BOSTON MEDICAL CENTER JANUARY 2022
Novel Naloxone Distribution Strategies
Grayken Center for Addiction at Boston Medical Center:
Training and Technical Assistance
BOSTON MEDICAL CENTER JANUARY 2022
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Novel Naloxone Distribution Strategies
Acknowledgments
The Novel Naloxone Distribution Strategies document was prepared by Justin Alves, RN, MSN,
ACRN, CARN, CNE; Vanessa Loukas, MSN, NP-C, CARN-AP; Kristin Wason, MSN, NPC,
CARN; Annie Potter, MSN, MPH, NP-C, CARN-AP; and Colleen T. LaBelle MSN, RN-BC,
CARN. We would also like to acknowledge the efforts of Victoria Rust, B.S., in the editing of
this document.
Disclaimer
Grayken Center for Addiction Boston Medical Center Training and Technical Assistance is
pleased to share its Novel Naloxone Distribution Strategies with other providers. Although
Boston Medical Center has attempted to confirm the accuracy of the information contained in
these documents, this information is not a substitute for informed medical decision making by an
appropriate, licensed provider. Clinicians must confirm the appropriateness of all treatment that
they provide to a patient and are responsible for the health care decisions they make when caring
for patients. If clinicians believe that any information included in these guidelines should be
revised or clarified, please contact Boston Medical Center at 617-414-7453. The contents of
these guidelines are solely the responsibility of the authors and do not necessarily represent the
official views of BSAS or any other part of the Massachusetts Department of Public Health.
This publication may be reproduced or copied with permission from Boston Medical Center.
This publication may not be reproduced or distributed for a fee without specific written
authorization. Citation of this source is appreciated:
Alves, J.D.; Loukas, V.L.; Wason, K.F.; Potter, A.L.; and LaBelle, C.T. Novel Naloxone
Distribution Strategies. Unpublished treatment manual, Boston Medical Center, January 2022.
Sponsorship
This publication has been made possible by BMC, Grayken Center for Addiction Training and
Technical Assistance, Massachusetts Department of Public Health Bureau of Substance
Addiction Services.
Originating Office
Boston Medical Center TTA
801 Massachusetts Avenue, 2nd floor
Boston, MA, 02118
Colleen T LaBelle MSN, RN-BC, CARN
Colle[email protected]
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Table of Contents
Acknowledgments ......................................................................................................................................... 1
Introducing Novel Nasal Naloxone Distribution Strategies ....................................................................... 6
Naloxone and Opioid Overdose Response ................................................................................................... 8
Mechanism of Action............................................................................................................................... 8
Formulation and Administration ........................................................................................................... 8
Recognizing and Reversing an Overdose .............................................................................................. 9
Overview of Current Clinical Overdose Education and Naloxone Distribution Practice ....................... 10
Third Party Prescribing ........................................................................................................................ 10
Co-Prescribing ....................................................................................................................................... 10
Overview of Community Overdose Education and Naloxone Distribution Practice ............................... 12
Standing Orders .................................................................................................................................... 12
Programs that Dispense Naloxone Under Standing Orders .............................................................. 12
Naloxone Distribution at Needle and Syringe Programs ................................................................... 12
Community Outreach Programs ......................................................................................................... 12
Recovery Support Centers or Recovery Support Programs................................................................ 13
Other Harm Reduction Support Centers or Programs for Drug-user Health .................................... 13
Family and Loved One Distribution Programs .................................................................................. 13
Post-Overdose Outreach Programs .................................................................................................... 13
Novel Distribution Pathways to Improve Nasal Naloxone Access ........................................................... 15
Ambulatory Distribution with Co-Located Pharmacy ...................................................................... 16
Practice Location Description ............................................................................................................ 16
Administrative Requirements .............................................................................................................. 16
Entities Involved .................................................................................................................................. 16
Steps of Distribution Workflow ........................................................................................................... 16
Potential Challenges ........................................................................................................................... 18
Example Forms ................................................................................................................................... 18
Ambulatory Distribution with an Off-Site Pharmacy ....................................................................... 19
Practice Location Description ............................................................................................................ 19
Administrative Requirements .............................................................................................................. 19
Entities Involved .................................................................................................................................. 19
Steps of Distribution Workflow ........................................................................................................... 19
Potential Challenges ........................................................................................................................... 23
Example Forms ................................................................................................................................... 24
Opioid Treatment Program with an Off-Site Pharmacy ................................................................... 25
Practice Location Description ............................................................................................................ 25
Administrative Requirements .............................................................................................................. 25
Entities Involved .................................................................................................................................. 25
Steps of Distribution Workflow ........................................................................................................... 25
Potential Challenges ........................................................................................................................... 26
Example Forms ................................................................................................................................... 27
Inpatient to Outpatient Disposition Distribution ............................................................................... 28
Practice Location Description ............................................................................................................ 28
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Administrative Requirements .............................................................................................................. 28
Entities Involved .................................................................................................................................. 28
Steps of Distribution Workflow ........................................................................................................... 28
Potential Challenges ........................................................................................................................... 30
Example Forms ................................................................................................................................... 31
Emergency Department Distribution .................................................................................................. 32
Practice Location Description ............................................................................................................ 32
Administrative Requirements .............................................................................................................. 32
Entities involved .................................................................................................................................. 32
Steps of Distribution Workflow ........................................................................................................... 32
Potential Challenges ........................................................................................................................... 33
Example Forms ................................................................................................................................... 33
References ................................................................................................................................................... 34
Appendix A .................................................................................................................................................. 38
Figure 1 Rates of Naloxone Co-prescription Within 7 Days Among Medicare Part D Beneficiaries
Receiving Prescription Opioids, United States, 2016-2017 ................................................................... 38
Appendix B .................................................................................................................................................. 39
Figure 1 Statewide Standing Order for Dispensing Naloxone Rescue Kits ......................................... 39
Figure 2 Boston Medical Center’s Standing Order for Dispensing Naloxone Rescue Kits to
Individuals at Risk of Experiencing or Witnessing Opioid-Related Overdose .................................... 40
Appendix C .................................................................................................................................................. 44
Figure 1 Naloxone Distribution Workflow: Ambulatory Distribution with Co-Located Pharmacy .. 44
Figure 2 Naloxone Distribution Workflow: Ambulatory Distribution with an Off-Site Pharmacy ... 45
Figure 3 Naloxone Distribution Workflow: Opioid Treatment Program with Off-Site Pharmacy .... 46
Figure 4 Naloxone Distribution Workflow: Inpatient to Outpatient Disposition Distribution ........... 47
Figure 5 Naloxone Distribution Workflow: Emergency Department Distribution ............................. 48
Appendix D .................................................................................................................................................. 49
Figure 1 Example Label for Naloxone in Clinic .................................................................................. 49
Figure 2 Example of Third-Party Prescription of Naloxone................................................................ 50
Figure 3 Nasal Naloxone Distribution Tracking Sheet ........................................................................ 51
Figure 4 OBAT Clinic Nasal Naloxone Inventory Tracking ............................................................... 52
Figure 5 Prescription Delivery Authorization Form ............................................................................ 53
Figure 6 Naloxone Intake Form ............................................................................................................ 54
Appendix E .................................................................................................................................................. 55
Figure 1 Patient Naloxone Storage Supplies ........................................................................................ 55
Figure 2 Patient Education Sheet on Overdose Identification and Response including Naloxone Use
................................................................................................................................................................. 56
Appendix F .................................................................................................................................................. 61
Figure 1 Example Nurse Script ............................................................................................................. 61
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Introducing Novel Nasal Naloxone Distribution Strategies
Throughout the last 20 years, spikes in deaths related to drug overdoses have significantly
impacted the United States (NIDA, 2021). The high death toll has increased in the last five to ten
years due to the introduction of synthetic opioids, such as fentanyl, into the illicit drug supply
(Lippold et al., 2019). Illicit fentanyl’s intensity and rapid onset of effects have resulted in over
130 daily deaths, a rate that is secondary to the daily summation of all opioid- overdose related
deaths (HRSA, 2018). For the last several decades, escalating trends in deaths related to
overdose have incentivized public health and policy to focus on a multifaceted approach that
strives to address the complexities encompassing the drug overdose epidemic.
According to the Biden-Harris Administration Office of National Drug Control Policy
seven priorities have been identified as necessary amidst the overdose and addiction crisis
(ONDCP, 2021). Specifically, priority three of the Biden-Harris administration plan, Enhancing
Evidence-Based Harm Reduction Efforts, identifies the need to explore funding streams for many
harm reduction services and treatments, including reimbursement for naloxone (ONDCP, 2021).
Naloxone, an antagonist that binds at the mu-opioid receptor, has often been referred to as the
antidote to an opioid overdose: Naloxone quickly takes effect in 2-3 minutes, lasting 60-80
minutes, effectively reversing overdose symptoms to restore spontaneous respirations
(McDonald et al., 2018).
For the last couple of decades, the distribution of nasal naloxone has been of vital focus
to confront risks associated with opioid use disorder, especially risks affecting patients and their
loved ones. Substantial evidence supports a correlation between the distribution of nasal
naloxone to community members and a reduction in mortality, as naloxone facilitates a rapid
response for overdose symptoms (LDI, 2019). Naloxone distribution is especially impactful
among groups with elevated risks of overdose. Distribution strategies have been implemented
and exemplified by methods such as secondary distribution, public safety distribution, and post-
overdose “door knock” programs. In addition, naloxone has become accessible through harm
reduction agencies, such as syringe service programs (Townsend et al., 2020).
