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Naloxone Rescue forOpioid Overdose in New Jersey
Marc Dreier, MD, FACEP
Medical Director Emergency ServicesThe Valley HospitalRidgewood, New Jersey
Medical Director Bergen County Prosecutor’s Office 10/18/17
Program Outline
• Rationale – Scope of Problem• Legal Authority• Pharmacology
• General Concepts• Opioids• Naloxone
• Intranasal Naloxone Protocol• Summary• Practical Skills Station
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“New Jersey Has The Dubious Distinction OfHaving Some Of The Least Expensive,
Highest Purity Street Heroin In The Nation.”
RationaleScope of the Problem
Governor’s Council on Alcoholism & Drug Abuse Task Force on Heroin and Other Opiate Use by New Jersey’s Youth and Young Adults. Confronting New Jersey’s New Drug Problem: A Strategic Action Plan to Address a Burgeoning Heroin/Opiate Epidemic Among Adolescents and Young Adults. Page 19. March 18, 2014.
RationaleScope of the Problem
Stephen StirilingNJ Advance Media for NJ.comSeptember 28, 2017
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RationaleScope of the Problem
Stephen StirilingNJ Advance Media for NJ.comSeptember 28, 2017
RationaleScope of the Problem
Stephen StirilingNJ Advance Media for NJ.comSeptember 28, 2017
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RationaleScope of the Problem
1. Newark2. Paterson3. Atlantic City4. Jersey City5. Toms River6. Camden7. Brick8. Elizabeth9. Egg Harbor Township10. Vineland11. Millville12. Berkeley Township13. Trenton14. Jackson15. Lower Township
16. Middletown17. Lacey Township18. Little Egg Harbor19. Asbury Park20. Manchester21. Stafford Township22. Plainfield23. East Orange24. Edison25. Keansburg26. Middlesex27. Old Bridge28. Woodbridge29. Galloway30. Long Branch Tom Davis
Morristown PatchAugust 14, 2017
2015 Top 30
RationaleScope of the Problem
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RationaleScope of the Problem
Misuse and Abuse of Prescription Medications Can Also Cause Overdose
Prescription Medications May be Considered Purer or Safer and May be Easier to Obtain
Than Illegal Drugs
Overdose May be Accidental
RationaleScope of the Problem
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New Jersey Revised Statutes 24:6 J1-J6 and 2C:35 30-31
Legal AuthorityOverdose Prevention Act
Signed Into Law by Governor ChristieMay 2, 2013
Provides Certain Immunity from Arrest, Charge, Prosecution and Conviction for Persons
Experiencing a Drug Overdose and Persons Seeking Medical Assistance for Someone
Experiencing a Drug Overdose When Evidence is Obtained as a Result of Seeking Medical
AssistanceNew Jersey Revised Statutes 24:6 J1-J6 and 2C:35 30-31
Legal AuthorityOverdose Prevention Act
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Immunity From Civil and Criminal Liability for Healthcare Professionals Prescribing and
Dispensing Naloxone
Immunity From Civil and Criminal Liability for Persons Other Than a Healthcare Professional
Administering Naloxone
New Jersey Revised Statutes 24:6 J1-J6 and 2C:35 30-31
Legal AuthorityOverdose Prevention Act
Defines a “Patient” as a Person Who isNot at Risk of an Opioid Overdose but
Who May be in a Position to Assist Another Individual During an Overdose
New Jersey Revised Statutes 24:6 J1-J6 and 2C:35 30-31
Legal AuthorityOverdose Prevention Act
Requires the Prescriber to Ensure the “Patient” is Educated on Opioid Overdose Prevention
and Recognition, Rescue Breathing, Antidote Dosage and Administration, Importance of Activating EMS and Care of the Victim After
Treatment
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Legal AuthorityS-295
June 9, 2017
Legal Authority
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Legal Authority
Legal Authority
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Legal Authority
Route of Administration is the Pathby Which a Drug is Taken Into the Body
PharmacologyRoute of Administration
TopicalOralInjection• Subcutaneous (SQ)• Intramuscular (IM)• Intravenous (IV)
Inhalation• Smoking• HuffingMucosal• Sublingual• Intranasal
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PharmacologyBioavailability
How Much of the Drug is Absorbed for a Given Route of Administration
Fraction of the Administered Dose that Reaches the Central Circulation
By Definition Intravenous (IV) is 100%
PharmacologyBioavailability
Wikipedia. Bioavailability. Accessed at http://en.wikipedia.org/wiki/Bioavailability. April 12, 2014.
