the person is conscious, they should be treated by a medical professional as soon as possible.

Is Naloxone Safe to Use?

Naloxone reverses the effects of any opioids in the system. For that reason, naloxone elicits withdrawal symptoms similar to those experienced by someone with an opioid addiction and who is going through withdrawal. These effects are uncomfortable but not life-threatening. Naloxone is also safe for pregnant women, although low doses should be used.

Does Naloxone Increase Opioid Use?

There is some concern that the availability of naloxone might lead those with an opioid use disorder to ingest more opiates. However, a number of studies have indicated that this is not a danger. Instead, naloxone gives the person who has overdosed an opportunity to receive treatment and begin recovery. Instead of increasing opioid use, naloxone can reduce it and save lives. The medical community supports efforts to make naloxone readily available for that reason.

What Are the Symptoms of Opioid Withdrawal?

Those who are addicted to opiates go into withdrawal when the drug leaves the system. Withdrawal produces specific symptoms that also occur when someone has overdosed on opioid drugs and is given naloxone. Withdrawal symptoms such as the following usually start within 12 hours after the last dose of opiate drugs has been ingested or immediately after naloxone is administered:

  • Vomiting and nausea
  • Trembling and shaking
  • Sweating
  • Chills and goosebumps
  • Muscle weakness
  • Anxiety
  • Runny nose
  • Yawning
  • Tearing
  • Abdominal cramps and diarrhea
  • Agitation
  • Muscle aches
  • Insomnia
  • Dilated pupils

Who Is at Risk for an Opiate Overdose?

People with an opiate use disorder are at risk. However, others are at risk as well, including:

  • Those who take high doses of or are addicted to prescription painkillers
  • People with an opioid use disorder who use illicit opioids like heroin and morphine
  • Those who have recently detoxed from opioids
  • People who mix opioids with other medications like sleeping pills, anti-anxiety medications, alcohol and antidepressants

How Can You Tell If Someone Has Overdosed?

There are characteristics associated with opiate overdose that can help you determine whether a dose of naloxone is needed. These signs include:

  • Breathing difficulties, including shallow respiration
  • Floppy limbs or a limp body
  • Pinpoint pupils
  • An inability to wake up
  • Gurgling and snoring
  • Blue fingertips, fingernails or lips
  • Vomiting

If you believe that someone has overdosed, call 911 before administering treatment. Good Samaritan laws in your state may help protect you from law enforcement if you are calling to summon emergency help for someone who has overdosed.

How Does Naloxone Overdose Treatment Work?

Opiate drugs are known as agonists; in other words, they initiate a physical response when they attach to opiate receptors. Naloxone blocks and reverses the effects of opiate drugs. As such, naloxone is an opioid antagonist. It attaches to opiate receptors without activating them. When an opiate antagonist is attached to these receptors, opiate drugs have no effect. Opiate drugs include:

  • Hydrocodone or Vicodin
  • Oxycodone, Percocet or OxyContin
  • Hydromorphone or Dilaudid
  • Methadone
  • Heroin
  • Morphine
  • Codeine
  • Buprenorphine
  • Meperidine or Demerol

Overdose Can Occur Multiple Times

The antagonistic effects of naloxone disappear within 30 to 90 minutes after administration. Although naloxone blocks the effects of opiates and usually revives someone who has overdosed within a few minutes, the person can still return to overdose mode after the effects of naloxone wear off. That’s because the effects of opiate drugs in the system last longer than naloxone.

If the person who has overdosed resumes unconsciousness or still is not breathing within two or three minutes after administering naloxone, you will have to administer the second dose to keep the person awake and breathing. After dosing with naloxone, you should remain with the person until emergency help arrives to ensure that they don’t again become unconscious.

As the effects of naloxone kick in, it can produce uncomfortable withdrawal symptoms. The person may want to use again right away because the symptoms are so uncomfortable. That can produce another overdose. It’s important to soothe the person and reassure them until they can be treated by a medical professional. Try to keep the person who has overdosed from using again until a professional can be seen.

Is Naloxone Covered by Insurance?