Ultimately, there has been a drastic uptick in the availability and accessibility of naloxone
in the community; however, public health dollars have been the primary source of funding for
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naloxone availability. Considering naloxone distribution is the only component in a necessary
multifactorial approach that addresses the drug overdose epidemic, there is an imperative need
for the implementation of cost-effective avenues across health systems (Murrin, 2020). A recent
report through Centers for Medicare & Medicaid Services (CMS) examines the utilization of
nasal naloxone through pharmacy distribution. The report reveals an astounding lack of access
through this cost-effective method of distribution (Murrin, 2020). Unfortunately, most
community members are accessing naloxone through distribution streams vastly subsidized by
public health dollars, despite the medication’s prompt availability through pharmacies and
insurance. The discrepancy is an urgent call to action to work collaboratively and creatively
within current healthcare frameworks to reduce barriers to naloxone access. It is vital that
patients can access this life-saving medication through traditional and reimbursable avenues
without reducing access to the medication at a community level.
The purpose of this document is to outline potential strategies to increase patient access
to nasal naloxone by serving as a guide for administrators, healthcare providers, and non-medical
providers attempting to create reimbursable streams for naloxone. There are five distinct
locations in which workflows have been designed to increase access to naloxone in a manner that
benefits the patient and the pharmacy by preventing and reducing the need for subsidized doses
of naloxone. Due to the collaborative nature of the workflows presented, the collective
cooperation of pharmacy partners, hospital administrators, billing specialists, and clinical staff is
critical in determining the most appropriate workflow for one’s organization, along with
adjustments based on local laws, institution policies, and institution procedures. All of these
models provide infrastructure to enable nurses to distribute nasal naloxone directly to the patient
in the treatment setting. This document outlines distribution methods that may be adapted by
other organizations to allow patients and community members to receive this life-saving
medication from the nurse in their treatment setting, decreasing barriers to overdose prevention.
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Naloxone and Opioid Overdose Response
Recognizing an overdose and knowing how to administer naloxone are critical elements
to decrease the rate of overdose-related deaths in the United States. This is especially true given
the prevalence of fentanyl in the drug supply and trends indicating escalating rates of overdose-
related deaths.
Mechanism of Action
• Naloxone is an opioid antagonist medication used for the reversal of opioid overdose.
• Opioid antagonists have a high affinity for the opioid receptors in the body, meaning that
they can both block and displace opioids at those receptor sites.
• In an opioid overdose, the opioid receptors in the central nervous system are saturated by
opioids leading to decreased respiratory rate, heart rate, risk for hypoxia/anoxia, and
associated death.
• Naloxone works by displacing the opioids occupying those receptors, reversing the
central nervous system suppression, and allowing the person to breathe again (SAMHSA,
2021).
Formulation and Administration
• Naloxone is available in a solution that may be administered intranasally, intravenously,
subcutaneously, and intramuscularly.
• Intranasal formulations of naloxone are traditionally used in outpatient and community
settings due to the ease of administration and rapid onset.
• Intranasal naloxone kits come with two actuated nasal sprays, each containing
4mg/0.1mL of naloxone, while intramuscular kits come in vials of 8mg/0.1mL of
naloxone. In addition to opioid overdose reversal, potential side effects of naloxone
administration are symptoms of acute opioid withdrawal, including body aches,
gastrointestinal upset (diarrhea, nausea, vomiting), anxiety, agitation, rhinorrhea, and
piloerection.
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Recognizing and Reversing an Overdose
• Naloxone is a very safe and effective medication. Administration of naloxone for
suspected opioid overdose, even without confirmation of opioid use, is recommended
(Wermeling, 2015).
• Signs of overdose include (1) pale or blue skin, (2) constricted pupils, (3) loss of
consciousness, (4) slow or shallow breathing, and (5) unresponsiveness to voice or sternal
rub (CDC, 2020).
• After identifying a suspected overdose, individuals should assess that the scene is safe for
intervention and determine if the person affected is conscious by speaking loudly and
administering a hard sternal rub to the chest plate (National Harm Reduction Coalition,
2020).
• If there is no response, call emergency services and proceed with inserting the intranasal
naloxone kit into the individual’s nostril and pressing the plunger for administration.
• Rescue breaths can be administered every 5 seconds by responders previously in contact
with the individual who has overdosed or by those with proper airway protection.
• Repeat administration of an additional dose after 2-3 minutes, alternating nostrils.
Continue to provide ventilation support until the person becomes conscious or emergency
services arrive. If the person responds to naloxone, turn them to their side into a recovery
position and provide support (National Harm Reduction Coalition, 2020).
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Overview of Current Clinical Overdose Education and Naloxone Distribution Practice
Current clinical practices for Overdose Education and nasal Naloxone Distribution
(OEND) focus on providing patients, at high risk of overdose, with improved access to naloxone
in both community and commercial pharmacies. Legislation has allowed for third party
prescribing of naloxone, while either encouraging or mandating co-prescribing of nasal naloxone
in conjunction with all opioid prescriptions for pain and opioid use disorder. Multiple studies’
findings have demonstrated efficacy in increasing naloxone access and distribution through
targeted clinical interventions. Targeted clinical interventions improve provider distribution of
nasal naloxone to high-risk patients.
Third Party Prescribing
• Laws which permit an individual prescriber to write a prescription for someone who is
not the end recipient of a specific medication.
• Allows providers to write prescriptions for family members or loved ones of an
individual at-risk for fatal opioid overdose.
• Permitted in all but two states (Kansas and Minnesota) (SAFE Project, 2021).
• Includes screening of all patients about whether they know anyone at risk for fatal
overdose and if they are interested in naloxone (Hughes, 2016).
• Reference Figure 2, Appendix D to view an example of a third-party naloxone
prescription.
Co-Prescribing
• A practice that involves a prescriber writing a prescription for naloxone at the same time
they write for opioid medications.
• May involve education and counseling around opioid overdose and the risks of substance
use disorder for patients on chronic opioid therapy.
• Naloxone should routinely be prescribed in conjunction with medications for opioid use
disorder, including those on methadone, buprenorphine, and naltrexone in the event of
unexpected, recurrent substance use.
• Consideration for co-prescribing should occur for patients who receive opioid
medications in combination with other CNS depressant medications, including
benzodiazepines.
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• Some electronic health records have “hard” stops to prevent providers from sending
prescriptions for opioid medications without also sending a prescription for naloxone.
• Data has demonstrated that laws requiring or encouraging co-prescribing have increased
rates of naloxone prescriptions for individuals at highest risk for opioid overdose
fatalities (see Figure 1, Appendix A).
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Overview of Community Overdose Education and Naloxone Distribution Practice
The introduction of standing orders for the dispensing of naloxone is a cornerstone of
community-level Overdose Education and Naloxone Distribution (OEND). Improved access to
nasal naloxone in non-traditional settings has been possible due to standing orders and changes
in legislation regarding distribution. Different standing orders can be viewed in Appendix B.
Examples provided in this section are of clinical and non-clinical settings in which nasal
naloxone distribution exhibits increased access for patients. Unfortunately, community-based
OEND practices are limited by barriers of cost to the public health department’s purchase of
naloxone doses.
Standing Orders
• A standing order is a system by which a healthcare provider with prescribing privileges,
often a state health officer, provides a prescription that permits the distribution of a
medication to a large group of people (SAFE Project, 2021). Standing orders from a state
health officer may additionally grant distribution of naloxone by non-clinical staff (public
safety, harm reduction, outreach workers, etc. (SAFE Project, 2021).
• Individual practice settings in which nurses are permitted to transmit naloxone to the
pharmacy in collaboration with a provider must follow federal and state regulations and
the organizations policies and procedures for standing orders.
• Refer to Figure 1, Appendix B to view a statewide standing order for MA and refer to
Figure 2, Appendix B to view standing order for Boston Medical Center.
Programs that Dispense Naloxone Under Standing Orders
Naloxone Distribution at Needle and Syringe Programs
Needle and syringe service agencies should have naloxone on site to distribute under a
standing order. The distribution is intended for individuals in the community at-risk for overdose
or individuals in frequent proximity to those at-risk for overdose. Naloxone is often provided to
these agencies through public health or grant funds, allowing individuals to have the medication
in hand (Lambdin, 2020).
Community Outreach Programs
Community outreach programs actively seek out individuals at risk of opioid overdose to
distribute naloxone. Community health workers (CHWs) or other recovery support personnel
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may provide counseling and education about OEND and demonstrate naloxone administration
from available stock (Wheeler et al., 2012).
Recovery Support Centers or Recovery Support Programs
Recovery coaches may engage those new to recovery or individuals in long-term
recovery in overdose prevention and education. Distribution of naloxone is essential as new
recoverees may have regular contact with people actively using, increasing one’s chances of
witnessing an overdose. People at any stage in their recovery from substance use are susceptible
to returning to use. Individuals with a period of recovery who have a recurrence of opioid use are
highly susceptible to accidental overdose given their loss of opioid tolerance. Therefore, it is
important that overdose education and prevention be incorporated into services for people in
recovery.
Other Harm Reduction Support Centers or Programs for Drug-user Health
Drug user health programs that are able to offer comprehensive services often have drop-
in models to obtain naloxone from non-clinical staff. Many of these programs are supported
through grants or public health funds to purchase naloxone stock for distribution (Piper et al.,
2008).
Family and Loved One Distribution Programs
Programs founded by families and loved ones affected by a loss to overdose may engage
in efforts to distribute naloxone to individuals at-risk and their family members. Third-party
prescribing and standing orders may work in tandem for families to obtain and distribute
naloxone. Family distribution programs may obtain naloxone in bulk from other agencies for
distribution, or they may receive and distribute naloxone through third-party prescribing
practices (Bagley et al., 2018).