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Amount of Time Requiredfor the Initial Amount of Drug in the System
to be Reduced by Half
Half-Life is Different for Each Drug
Half-Life May Vary From Person to Person for the Same Drug
PharmacologyHalf-Life (t1/2)
PharmacologyGeneral Concepts
AgonistChemical That Binds to a Receptor to Produce a Response (Lock and Key Model)
Antagonist (or Inhibitor)Chemical That Blocks the Receptor and Decreases the Agonist Mediated Response
AGONISTANTAGONIST
RECEPTOR
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PharmacologyTolerance
Frequent or Continued Use of Some Drugs Leads to Tolerance
Tolerance is Characterized by Requiring Higher Doses of to Achieve the Same Effect
PharmacologyDependence
Dependence is Characterized byWithdrawal Symptoms if the Drug
is Abruptly Discontinued
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An Opioid is a Chemical thatResembles Morphine in its Pharmacological
Effects
Naturally OccurringSemi-Synthetic
Synthetic
PharmacologyOpioids
An Opiate is a Naturally Occurring SubstanceFound in the Resin of the Opium Poppy
(Papavar somniferum)
PharmacologyOpioids
SEEDPODBLOOM
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Natural• Codeine (Tylenol #3)• Morphine (Kadian)
Semi-Synthetic• Diacetyl Morphine (Heroin)• Hydrocodone (Vicodin/Zohydro)• Hydromorphone (Dilaudid)• Oxycodone (Percocet)• Oxymorphone (Opana)• Buprenorphine (Buprenex/Suboxone)
PharmacologyOpioids
Fully Synthetic• Propoxyphene (Darvocet)• Meperidine (Demerol)• Pentazocine (Talwin)• Methadone• Levorphanol• Fentanyl (Actiq/Duragesic)• Sufentanyl (Sufenta)• Etorphine• Carfentanyl
PharmacologyOpioids
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PharmacologyOpioids
PharmacologyOpioids
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PharmacologyOpioids
PharmacologyOpioids
Central Nervous System (CNS) Depression• Analgesic – Decreased Perception of Pain• Sedative – Promote Sleep• Euphoric – Warm, Drowsy, Content• Unconsciousness
Respiratory Depression – Decreased BreathingInsufficient OxygenBrain DamageDeath
Pinpoint Pupils (Miosis)
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PharmacologyOpioids
Central Nervous System (CNS) Depression• Analgesic – Decreased Perception of Pain• Sedative – Promote Sleep• Euphoric – Warm, Drowsy, Content• Unconsciousness
Respiratory Depression – Decreased BreathingInsufficient OxygenBrain DamageDeath
Pinpoint Pupils (Miosis)
PharmacologyOpioids
Central Nervous System (CNS) DepressionRespiratory DepressionPinpoint Pupils
Decreased Heart Rate
Decreased Blood Pressure
Emetic – Induces Nausea/Vomiting
Decrease GI Motility - Constipating
Histamine Release – Rash/Itching
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PharmacologyNaloxone (Narcan)
Opioid Antagonist
No Potential for Abuse
Very Good Safety Profile
Requires a Prescription by Federal Regulation
PharmacologyNaloxone
Opioid Antagonist
Binds to and Displaces Opioid from the Opioid Receptors But Does not Produce the
Pharmacologic Effect
Blocks the Effects of the Opioid
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PharmacologyNaloxone
Will Not Reverse Other Intoxicants That May Produce Symptoms Similar to an Opioid Overdose
AlcoholCannabinoidsBenzodiazepines• Alprazolam (Xanax)• Diazepam (Valium)• Lorazepam (Ativan)CocaineMDMA (Ecstasy)KetamineDesigner Drugs
PharmacologyNaloxone
Will Not Treat or Reverse Medical Conditions That May Produce Symptoms Similar to an
Opioid Overdose
StrokeHypoglycemia
SeizuresInfection/Sepsis
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PharmacologyNaloxone
The Half-Life (t1/2) of Naloxone is ≈ 60 Minutes
Duration of Action 30-90 Minutes
PharmacologyNaloxone
Duration of Action of Naloxone May be Shorter Than the Duration of Action of Many Opioids
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PharmacologyNaloxone
The Duration of Action of Many Opioids Exceeds the Duration of Action of Naloxone
and the Effect of the Opioid and Symptoms of Overdose May Return
All Patients Treated With Naloxone Must Be Evaluated in an Emergency Department as
Symptoms of Overdose May Recur
Refusal of Medial Assistance is Not an Option
PharmacologyOpioid Overdose vs. Withdrawal
Central Nervous System (CNS) Depression• Analgesic – Decreased Perception of Pain• Sedative – Promote Sleep• Euphoric – Warm, Drowsy, Content
Respiratory Depression – Decreased Breathing
Pinpoint Pupils (Miosis)
Decrease GI Motility - Constipating
Decreased Heart Rate
Decreased Blood Pressure
Central Nervous System (CNS) ExcitationPain – Body AchesAgitated - Restlessness, Insomnia, ShiveringDysphoric – Irritable, Anxious, Craving Opioid
Rapid Respirations/Yawning
Dilated Pupils (Mydriasis)