The manufacturers of Narcan say that 80 percent of prescriptions for naloxone nasal spray are covered by insurance with a copay amount of 20 percent. If you don’t have insurance, the cost of a two-pack of naloxone nasal spray costs about $125.

Sometimes, the manufacturer or a local pharmacy will offer coupons or special offers for uninsured buyers to offset the cost. On the website for Narcan, you can find information about the cost of naloxone in your area.

To learn about the cost of the naloxone auto-injector called EVZIO for patients with and without insurance, you can visit the website of EVZIO or Kaleo, the manufacturer. Kaleo manufactures the only auto-injector naloxone formulation available. The cash price of EVZIO for those without insurance is about $360. Those with insurance should be able to purchase the product with a $0 copay. Most insurance plans cover the cost of the drug, so have your pharmacist check with your insurance company before you pay full price.

In 2014, EVZIO was approved for use in the U.S.

How to Use Narcan in Nasal Spray Form

Nasal naloxone is administered when the person is lying down with their head tilted back and their chin in the air. The steps to administer naloxone are as follows:

  1. Perform rescue breathing briefly if the person isn’t breathing on their own.
  2. Attach the nasal atomizer to the syringe and then add a glass cartridge of naloxone.
  3. Spray one half of the total spray amount into one nostril and the other half into the other nostril.
  4. Perform rescue breathing while waiting for the naloxone to kick in.

If the person doesn’t resume consciousness or start breathing within two or three minutes or the breathing is very shallow, give them a second dose of naloxone and continue rescue breathing. If the individual still doesn’t resume consciousness, the heart may have stopped, or there may be no opiate drugs in the body. The other possibility is that the level of opiate drugs in the person’s body is exceptionally high and the person needs more naloxone. This sometimes happens with fentanyl, an exceptionally strong opioid.

How to Use Narcan in Injectable Form

Injectable naloxone is available in multi-dose 10-millimeter vials and single-dose 1-millimeter flip-top vials with pop-off tops. Injectable naloxone is also available in an auto-injector formulation.

Check the expiration date to ensure that the product is fresh, and be sure to keep the product away from light. Injectable naloxone works like the nasal spray, but the mode of administration is different. The naloxone kit known as EVZIO has two auto-injectors and a training device that lets you practice using the auto-injector in advance. To use injectable naloxone, follow these steps:

  1. Perform rescue breathing.
  2. Use a long IM or intramuscular needle. They’re available at pharmacies.
  3. Remove the top of the vial.
  4. Pull 1 cubic centimeter of naloxone into the syringe.
  5. Inject the naloxone directly into a muscle like the upper and outer quadrant of the buttocks, the thighs or a shoulder, making sure to inject the solution straight into the muscle.
  6. If a long IM needle isn’t available, use a smaller needle size and inject the solution under the skin.
  7. Continue rescue breathing for two or three minutes.
  8. If, after three minutes, there’s still no response, deliver a second dose of injectable naloxone and continue rescue breathing.
  9. A third dose of naloxone may be needed if the person has ingested a high dosage of opioids such as fentanyl.

If the individual has still not been revived, continue rescue breathing until help arrives. If he or she is not responding to naloxone, not breathing, unresponsive to stimulation and without a pulse, the person needs CPR and emergency medical care.

Where to Get Naloxone

In most states, naloxone is available in pharmacies without a prescription in the nasal spray, injection and auto-injector formulations. If naloxone is not currently available in the stores in your area, you can ask the pharmacist to order it for you.

Regulations regarding naloxone are somewhat new, so your local pharmacist might be unclear about the regulations covering opioid antagonists. The medication is legally available to anyone who might be able to use it to save a life. It does not necessarily have to be for yourself. You are allowed legally to carry naloxone in both the nasal spray and injectable forms if you, a friend or a family member is using heroin, morphine or opiate painkillers.

In over half of the states as well as the District of Columbia, there are Good Samaritan laws that protect citizens who are helping someone who has experienced an overdose.

Naloxone is so effective as an overdose treatment that the White House drug policy office now encourages first responders such as police and firefighting personnel to carry it and use it in the event of an emergency because it saves lives. If you’re worried about a friend or a family member who uses opiate drugs, talk to your pharmacist or your doctor about naloxone.