Post-Overdose Outreach Programs
Post-Overdose Outreach Programs. These programs sometimes referred to as “Door-
Knock” programs, are staffed by community outreach workers, harm reduction specialists,
emergency medical services providers, public safety officers, or a combination of all. Typically
2-3 days after an overdose, specialty teams or individuals may return to an address or a site of an
opioid overdose to offer individuals naloxone. In communities at-risk for repeated opioid
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overdoses or for socially isolated individuals, post-overdose outreach programs may prevent a
subsequent overdose (McCammon, 2018) (Formica et al, 2021).
Emergency Outreach Programs. Emergency service personnel may distribute nasal
naloxone to an individual or peers at the scene of a prior opioid overdose. Some community
outreach programs may contact a person who has been discharged from an emergency room
post-overdose to check in and offer naloxone from a community supply (Albright & Castillo,
2018).
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Novel Distribution Pathways to Improve Nasal Naloxone Access
The following novel naloxone distribution pathways have been identified and described
to address both the growing need for rapid naloxone access and disparities in access due to
barriers. Each of the unique pathways increases naloxone distribution directly to patients through
the nurse on their treatment team covered by their insurance provider. Pathway descriptions
include (1) a description of the practice location, (2) the necessary entities or team members
involved in maintaining the pathway, (3) the steps of a workflow for the program currently
instituted (4) and an overview of potential implementation challenges and potential solutions.
The entities included in each pathway lists team members central to naloxone distribution in the
example practice setting but should not limit organizations from adapting these work flows to
meet their needs by integrating other team members. In addition, each distribution pathway
includes an illustration to demonstrate the naloxone distribution workflow for easy reference for
participating entities. Illustrations of workflow can be found among figures in Appendix C.
Relevant practice agreements, tracking documents, example naloxone labels, and order and
delivery forms described in distribution pathways are provided among figures in Appendix D.
Depictions of patient education sheets and storage supplies referenced in workflows are provided
in Appendix E. Lastly, a Nasal Naloxone Protocol is provided in Appendix F.
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Ambulatory Distribution with Co-Located Pharmacy
Practice Location Description
The Boston Medical Center Office Based Addiction Treatment (OBAT) Program is an
addiction treatment program within a primary care setting using the nurse-care manager model.
In the nurse-care manager model, nurses work to the fullest scope of their license to provide
patients with comprehensive addiction treatment in an outpatient, primary care setting. The
model achieves efficient coordination of complex patient care through a multidisciplinary team
of professionals. Most patients treated in the OBAT program receive medications for opioid use
disorder, most common of which is buprenorphine. The OBAT program has adopted a harm
reduction approach to addiction treatment; therefore, nurses often follow patients who have
recently used a substance, who recurrently use an illicit substance while receiving treatment, or
who may be new to treatment. Patients are not only at an elevated risk for overdose, but may
interact with social networks in which individuals are more likely to experience an opioid
overdose. Rapid access to naloxone in a clinical setting allows nurses to ensure that a patient
receives the life-saving medication and develops creative strategies for storing naloxone for
ready availability on their person.
Administrative Requirements
• Organization specific naloxone protocol, nursing standing orders for naloxone
transmission to pharmacy in collaboration with provider.
Entities Involved
• OBAT clinic nurses, providers, hospital administration, internal pharmacy staff.
Steps of Distribution Workflow
Nurse care managers offer nasal naloxone to all patients in OBAT care: The medication is
offered to all patients with a substance use disorder, not only those with an opioid use disorder.
In providing all patients with naloxone, nurses acknowledge the high risk of fentanyl adulterated
drug supply and understand the public health importance of preparing individuals to respond to a
suspected overdose. The steps of the workflow for OBAT’s distribution are as follows (also
illustrated in Figure 1, Appendix C):
1. Given the varied experiences of people who use drugs, it is important to assess the level
of knowledge patients have regarding overdose identification, response, and reversal. For
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patients with ample experience, it is prudent to provide focused education and
information about naloxone and availability (see Figure 2, Appendix E).
2. For patients unfamiliar with overdose response and naloxone administration, they should
receive education regarding overdose identification and response, including the
administration of naloxone and emergency response.
3. Nurses explain to the patient that their insurance will be billed for naloxone received in
the clinic that day.
4. Nurse documents distribution of naloxone in the patient’s electronic medical record and
updates the patient’s medication list or routes to provider for historical documentation
based on the organization’s policies and procedures.
5. The nurse removes two doses of nasal naloxone 4mg/0.1mL actuation nasal spray (one
rescue kit) from the clinic supply and affixes a patient label to both the medication and
the Nasal Naloxone Distribution Tracking Sheet (see Figure 3, Appendix D).
6. The nurse may work with the patient to remove the medication from the manufacturer
package and identify alternative storage methods to accommodate discretion and rapid
access to medication in the event of an overdose. Often, when patients carry naloxone,
they may want to keep their naloxone concealed. In its original packaging, naloxone is
contained in a bulky box. To respect the privacy of patients while also keeping patients
safe, the following repackaging measures can be taken to make patients comfortable:
a. The OBAT program offers patients several small nylon pouches, including a
zipper and carabiner clip (see Figure 1, Appendix E).
b. Pouches fit two doses of naloxone, gloves, and a face shield.
c. Pouches can fit in a purse, backpack, lanyard or attach to an article of clothing or
accessories with a carabiner.
7. Weekly, the charge nurse sends the Nasal Naloxone Distribution Tracking Sheet to the
pharmacy team member responsible for billing for naloxone.
8. The registered pharmacist may contact the patient directly or reach out to clinic staff to
clarify matters related to patient’s insurance or demographic information.
9. Repeat the distribution process as necessary. Continue to offer naloxone to patients in
living or social situations that elevate the risk of encountering or responding to an opioid
overdose to ensure improved distribution.
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Potential Challenges
• Storage of medication within the clinic that is secure and easily accessible to clinic staff
when needed.
o Daily inventory and inventory on the dispensation of the naloxone supply is
recommended to prevent the loss or theft of the naloxone supply.
o Regularly check medication expiration dates to ensure the supply is safe for
distribution.
• Consistent communication between the pharmacy team and clinic staff, particularly in
regards to patient’s insurance coverage.
o A regular check-in between pharmacy staff and OBAT staff should occur to
rectify any outstanding concerns or issues.
o In the event that a patient is uninsured or their insurance does not cover the cost of
naloxone, a pre-identified process should exist for the pharmacy to recoup the
cost of the medication (cost center, private fund, etc.).
Example Forms
• Boston Medical Center’s OBAT Nasal Naloxone Protocol at Figure 2, Appendix F and
the Nursing Script at Figure 1, Appendix F.
• Nasal Naloxone Distribution Tracking Sheet can be viewed at Figure 3, Appendix D.
• OBAT Clinic Nasal Naloxone Inventory Tracking document can be viewed at Figure 4,
Appendix D.
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Ambulatory Distribution with an Off-Site Pharmacy
Practice Location Description
The Community Health Center has an existing Office Based Addiction Treatment
(OBAT) program, however the institution does not have a pharmacy within the current practice
location. Thus, the patient care team relies on local commercial pharmacies for patients to access
all of their medications. To improve access and distribution of nasal naloxone to at-risk patients,
the Community Health Center and a commercial pharmacy collaborate on an agreement to
reduce barriers to traditional patient medication access.
Administrative Requirements
• Organization specific naloxone protocol, nursing standing orders for naloxone
transmission to pharmacy in collaboration with provider.
Entities Involved
• OBAT clinic staff (nurses, providers, recovery coaches, care coordinators), community
pharmacy partners (pharmacists, pharmacy technicians).
Steps of Distribution Workflow
Establishing a practice agreement between the commercial pharmacy and the community
health center may be beneficial to creating an efficacious workflow between the two
organizations. A collaborative practice agreement may outline different strategies for naloxone
distribution to the health center level by the pharmacy, including (1) providing a small stock of
naloxone for the health center, (2) providing a weekly or daily delivery of naloxone to the health
center, or (3) providing a same day courier service to specific practice locations.
The practice agreement between the Community Health Center and the commercial
pharmacy outlined enables the Community Health Center to store a small stock of nasal
naloxone from the commercial pharmacy, which is replenished weekly by a courier service, to be
billed to patient insurance following distribution. The steps of the workflow for the Community
Health Center’s distribution with a clinic supply of naloxone are as follows (also illustrated in
Figure 2, Appendix C):
1. Nurse care managers offer naloxone to all patients in OBAT care: The medication is
offered to all patients with a substance use disorder, not only those with an opioid use
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disorder. Offering the medication to all patients with an opioid use disorder and other
substance use disorders acknowledges the high risk of fentanyl adulterated drug
supply and the public health importance of responding to a suspected overdose.
2. Given the varied experiences of people who use drugs, it is important to assess the
level of knowledge patients have regarding overdose identification, response, and
reversal. For patients with ample experience, it is prudent to provide focused
education and information about naloxone and availability (see Figure 2, Appendix
E).
3. Nurses explain to the patient that their insurance will be billed for naloxone received
in the clinic that day.
4. Nurse documents distribution of naloxone in the patient’s electronic medical record
and updates the patient’s medication list or routes to provider for historical
documentation based on the organization’s policies and procedures.
5. The nurse removes two doses of nasal naloxone 4mg/0.1mL actuation nasal spray
(one rescue kit) from the clinic supply and affixes a patient label to both the
medication and the Nasal Naloxone Distribution Tracking Sheet (see Figure 3,
Appendix D).