Increased GI MotilityAbdominal Cramps, Nausea/Vomiting/Diarrhea
Increased Heart Rate
Increased Blood Pressure
Overdose Withdrawal
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PharmacologyOpioid Withdrawal
Agitation Produced by Rapid Reversalof an Opioid Dependent Individual
May Place the Patient, Rescuers and Bystanders at Risk of Injury
NaloxoneAdministration
Naloxone Can Be Administered
• Intravenous (IV)• Intramuscular (IM)• Subcutaneous (SQ)• Intranasal (IN)
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Commercially AvailableNaloxone Devices – FDA Approved
Parenteral NaloxoneFDA Approved
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Intranasal NaloxoneOff Label
Naloxone - Cost
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Naloxone - Cost
$4400 ($2200)
Naloxone - Cost
$4400 ($2200)
$109.99 ($55)
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Naloxone - Cost
$4400 ($2200)
$109.99 ($55)
$28.30
Naloxone - Cost
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Intranasal Naloxone
Intranasal (IN) Route is Preferred• Faster to Administer than IV• Bioavailability is 100% in Animal Studies• Onset of Action ≈ 8 Minutes• 74-91% First Dose Success Rate• Painless• Does Not Require Sterility• No Risk of Needlestick
Intranasal Naloxone ProtocolNaloxone Rescue Kit
Naloxone 2 mg/2ml Leur-Jet SyringeMAD Nasal Intranasal Mucosal Atomization Device
Rescue Breathing Barrier ShieldGloves
Instruction Sheet
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Intranasal Naloxone ProtocolNaloxone Rescue Kit
Must Be Stored at Room Temperature (77°F)Excursions Permitted 59°-86°F
Cannot be Left in Vehiclesin Excessive Heat or Cold
Vials are Glass and May Break
Must be Removed From Serviceand Disposed of Prior to Expiration
Intranasal Naloxone Protocol
Potential Opioid Overdose Victim (Age > 2 Years)
• Unresponsive or Minimally Responsive (Yelling/Sternal Rub)
• Shallow, Slow or Absent Breathing• May Have Pinpoint Pupils
AND
Known or Suspected Opioid Overdose
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Intranasal Naloxone Protocol
Known or Suspected Opioid Overdose
Report of WitnessDrugs or Drug Paraphernalia at Scene
Track MarksMedical History Consistent with Opioid Use
Overdose May be Accidental
Intranasal Naloxone Protocol
Activate EMS (Including Request for ALS)
Remember ABCs• Open the Airway• Rescue Breathing Using A Barrier Device• or Bag-Valve Mask with Supplemental
Oxygen• Chest Compressions & AED if No Pulse
Administer Naloxone Per Protocol
Naloxone Is Not A Substitute for Rescue Breathing
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Intranasal Naloxone Protocol
INJECTOR
GLASS VIALMAD NASAL
• Check Expiration Date – Do Not Use if Expired• Check That Fluid is Clear and Without Particles – Do Not Use if Not Clear
• Pop Off the Two Yellow Caps on the Injector andthe One Purple Cap on the Glass Vial (Luer-Jet)
• Attach the MAD Nasal to the Leur-Lock End of the Injector• Screw the Glass Vial Into the Injector With A Clockwise Twisting Motion
• Don Gloves – Maintain Universal Precautions
Intranasal Naloxone Protocol
Spray ½ of the Naloxone (1 mg) in One Nostril and ½ (1 mg) in the Other Nostril
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Intranasal Naloxone ProtocolPost Treatment
Continue Rescue Breathing if Inadequate Breathing and CPR if No Pulse
Administer a Second Dose of Naloxone if No Response in 5 Minutes
If Victim Responds to Treatment, Place in the Recovery Position to Decrease Risk of Aspiration if Vomiting
Monitor Until EMS Arrives
Patient Must Be Evaluated in the Emergency DepartmentEven if Responds to Naloxone
Intranasal Naloxone Protocol
Dispose of Spent (or Expired) Naloxone Rescue Kits in an Approved Rigid Biohazard Container
Designed to Contain Contaminated Sharp Instruments
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Summary
• Overdose Prevention Act Provides Immunity• Opioid Overdose
• CNS Depression• Depressed Respirations• Pin Point Pupils
• Naloxone is an Opioid Antagonist• Duration of Action of Naloxone May be Shorter Than the Duration of Action of the Opioid• Abrupt Reversal of Opioid Overdose May Precipitate a Withdrawal Syndrome with Agitation• Intranasal Naloxone Protocol
• Store Kit at Room Temperature 77°F (59°-86°F)• Age > 2 Years• CNS Depression/Depressed Respirations/Pinpoint Pupils AND
Known or Suspected Opioid Overdose• Request EMS• Rescue Breathing/CPR/AED• Assemble the Naloxone Leur-Jet and MAD• Spray ½ of the Naloxone in One Nostril and ½ in the Other Nostril• Monitor Victim Continue Rescue Breathing and CPR as Needed• Repeat Dose One Time in 5 Minutes if No Response• Victim Must be Evaluated in the Emergency Department• Dispose of Spent Kit in a Rigid Biohazard Container