6. The nurse may work with the patient to remove the medication from the manufacturer
package and identify alternative storage methods to accommodate discretion and
rapid access to medication in the event of an overdose. Often, when patients carry
naloxone, they may want to keep their naloxone concealed. In its original packaging,
naloxone is contained in a bulky box. To respect the privacy of patients while also
keeping patients safe, the following repackaging measures can be taken to make
patients comfortable:
a. Discuss patient hesitance or discomfort with carrying naloxone and provide
patients with a reliable and easily transportable mechanism for storing
naloxone to encourage keeping naloxone on their person.
b. Offer patients several small pouches, including a zipper and an optional
carabiner clip (see Figure 1, Appendix E).
c. Accommodate patients with pouches that can fit in a purse, backpack, lanyard,
or attach to an article of clothing or accessories with a carabiner.
BOSTON MEDICAL CENTER JANUARY 2022
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7. Weekly, the nurse sends the Nasal Naloxone Distribution Tracking Sheet to the
commercial pharmacy team member responsible for billing for naloxone.
8. The registered pharmacist may contact the patient directly or reach out to clinic staff
to clarify matters related to patient’s insurance or demographic information.
9. Repeat the distribution process as necessary. Continue to offer naloxone to patients in
living or social situations that elevate the risk of encountering or responding to an
opioid overdose to ensure improved distribution.
The Community Health Center, without the ability to ensure clinic supply of naloxone,
may (1) send the naloxone prescription to the patient’s preferred pharmacy to be picked up by
the patient and/or (2) collaborate with a pharmacy to provide delivery of naloxone ordered for a
specific patient to be distributed at the next visit. Meaning, that rather than having a clinic supply
of naloxone that could be distributed to any patient and billed to insurance following, this site
would send a prescription to the pharmacy to be billed to insurance and delivered to the site for
distribution to that specific patient. The Community Health Center may choose to both send a
prescription for patient pick-up and arrange for future delivery of naloxone to ensure immediate
access to naloxone at upcoming appointments. The steps of the workflow outlined below is for
the Community Health Center’s distribution without a clinic supply of naloxone are as follows
(also illustrated in Figure 2, Appendix C):
1. Nurse care managers offer naloxone to all patients in OBAT care: The medication is
offered to all patients with a substance use disorder, not only those with an opioid use
disorder. Offering the medication to all patients with an opioid use disorder and other
substance use disorders acknowledges the high risk of a fentanyl adulterated drug
supply and the public health importance of responding to a suspected overdose.
2. Given the varied experiences of people who use drugs, it is important to assess the
level of knowledge patients have regarding overdose identification, response, and
reversal. For patients with ample experience, it is prudent to provide focused
education and information about naloxone and availability (see Figure 2, Appendix
E).
3. Nurses explain to the patient that nasal naloxone 4mg/0.1mL actuation nasal spray
will be sent to the pharmacy for same-day pick up.
BOSTON MEDICAL CENTER JANUARY 2022
22
4. Nurse explains that a prescription for naloxone 4mg/0.1 mL actuation nasal spray can
also be sent to a community pharmacy for delivery to the health center for distribution
to the patient at future visits. This discussion should be completed during the first
nursing encounter to ensure patients can receive same day naloxone in clinic at future
appointments.
a. Patient’s who agree to naloxone delivery will complete the Prescription
Delivery Authorization Form (see Figure 5, Appendix D).
5. Nurse documents patient preference for delivery of naloxone to the community health
center in the patient’s electronic medical record and ensures nasal naloxone was
transmitted to community pharmacy or routes to provider for transmission following
the organization’s policies and procedures.
6. During subsequent encounters in which naloxone is distributed directly to the patient,
the nurse may educate the patient on how to remove the medication from the
manufacturer package and identify alternative storage methods to accommodate
discretion and rapid access to medication in the event of an overdose following
receipt of naloxone pharmacy or in clinic.
a. Discuss patient hesitance or discomfort with carrying naloxone and provide
patients with a reliable and easily transportable mechanism for storing
naloxone to encourage keeping naloxone on their person.
b. Offer patients several small pouches, including a zipper and an optional
carabiner clip (see Figure 1, Appendix E).
c. Accommodate patients with pouches that can fit in a purse, backpack, lanyard,
or attach to an article of clothing or accessories with carabiner.
7. The nurse completing the visit ensures naloxone was sent to collaborating community
pharmacy with ample refills. For example, dispense 4 nasal naloxone 4mg/0.1mL
actuation nasal spray with 99 refills.
8. Nurse documents distribution of naloxone in the patient’s electronic medical record
and ensures naloxone is on the patient’s medication list or routes to provider for
historical documentation based on the organization’s policies and procedures.
9. Weekly, the nurse or clinic staff reviews new and current patients to ensure those who
have agreed to have naloxone delivered to the health center have active prescriptions
BOSTON MEDICAL CENTER JANUARY 2022
23
with the community pharmacy. Upon receipt of delivery, naloxone should be logged
and stored per organization protocols and noted in upcoming patient appointment to
remind team to distribute to the patient. See Nasal Naloxone Distribution Tracking
Sheet (see Figure 3, Appendix D).
10. The community pharmacist may contact the patient directly or reach out to clinic staff
to clarify matters related to patient’s insurance or demographic information.
11. Repeat the distribution process as necessary. Continue to offer naloxone to patients in
living or social situations that elevate the risk of encountering or responding to an
opioid overdose to ensure improved distribution.
Potential Challenges
• The primary challenge in establishing an alternative pathway for naloxone distribution
with an off-site commercial pharmacy is identifying a potential collaborative partner.
o Start by meeting with commercial pharmacies that are known to serve patients
from the OBAT clinic and have been good partners in the past.
o Communicate requests for collaboration before meeting with the pharmacy to
allow internal discussion of workflow and request permission from their corporate
office.
o Smaller community pharmacies may be more willing to partner with your agency
if they have been serving OBAT patients for an extended period of time.
o Have alternative strategies for naloxone distribution (storage at the clinic vs.
delivery to the clinic) to provide the commercial entity with options that may
better suit their needs.
• Storage of medication within the clinic that is secure and easily accessible to clinic staff
when needed.
o Daily inventory and inventory on the dispensation of the naloxone supply is
recommended to prevent the loss or theft of the naloxone supply.
o Regularly check medication expiration dates to ensure the supply is safe for
distribution.
• Consistent communication between the pharmacy team and clinic staff, particularly in
regards to patient’s insurance coverage.
BOSTON MEDICAL CENTER JANUARY 2022
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o A regular check-in between pharmacy staff and OBAT staff should occur to
rectify any outstanding concerns or issues.
o In the event that a patient is uninsured or their insurance does not cover the cost of
naloxone, a pre-identified process should exist for the pharmacy to recoup the
cost of the medication (cost center, private fund, etc.).
Example Forms
The Nasal Naloxone Distribution Tracking Sheet can be viewed at Figure 3, Appendix
D. The Prescription Delivery Authorization Form can be viewed at see Figure 5, Appendix D.
BOSTON MEDICAL CENTER JANUARY 2022
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Opioid Treatment Program with an Off-Site Pharmacy
Practice Location Description
The Spectrum Opioid Treatment Program (OTP), located at Lincoln St. in Worcester, is
an opioid treatment program that provides daily dosing of medications for opioid use disorder
with clinician observation. Most patients utilize the practice for daily methadone dosing to treat
opioid use disorders. Patients who receive methadone treatment may be engaged in social
networks with individuals who are also at elevated risk of an opioid overdose due to recurrent
illicit opioid use or at risk in the early stages of recovery. Daily visits with OTP staff make the
collaboration with local commercial pharmacies a viable option for direct naloxone distribution
for patients that may be involved with others or at elevated risk themself for opioid overdose.
Administrative Requirements
• Organization specific naloxone protocol, nursing standing orders for naloxone
transmission to pharmacy in collaboration with provider.
Entities Involved
• OTP team (nurses, providers, administrative team, clinical staff), community pharmacy
partners (pharmacists, pharmacy technicians).
Steps of Distribution Workflow
Spectrum Opioid Treatment Program’s workflow involves multiple entities and does not
result in same-day access to naloxone. However, the nature of the OTP setting requiring patients
receive daily methadone doses under observation facilitates a one-to-two-hour delivery time for
any patient requesting naloxone. The steps of the workflow for Spectrum OTP’s distribution at
are as follows (also illustrated in Figure 3, Appendix C):
1. A patient receiving services at the OTP must first tell their provider (nurse or
clinician) that they are interested in obtaining naloxone.
2. The patient will complete the Prescription Delivery Authorization Form (see Figure
5, Appendix D) and the Naloxone Intake Form (see Figure 6, Appendix D).
3. OTP staff faxes the Naloxone Intake Form and the Prescription Delivery
Authorization Form to the partner commercial pharmacy.
4. The pharmacy reviews the order form and contacts the patient directly by phone with
any questions regarding the patient’s insurance information and request.
BOSTON MEDICAL CENTER JANUARY 2022
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5. The pharmacy fills the nasal naloxone and has it delivered to the OTP staff.
6. OTP staff provides the patient with the ordered doses of naloxone and reviews
overdose prevention and response counseling.
7. The patient is provided with a printed-out education pamphlet regarding use of
naloxone and overdose response strategies (see Figure 2, Appendix E).
8. Nurse documents distribution of naloxone in the patient’s electronic medical record
and updates the patient’s medication list or routes to provider for historical
documentation based on the organization’s policies and procedures.
9. Repeat the order form process as necessary. Continue to offer naloxone to patients in
living or social situations that elevate the risk of encountering or responding to an
opioid overdose to ensure improved distribution.
Potential Challenges
• The primary challenge in establishing an alternative pathway for naloxone distribution
with an offsite commercial pharmacy is identifying a potential collaborative partner.
o Start by meeting with commercial pharmacies that are known to serve patients
from the OBAT clinic and have been good partners in the past.
o Communicate requests for collaboration before meeting with the pharmacy to
allow internal discussion of workflow and request permission from their corporate
office.
o Smaller community pharmacies may be more willing to partner with your agency
if they have been serving OBAT patients for an extended period of time.
o Have alternative strategies for naloxone distribution (storage at the clinic vs.
delivery to the clinic) to provide the commercial entity with options that may
better suit their needs.
o Distribution delays in a system that relies on regular medication delivery to the
site can be problematic, particularly for locations that may be affected by
inclement weather.
o Be proactive in placing requests for nasal naloxone. Consider upon entry into the
OTP and then with regular intervals.
o Consider ordering naloxone for patients and allowing patients to store excess
naloxone on-site in a medication locker or patient medication box.
BOSTON MEDICAL CENTER JANUARY 2022
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Inpatient to Outpatient Disposition Distribution
Practice Location Description
The D-Unit at Boston Medical Center is a 12-bed inpatient unit located within Boston
Medical Center’s Emergency Department. The location and structure of the unit require that
patients assigned to the D-Unit (D-POD) are cognitively intact, ambulatory, and requiring of a
short inpatient medical stay. Many of the patients admitted to this unit receive care from Family
Medicine, General Medicine, Hospitalist Service, and Infectious Disease. In addition, the
Addiction Consult Service is frequently called for patients admitted to the D-POD with
substance use disorders. Patients experiencing a substance use disorder may require management
of their withdrawal symptoms, or they may request the initiation of medication for their
addiction. The D-unit experiences high and frequent patient turnover, as patients are often
diagnosed and treated quickly and efficiently. The D-POD is exclusively staffed by Medical-
Surgical Float Pool Nurses.
Administrative Requirements
Organization specific naloxone protocol.
Entities Involved
Medical-Surgical Float Pool nurses, care managers, inpatient medical teams, consulting
services, social work.
Steps of Distribution Workflow
A standing order for nasal naloxone is required to authorize nurses to dispense naloxone
rescue kits to (1) a person at risk of experiencing an opioid-related overdose or (2)a family
member, friend, or another person in a position to assist a person at risk of experiencing an
opioid-related overdose (see Figure 2, Appendix B). The steps of the workflow for the D-POD’s
inpatient to outpatient disposition distribution at are as follows (also illustrated in Figure 4,
Appendix C):
1. Nurses provide a brief risk assessment and offer naloxone to all patients admitted to the
D-POD identified as having high risk for an opioid overdose or likely to witness an
overdose. Discussion and promotion of naloxone should be provided to any patient who
has identified a concern for themselves, a family member, friend, colleague, or
acquaintance who may be at risk for an opioid overdose.
BOSTON MEDICAL CENTER JANUARY 2022
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2. Patients receive education regarding overdose identification and response, including
naloxone administration (see Figure 2, Appendix E).
3. Nurses explain to the patient that their insurance will be billed for the receipt of naloxone.
4. Nurses document nasal naloxone 4mg/0.1 mL actuation nasal spray in the patient’s
historical medication list in the electronic medical records (EMR).
5. The nurse removes two doses of nasal naloxone 4mg/0.1mL actuation nasal spray (one
rescue kit) from the clinic supply and affixes a patient label to both the medication and
the Nasal Naloxone Distribution Tracking Sheet.
6. The nurse may work with the patient to remove the medication from the manufacturer
package and identify alternative storage methods to accommodate discretion and rapid
access to medication in the event of an overdose. Often, when patients carry naloxone,
they may want to keep their naloxone concealed, and in its original packaging, naloxone
is contained in a bulky box. To respect the privacy of patients while also keeping patients
safe, the following repackaging measures can be taken to make patients comfortable:
a. Discuss patient hesitance or discomfort with carrying naloxone and provide
patients with a reliable and easily transportable mechanism for storing naloxone
to encourage keeping naloxone on their person.
b. Offer patients several small pouches, including a zipper and an optional carbainer
clip (see Figure 1, Appendix E).
c. Accommodate patients with pouches that can fit in a purse, backpack, lanyard, or
attach to an article of clothing or accessories with carabiner.
7. Daily, the charge nurse will send the Nasal Naloxone Distribution Tracking Sheets to a
designated member of the pharmacy team responsible for appropriate billing for
naloxone. This communication can be done using an image captured on a work phone
that is sent to the pharmacy contact. This communication will also provide information
necessary for maintaining an adequate supply of naloxone for the unit.
8. The registered pharmacist may contact the patient directly or reach out to clinic staff to
clarify matters related to patient’s insurance or demographic information.
9. Repeat the distribution process as necessary. Continue to offer naloxone to patients in
living or social situations that elevate the risk of encountering or responding to an opioid
overdose to ensure improved distribution.
BOSTON MEDICAL CENTER JANUARY 2022
30
Potential Challenges
• Storage of medication within the unit that is secure and easily accessible to clinic staff
when needed.
o Daily inventory and inventory on the dispensation of the naloxone supply is
recommended to prevent loss or theft.
o Regularly check medication expiration dates to ensure the supply is safe for
distribution.
• Consistent communication between the pharmacy team and clinic staff, particularly in
regards to patient’s insurance coverage.
o A regular check-in between pharmacy staff and OBAT staff should occur to
rectify any outstanding concerns or issues.
o In the event that a patient is uninsured or their insurance does not cover the cost of
naloxone, a pre-identified process should exist for the pharmacy to recoup the
cost of the medication (cost center, private fund, etc.).
• Education and comfort of inpatient nursing staff regarding the identification and distribution
of the medication is another important component of this distribution process.
o Training for inpatient nursing staff to be able to autonomously identify
patients at elevated risk for opioid overdose.
o Training for inpatient nursing staff on how to provide naloxone
administration, education and opioid overdose response.
o Education to nursing staff about 3
rd
party prescribing of nasal naloxone to
individuals who may be in contact with others at elevated risk for opioid
overdose.
o Consider a pilot program with one unit of smaller staff in the hospital before
larger scale roll out to other units to identify problems in the workflow.
o Consider having a unit champion who can be used for informal education and
troubleshooting with other nurse colleagues to promote this distribution
pathway.
BOSTON MEDICAL CENTER JANUARY 2022
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Emergency Department Distribution
Practice Location Description
The Massachusetts General Hospital (MGH) and Boston Medical Center (BMC) are busy
urban emergency departments (ED) located in the city of Boston. Patients in the emergency
department range from acute or crisis level of care to ambulatory care needs. Patients may be
seen for overdose or post-overdose care, and patients may vary in readiness to address their
substance use. An addiction team, consisting of advanced practice nurses and recovery coaches,
offer specialized addiction care in the emergency department, in addition to other emergency
services.
Administrative Requirements
Emergency room/organization specific naloxone protocol.
Entities involved
• Emergency department team (nurses, providers, clinicians, and recovery coaches),
internal outpatient/emergency department pharmacists and staff.
Steps of Distribution Workflow
The steps for the workflow of Emergency Department distribution are as follows (also
illustrated in Figure 5, Appendix C):
1. Patients who arrive to the emergency department are assessed as needing nasal naloxone;
they present at elevated risk for overdose or request it.
2. Given the varied experiences of people who use drugs it is important to assess the level of
knowledge patients have regarding overdose identification, response, and reversal. For
patients with ample experience, it is prudent to provide focused education and
information about naloxone and availability (see Figure 2, Appendix E).
3. The addiction team or the primary provider caring for the patient in the emergency room
setting can place an order for nasal naloxone 4mg/0.1 mL actuation nasal spray through
the discharge medication set in the electronic medical record (EMR).
4. Emergency room pharmacy staff receive and process the order for nasal naloxone
4mg/0.1 mL actuation nasal spray through the patient’s insurance as an outpatient
medication to be dispensed to the patient upon discharge from the emergency department
setting.
BOSTON MEDICAL CENTER JANUARY 2022
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5. The emergency room pharmacist delivers the nasal naloxone rescue kit to the patient’s
bedside with the appropriately affixed label and scan code (see Figure 1, Appendix D).
6. The emergency room pharmacist (or provider or nurse) provides the patient with
education regarding the use of the nasal naloxone kit and overdose prevention. Inform the
patient that the scan code on the manufacturer packaging contains links to overdose
prevention education.
7. In the event of downtime, a paper prescription may be printed and brought to an
outpatient pharmacy for medication pickup or for drop off by pharmacy staff to the
patient in the emergency department.
Potential Challenges
• Staffing challenges in the emergency department setting may limit the amount of time
nursing or other clinical staff have to pick up medications from the pharmacy.
o Consider utilization of other members of the healthcare team: pharmacists,
nursing assistants, recovery coaches, patient transport staff, and mental health
workers to facilitate delivery of the medication bedside.
• Educating the emergency nursing staff regarding the identification and distribution of the
medication is an important component of this distribution process.
o Train emergency room nursing staff to be able to autonomously identify patients
at elevated risk for opioid overdose.
o Train inpatient nursing staff on how to provide naloxone administration education
and opioid overdose response.
o Educate the nursing staff about 3
rd
party prescribing of nasal naloxone to
individuals who may be in contact with others at elevated risk for opioid
overdose.
o Consider having a unit champion who can be used for informal education and
troubleshooting with other nurse colleagues to promote this distribution pathway.
Example Forms
• Example of Emergency Department Protocol see Figure 5, Appendix C.
BOSTON MEDICAL CENTER JANUARY 2022
34
References
Albright, Jim, & Castillo, T. (2018, May 1). How to start an EMS naloxone distribution
program. EMS1. https://www.ems1.com/opioids/articles/how-to-start-an-ems-naloxone-
distribution-program-l6Pw0CcO04NN4QJc/
Bagley, S. M., Forman, L. S., Ruiz, S., Cranston, K., & Walley, A. Y. (2018). Expanding access
to naloxone for family members: The Massachusetts experience: Family naloxone access.
Drug and Alcohol Review, 37(4), 480–486. https://doi.org/10.1111/dar.12551
CDC. (2020, October 7). How to recognize an overdose. Centers for Disease Control and
Prevention. https://www.cdc.gov/opioids/overdoseprevention/index.html
Formica SW, Waye KM, Benintendi AO, Yan S, Bagley SM, Beletsky L, Carroll JJ, Xuan
Z, Rosenbloom D, Apsler R, Green TC, Hunter A, Walley AY. Characteristics of post-
overdose public health-public safety outreach in Massachusetts. Drug Alcohol Depend.
2021 Feb 1;219:108499. doi: 10.1016/j.drugalcdep.2020.108499. Epub 2020 Dec 31.
PMID: 33421800.
Formica SW, Apsler R, Wilkins L, Ruiz S, Reilly B, Walley AY. Post opioid overdose
outreach by public health and public safety agencies: Exploration of emerging programs
in Massachusetts. Int J Drug Policy. 2018 Apr;54:43-50. doi:
10.1016/j.drugpo.2018.01.001. Epub 2018 Feb 8. PMID: 29414484.
Green, T. C., Davis, C., Xuan, Z., Walley, A. Y., & Bratberg, J. (2020). Laws Mandating
Co-prescription of Naloxone and Their Impact on Naloxone Prescription in Five US
States, 2014–2018. American Journal of Public Health, 110(6), 881–887.
https://doi.org/10.2105/AJPH.2020.305620
BOSTON MEDICAL CENTER JANUARY 2022
35
Health and Human Services, D. C. (2018, May 8). 5-Point Strategy To Combat the Opioid Crisis
[Text]. HHS.Gov; https://plus.google.com/+HHS. https://www.hhs.gov/opioids/about-
the-epidemic/hhs-response/index.html
HRSA. (2018, March 22). Opioid Crisis [Text]. Official Web Site of the U.S. Health Resources
& Services Administration. https://www.hrsa.gov/opioids
Hughes, J. (2016). Naloxone Access Statutes. 63.
Jones, C. M., Compton, W., Vythilingam, M., & Giroir, B. (2019). Naloxone Co-prescribing to
Patients Receiving Prescription Opioids in the Medicare Part D Program, United States,
2016-2017. JAMA, 322(5), 462. https://doi.org/10.1001/jama.2019.7988
Lambdin, B. H. (2020). Overdose Education and Naloxone Distribution Within Syringe Service
Programs—United States, 2019. MMWR. Morbidity and Mortality Weekly Report, 69.
https://doi.org/10.15585/mmwr.mm6933a2
LDI & CHERISH. (2019, May 29). Expanding Access to Naloxone: A Review of Distribution
Strategies. LDI. https://ldi.upenn.edu/brief/expanding-access-naloxone-review-
distribution-strategies
Lippold, K. M., Jones, C. M., Olsen, E. O., & Giroir, B. P. (2019). Racial/Ethnic and Age Group
Differences in Opioid and Synthetic Opioid–Involved Overdose Deaths Among Adults
Aged ≥18 Years in Metropolitan Areas—United States, 2015–2017. Morbidity and
Mortality Weekly Report, 68(43), 967–973. https://doi.org/10.15585/mmwr.mm6843a3
McCammon, S. (2018, October 24). Knocking On Doors To Get Opioid Overdose Survivors Into
Treatment. NPR. https://www.npr.org/sections/health-
shots/2018/10/24/657894138/knocking-on-doors-to-get-opioid-overdose-survivors-
into-treatment
BOSTON MEDICAL CENTER JANUARY 2022
36
McDonald, R., Lorch, U., Woodward, J., Bosse, B., Dooner, H., Mundin, G., Smith, K., &
Strang, J. (2018). Pharmacokinetics of concentrated naloxone nasal spray for opioid
overdose reversal: Phase I healthy volunteer study. Addiction (Abingdon, England),
113(3), 484–493. https://doi.org/10.1111/add.14033
Murrin, S. (2020). CMS Should Pursue Strategies To Increase the Number of At-Risk
Beneficiaries Acquiring Naloxone Through Medicaid. 32.
NIDA, (2021, March 11). Opioid Overdose Crisis. National Institute on Drug Abuse.
https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis
Naloxone. (2021, August 08). SAMHSA Substance Abuse and Mental Health Services
Administration. https://www.samhsa.gov/medication-assisted-treatment/medications-
counseling-related-conditions/naloxone
National Harm Reduction Coalition. (2020, September 1). Opioid Overdose Basics: Responding
to an Opioid Overdose.
https://harmreduction.org/issues/overdoseprevention/overview/overdose-
basics/responding-to-opioid-overdose/
NIDA. 2019, August 6. Co-prescribing naloxone in Medicare Part D increases. Retrieved from
https://www.drugabuse.gov/news-events/news-releases/2019/08/co-prescribing-
naloxone-in-medicare-part-d-increases on 2021, August 18
Piper, T. M., Stancliff, S., Rudenstine, S., Sherman, S., Nandi, V., Clear, A., & Galea, S. (2008).
Evaluation of a Naloxone Distribution and Administration Program in New York City.
Substance Use & Misuse, 43(7), 858–870. https://doi.org/10.1080/10826080701801261
SAFE Project—State Naloxone Access Rules and Resources. (2021). SAFE Project.
https://www.safeproject.us/naloxone-awareness-project/state-rules/
BOSTON MEDICAL CENTER JANUARY 2022
37
SAMHSA. (2021, August 08). Naloxone. Substance Abuse and Mental Health Services
Administration. https://www.samhsa.gov/medication-assisted-treatment/medications-
counseling-related-conditions/naloxone
Townsend, T., Blostein, F., Doan, T., Madson-Olson, S., Galecki, P., & Hutton, D. W. (2020).
Cost-effectiveness analysis of alternative naloxone distribution strategies: First responder and
lay distribution in the United States. International Journal of Drug Policy, 75, 102536.
https://doi.org/10.1016/j.drugpo.2019.07.031
Waye, K. M., Goyer, J., Dettor, D., Mahoney, L., Samuels, E., Yedinak, J. L., & Marshall, B. D.
L. (2019). Implementing Peer Recovery Services for Overdose Prevention in Rhode
Island: An Examination of Two Outreach-Based Approaches. Addictive Behaviors, 89,
85–91. https://doi.org/10.1016/j.addbeh.2018.09.027
Wermeling D. P. (2015). Review of naloxone safety for opioid overdose: practical
considerations for new technology and expanded public access. Therapeutic advances in
drug safety, 6(1), 20–31. https://doi.org/10.1177/2042098614564776
Wheeler, E., Davidson, P. J., Jones, T. S., & Irwin, K. S. (2012). Community-Based Opioid
Overdose Prevention Programs Providing Naloxone—United States, 2010. MMWR.
Morbidity and Mortality Weekly Report, 61(6), 101–105.
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Appendix A
Figure 1 Rates of Naloxone Co-prescription Within 7 Days Among Medicare Part D
Beneficiaries Receiving Prescription Opioids, United States, 2016-2017
Note. The data indicates an increase in co-prescribing of naloxone with opioids prescribed for
chronic pain within a year. Trends of an increase in co-prescribing practices with naloxone
among Medicare D patients are confirmed by researches from the National Institutes of Health,
the Centers for Disease Control and Prevention, and the Office of Assistant Secretary of Health
(NIDA, 2019). From Naloxone Co-prescribing to Patients Receiving Prescription Opioids in the
Medicare Part D Program, United States, 2016-2017, by Jones et al., 2019, JAMA, 322(5), p.
463.
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Appendix B
Figure 1 Statewide Standing Order for Dispensing Naloxone Rescue Kits
StandingOrderforDispensingNaloxoneRescueKits
ThisstandingorderisissuedpursuanttoM.G.L.c.94C,§19B,asamendedbysection32ofchapter208ofthe
actsof2018,AnActforPreventionandAccesstoAppropriateCareandTreatmentofAddiction,whichexpands
accesstonaloxonethroughastatewidestandingorder,ratherthanrequiringeachpharmacytosecureandfile
oneindividually.Thisstandingorderauthorizeslicensedpharmaciststodispensenaloxonerescuekitstoa
personatriskofexperiencinganopioid-relatedoverdose,familymember,friendorotherpersoninapositionto
assistapersonatriskofexperiencinganopioid-relatedoverdose.
Chapter208protectsthephysiciansigningthestatewideorder,andallpractitionersprescribingordispensing
naloxonefromcriminalorcivilliabilityoranyprofessionaldisciplinaryaction.(M.G.L.c.94C,§19B(f))Inaddition
totheimmunityestablishedunderM.G.L.c.94C,§34A,chapter208alsoprovidescriminalandcivilimmunity
foranyone,actingingoodfaith,whoadministersanopioidantagonisttoanindividualappearingtoexperience
anopioid-relatedoverdose.(M.G.L.c.94C,§19B(g))
Forintranasaladministration:
• Naloxone4mg/0.1mLnasalspray
Dispense2doses.
Directionsforuse:Administerasinglesprayofnaloxoneinonenostril.Repeatafter3minutesifnoor
minimalresponse.
OR
• Naloxone2mg/2mLsingle-doseLuer-Jetprefilledsyringe
Dispense2doses.
Includeoneluer-lockmucosalatomizationdevice(MAD300)perdosedispensed.
Directionsforuse:Spray1mLineachnostril.Repeatafter3minutesifnoorminimalresponse.
Forintramuscularinjection:
• Naloxone0.4mg/mLin1mLsingledosevials
Dispense2doses.
Includeone3cc,25gauge,1”syringeperdosedispensed.
Directionsforuse:Inject1mLIMinshoulderorthigh.Repeatafter3minutesifnoorminimalresponse.
OR
• Naloxone2mg/0.4mLauto-injector
Dispense2doses.
• Directionsforuse:Followaudioinstructionsfromdevice.Placeonthighandinject0.4mL.
Repeatafter3minutesifnoorminimalresponse.
October4,2018
Physician’sSignature Date
AlexanderY.Walley,MD,MSc MA221133
Physician’sNameandMALicenseNo.(printlegibly)
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Figure 2 Boston Medical Center’s Standing Order for Dispensing Naloxone Rescue Kits to
Individuals at Risk of Experiencing or Witnessing Opioid-Related Overdose
Massachusetts Department of Public Health
Naloxone
Boston Medical Center Outpatient Pharmacy
Requirements:
• A copy of the standing order must be maintained on file and readily retrievable
at each participating pharmacy site
• Standing order must be filed with the Board of Registration in Pharmacy (Board)
Boston Medical Center’s Standing Order for Dispensing Naloxone Rescue Kits to Individuals at
Risk of Experiencing or Witnessing an Opioid-Related Overdose
Naloxone Overview
• Patient indications for Naloxone Distribution
Naloxone is indicated for the reversal of respiratory depression or unresponsiveness caused
by an opioid overdose. It may be delivered intranasally with the use of a mucosal atomizer
device or intramuscularly with use of a needle.
Take-home naloxone rescue kits can be dispensed by a pharmacist without a prescription
under this standing order to patients at risk of an opioid overdose or witnessing an opioid
overdose.
Some indications for dispensing naloxone are:
1. Previous opioid intoxication or overdose
2. History of nonmedical opioid use
3. Treatment with methadone or buprenorphine for an opioid use disorder
4. Higher-dose (>50 mg morphine equivalent/day) opioid prescription
5. Receiving any opioid prescription for pain plus:
a. Rotated from one opioid to another because of possible incomplete cross-
tolerance
b. Smoking, COPD, emphysema, asthma, sleep apnea, respiratory infection,
other respiratory illness
c. Renal dysfunction, hepatic disease, cardiac illness, HIV/AIDs
d. Known or suspected concurrent alcohol use
e. Concurrent benzodiazepine or other sedative prescription
f. Concurrent antidepressant prescription
6. Patients who may have difficulty accessing emergency medical services (distance,
remoteness)
7. Voluntary request from patient or caregiver
• Side Effects:
Naloxone can neither be abused nor cause overdose. Hypersensitivity (rash, worsening
difficulty breathing, anxiety) is very rare. Too much naloxone can cause withdrawal
symptoms such as:
o Anxiety, runny nose and eyes, chills, muscle discomfort, disorientation,
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Appendix C
Figure 1 Naloxone Distribution Workflow: Ambulatory Distribution with Co-Located Pharmacy
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Figure 2 Naloxone Distribution Workflow: Ambulatory Distribution with an Off-Site Pharmacy
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Figure 3 Naloxone Distribution Workflow: Opioid Treatment Program with Off-Site Pharmacy
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Figure 4 Naloxone Distribution Workflow: Inpatient to Outpatient Disposition
Distribution
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Figure 5 Naloxone Distribution Workflow: Emergency Department Distribution
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Appendix D
Figure 1 Example Label for Naloxone in Clinic
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Figure 2 Example of Third-Party Prescription of Naloxone
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Figure 3 Nasal Naloxone Distribution Tracking Sheet
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Figure 4 OBAT Clinic Nasal Naloxone Inventory Tracking
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Figure 5 Prescription Delivery Authorization Form
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Figure 6 Naloxone Intake Form
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Appendix E
Figure 1 Patient Naloxone Storage Supplies
Note. The Boston Medical Center’s OBAT program provides patients with a neoprene pouch
with a zipper and carabiner to optimize patient storage and ready access to naloxone.
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Figure 2 Patient Education Sheet on Overdose Identification and Response including Naloxone
Use
p.11
How to Respond to an Overdose
1. RECOGNIZING AN OVERDOSE
It is important to be able to distinguish an overdose from the symptoms of being high on opioids.
Really High
Opioid Overdose
• Nodding
• Will respond to stimulation like yelling,
sternal rub, pinching, etc.
• Not responsive to stimulation (verbal
and physical)
• Drowsy, but breathing
-8 or more times per minute
• Deep snoring or gurgling (death rattle)
• Very infrequent or no breathing
• Speech is slow/slurred
• Pinpoint pupils
• Unable to talk, whether awake or not
• Pinpoint pupils
• Muscles become relaxed
• Sleepy looking
• Normal skin tone
• Slow heart beat/pulse
• Blue/gray lips and fingertips
• Pale, clammy skin
Stimulate and observe!
Overdose rescue!
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p.12
Street Methods Now Have Better Alternatives
Many strategies have been used over the years to rescue people from an opioid overdose. While there are
better alternatives today, applaud folks’ ability to figure out how to keep people alive. Individuals who use
drugs are creative, resilient, and care about keeping their friends and family alive. Street knowledge about
how to treat an overdose often works but there is a safer and more timely method.
Mostly, the reason why street methods have worked is due to
stimulation
.
DO NOT…
These methods of stimulation take more time and can add more risk. There is a better alternative form of
stimulation: THE STERNAL RUB
Stimulation: Sternal Rub
• If a person is not responding and you suspect
an overdose, try to wake them up
• Call name and shake the person. If this
doesn’t work, rub your knuckles into the
sternum (the breastbone in middle of chest)
You can also rub your knuckles on
their upper lip
Tell them you are going to administer
naloxone and continue to explain out-
loud the steps you are taking in the response
2. CALLING 9-1-1
If a person does not respond to stimulation, call 9-1-1!
• Call 9-1-1 whether person responds to naloxone or not
• Person overdosing may have other medical issues
• Person can overdose again once naloxone wears off
Good Samaritan Law
The Massachusetts Good Samaritan Law encourages friends,
family, and/or bystanders to assist people having an overdose
and to seek emergency medical assistance. The law provides
limited immunity to overdose victims and bystanders that call 9-1-1.
The law protects victims and those who call 9-1-1 for help from charge, prosecution, and conviction for
possession or use of controlled substances. The Law, Chapter 94C, Section 34A: “Immunity from
prosecution under Secs. 34 or 35 for persons seeking medical assistance for self or other experiencing a
drug-related overdose” can be found on the Massachusetts Legislature General Laws website.
https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXV/Chapter94C/Section34A
• Leave the person alone
• Put them in a bath
• Induce vomiting
• Put ice down their pants
• Slap, kick, punch, burn, or cause harm
• Inject them with anything other than naloxone (saltwater, cocaine, milk)
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p.13
3. ADMINISTER NALOXONE
As soon as naloxone is available, the opioid overdose
responder should administer the first dose. The second
dose should be administered 3 minutes after the first if
the person remains unresponsive with impaired
breathing. While waiting for the naloxone to work, the
responder should rescue breath (see Step 4) and
continue to stimulate the person. Typically, one or two
doses of naloxone is sufficient to successfully reverse
the effects of the opioid overdose. In some overdose
situations, more than two doses may be necessary.
How to Administer Single Step Naloxone
• PEEL back the package to remove the device. Hold the device with your thumb on the
bottom of the plunger and two fingers on the nozzle.
• PLACE and hold the tip of the nozzle in either nostril until your fingers touch the bottom of
the person’s nose.
• PRESS the plunger firmly to release the dose into the person’s nose.
How to Administer Multi-Step Naloxone
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p.14
Intramuscular Naloxone
Many successful overdose prevention programs worldwide use intramuscular naloxone and have found
that needle stick injury with intramuscular naloxone is rare. A limited number of MDPH OEND
program sites offer IM naloxone to program participants. In MA, IM naloxone uses the naloxone from
the above-mentioned multi-step naloxone and affixes a luer-lock safety needle to the dose.
Some key points about intramuscular naloxone include:
• IM allows for titration of the naloxone dose
• More potent than multi-step nasal naloxone
• More potent than traditional IM (2mg/2ml vs. 0.4mg/1ml)
How to administer intramuscular naloxone:
• Pop off the orange top vial
• Draw up 1cc of naloxone into the syringe
1cc=1mL=100u
• Intramuscular injection sites include the thigh,
shoulder, or upper/outer quadrant of the butt
• Insert the needle straight in to make sure to hit the
muscle
• Withdraw before injecting to ensure the needle is not
in a blood vessel
Figure: Inject into the muscle
4. RESCUE BREATHING
• Make sure there is nothing in the mouth
• Tilt head back, lift chin, pinch nose
• Give a breath every 5 seconds
• If the opioid overdose responder is
trained in CPR, they should proceed as
per the rescuer’s level of training
Equipment to Assist Rescue Breathing
• CPR masks/mouth barriers/Ambu bags
can protect the rescuer. They are one-time-only use equipment.
o Discard after each use and replace
• Practice using these devices is worthwhile
• Proper Use:
o If using CPR mask, place mask over the nose and mouth and apply pressure to make a
tight seal. Breathe into mask and watch chest rise.
o If using mouth barrier, place barrier over mouth, apply pressure to make a tight seal and
pinch nose. Breathe into barrier and watch chest rise.
• If an Ambu bag is attached to the CPR mask, squeeze the bag to force air through the mask and
watch chest rise. If stomach expands, readjust mask or barrier to create a tight seal, and attempt
again.
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p.15
5. STAY UNTIL HELP ARRIVES
If you must leave the scene of an overdose for whatever reason, ensure that the person who overdosed is
in the recovery position and easily accessible by first responders.
If the person is breathing well
, put them on their side as per the illustration.
If they are not breathing well
, continue rescue breathing.
Monitor and Support: It is important to monitor and
support the person who just overdosed because:
• Naloxone lasts 30-90 minutes…
But the duration of the opioid effect can last
4 hours or longer, especially with longer
acting opioids like methadone.
• The person who overdosed will need to understand
that they should not use again until the naloxone
wears off to reduce the risk of re-overdose.
• The likelihood of overdosing again depends on
several things including:
How much of the opioid was used in the
first place and the duration of action of the
drug(s) taken
The health of the person who overdosed
If the person uses again
• The opioid overdose responder should encourage
that person to seek additional medical attention
from the hospital.
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Appendix F
Figure 1 Example Nurse Script
We like to offer nasal naloxone to all of the patients because of the ongoing opioid epidemic and
the heightened risk that you may witness or experience an opioid overdose, even if you aren’t
using illicit opioids. Would you like a prescription for nasal naloxone today?
The nasal naloxone we will provide you with today will be billed through the BMC pharmacy
downstairs and will be on your medication list in the EHR.
Have you ever used nasal naloxone before? Have you ever received nasal naloxone in the past?
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Figure 2 The Boston Medical Center’s Nasal Naloxone Protocol
Nasal Naloxone Protocol
Office-Based Addiction Treatment (OBAT)
INDICATIONS
• Patients presenting to the OBAT clinic at risk for opioid overdose.
TYPES
• Nasal Naloxone 4mg/actuation spray
MECHANISM OF ACTION: Mu-Opioid Antagonist
INDICATIONS (WHO)
• Patients diagnosed with an opioid use disorder.
• When patients are at risk for an opioid overdose:
o Illicit substance use
o A current opioid prescription
o Previous opioid overdose
• When patients are at elevated risk to witness an opioid overdose:
o Attends recovery support meetings
o Lives or works in a residential treatment setting
o Close family members or friends with an opioid use disorder.
o Close family members or friends with a current opioid prescription.
o Reports witnessing a previous opioid overdose.
o Communal spaces that may require shared spaces with patients with opioid use
disorder (eg, homeless shelter, mental health facility, public transportation, public
restrooms, etc.)
EFFICACY (See references)
• Efficacy of bystander administered nasal naloxone has been a utilized intervention since
the early 2000s to reduce mortality related to the opioid epidemic.
o Bystander administered nasal naloxone administration has a greater than 92% rate
of recovery from opioid overdose.
• Efficacy of nasal naloxone to reverse overdose may be negatively affected by
polysubstance use of the patient with life threatening respiratory depression.
ELIGIBILITY
• A patient who is registered with the hospital and have their own medical record number.
• Patients who ask for nasal naloxone should be provided with the medication.
• Patients at risk to witness an opioid overdose:
o Attends recovery support meetings
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o Lives or works in a residential treatment setting
o Close family members or friends with an opioid use disorder.
o Close family members or friends with a current opioid prescription.
o Reports witnessing a previous opioid overdose.
o Communal spaces that may require shared spaces with patients with an opioid use
disorder (eg, homeless shelter, mental health facility, public transportation, public
restrooms, etc.)
• Patients at risk for an opioid overdose:
o Diagnosis of an opioid use disorder
o Illicit substance use
o A current opioid prescription
o Previous opioid overdose
SIDE EFFECTS
• Nasal naloxone
o Recurrent sedation
In patients who are not monitored after nasal naloxone administration
there is a risk that the patient will experience recurrent sedation and
possibly overdose again.
o Precipitated withdrawal
The emergent use of a mu-receptor antagonist in a patient with an opioid
use disorder puts them at risk for precipitated withdrawal for the period of
which the drug is active in the system.
WORK FLOW
• Storage and Inventory
o Doses of nasal naloxone will remain locked in the medication room after they
have been received from pharmacy.
o A medication count and expiration review should occur upon delivery of
medication from the pharmacy and at least once weekly and be signed by at least
two staff members of the OBAT team.
o Pharmacy should be notified of the need for additional nasal naloxone doses when
only 10 doses of medication remain in the locked medication cabinet.
• RN visit
o Offer nasal naloxone to all patients coming in for routine OBAT visits with RN.
o Patients should be counseled regarding opioid overdose identification and reversal
and provided with written or electronic materials regarding the use of nasal
naloxone.
o Patients should be alerted that the medication will be billed through their
insurance.
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o Nurses must document nasal naloxone 4mg/actuation nasal spray to the patient’s
historical medication list in the EMR.
o Nurses should affix a patient label to the Nasal Naloxone Distribution Tracking
sheet and identify the number of doses provided to the patient.
o The charge nurse or nursing supervisor should collect Nasal Naloxone
Distribution Tracking Sheets and fax them to the pharmacy for review and
appropriate billing by RPh.
o Tracking sheets should be saved in a folder in a locked filing cabinet. Sheets
should be scanned into secure folder in the G: Drive once monthly and hard
copies should be destroyed.
Education from the Nurse
Review patient education materials and the information below:
Nasal naloxone is a mu-receptor antagonist, or the antidote to an opioid
overdose. If you think a patient may be overdosing from opioids they will be
taking slow, shallow breaths, may be turning blue or gray, and will not respond to
painful stimuli. If you are concerned about an opioid overdose and the person is
unresponsive to your questions regarding their well being, using your fingers in a
fist apply pressure to the patient’s sternum or their maxilla just below the nose.
For patients that are unresponsive to painful stimuli send for help and then
provide the person with some rescue breaths to ensure adequate oxygenation of
the brain. At this point you can place the atomizer in the patient’s nose and
administered the dose of medication. It may take 1-2 minutes for the medication to
begin to work, Don’t Panic, continue to wait and provide rescue breaths as
needed. When the patient is able to breathe again without assistance encourage
the patient to seek evaluation by an emergency room or another medical
professional for adequate work up of the consequences of an opioid overdose,
specifically acquired or traumatic brain injury.
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References
Abouk, R., Pacula, R. L., & Powell, D. (2019). Association Between State Laws Facilitating
Pharmacy Distribution of Naloxone and Risk of Fatal Overdose. JAMA Internal Medicine,
179(6), 805. https://doi.org/10.1001/jamainternmed.2019.0272
APhA-LetsTalkAboutNaloxone.pdf. (n.d.). Retrieved August 29, 2020, from
https://www.naloxonesaves.org/files/2020/02/APhA-LetsTalkAboutNaloxone.pdf
Davis, C., & Carr, D. (2017). State legal innovations to encourage naloxone dispensing. Journal of the
American Pharmacists Association, 57(2), S180–S184.
https://doi.org/10.1016/j.japh.2016.11.007
Davis, C. S., Ruiz, S., Glynn, P., Picariello, G., & Walley, A. Y. (2014). Expanded Access to
Naloxone Among Firefighters, Police Officers, and Emergency Medical Technicians in
Massachusetts. American Journal of Public Health, 104(8), e7–e9.
https://doi.org/10.2105/AJPH.2014.302062
Doe-Simkins, M., Walley, A. Y., Epstein, A., & Moyer, P. (2009). Saved by the Nose: Bystander-
Administered Intranasal Naloxone Hydrochloride for Opioid Overdose. American Journal of
Public Health, 99(5), 788–791. https://doi.org/10.2105/AJPH.2008.146647
Download.pdf. (n.d.). Retrieved August 29, 2020, from https://www.mass.gov/doc/mdph-oend-
program-core-competencies/download
Giglio, R. E., Li, G., & DiMaggio, C. J. (2015). Effectiveness of bystander naloxone administration
and overdose education programs: A meta-analysis. Injury Epidemiology, 2(1).
https://doi.org/10.1186/s40621-015-0041-8
Mundin, G., McDonald, R., Smith, K., Harris, S., & Strang, J. (2017). Pharmacokinetics of
concentrated naloxone nasal spray over first 30 minutes post-dosing: Analysis of suitability for
BOSTON MEDICAL CENTER JANUARY 2022
66
opioid overdose reversal: Pharmacokinetics of naloxone nasal spray. Addiction, 112(9), 1647–
1652. https://doi.org/10.1111/add.13849
NARCAN-Instructions2.pdf. (n.d.). Retrieved August 29, 2020, from
https://www.naloxonesaves.org/files/2020/02/NARCAN-Instructions2.pdf
OVERDOSE PREVENTION. (n.d.). Retrieved August 29, 2020, from
https://www.bphc.org/whatwedo/Recovery-Services/prevention/Pages/Narcan-Program.aspx
Rando, J., Broering, D., Olson, J. E., Marco, C., & Evans, S. B. (2015). Intranasal naloxone
administration by police first responders is associated with decreased opioid overdose deaths.
The American Journal of Emergency Medicine, 33(9), 1201–1204.
https://doi.org/10.1016/j.ajem.2015.05.022
SAFE Project. “State Naloxone Access Rules and Resources.” Accessed December 28, 2021.
https://www.safeproject.us/naloxone-awareness-project/state-rules/.
Scholl, L., Seth, P., Kariisa, M., Wilson, N., & Baldwin, G. (2018). Drug and Opioid-Involved
Overdose Deaths—United States, 2013–2017. MMWR. Morbidity and Mortality Weekly Report,
67(5152). https://doi.org/10.15585/mmwr.mm675152e1
Strang, J., McDonald, R., Campbell, G., Degenhardt, L., Nielsen, S., Ritter, A., & Dale, O. (2019).
Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public
Health Application of an Emergency Medicine. Drugs, 79(13), 1395–1418.
https://doi.org/10.1007/s40265-019-01154-5
Videos. (n.d.). Retrieved August 29, 2020, from https://prescribetoprevent.org/patient-
education/videos/
