DISPENSING NALOXONE KITS TO CLIENTS AT RISK OF OPIOID OVERDOSE

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1 Please Note: On March 22, 2016, Health Canada announced the change in scheduling for naloxone. The College of Pharmacists of BC have announced that naloxone will now be listed as a Schedule II drug, making it available behind the counter in BC pharmacies (available without requiring a prescription). CRNBC s limits and conditions for dispensing, compounding or administering naloxone remain in effect until they are updated to support non-prescription naloxone. Current practice remains unchanged. This Decision Support Tool will undergo revision to reflect updates to CRNBC limits and conditions once they are integrated into the CRNBC Practice Standard for Dispensing Medication. DISPENSING NALOXONE KITS TO CLIENTS AT RISK OF OPIOID OVERDOSE PREAMBLE Opioid overdose from prescription and illicit drugs is an important public health issue. In 2013, there were 334 deaths due to drug overdose, and the BC Ambulance Service administered naloxone, an opioid antagonist, in 2011 events to reverse opioid-related respiratory depression. In British Columbia, the Take Home Naloxone (THN) program was initiated in August Based at the BC Center for Disease Control, the program distributes naloxone to individuals at risk of opioid overdose. This has been shown to be an effective harm reduction strategy in reducing opioid overdose-related morbidity and mortality. The Nurses (Registered) and Nurse Practitioners Regulation permits registered nurses to compound, dispense or administer Schedule 1 drugs autonomously for the purpose of treating opiate overdose. This authority is subject to standards, limits and conditions established by the College of Registered Nurses of B.C. (CRNBC). CRNBC limits and conditions for registered nurses who dispense naloxone to treat suspected drug/opiate overdose require that they possess the competencies established by the B.C. Centre for Disease Control (BCCDC) and follow decision support tools established by BCCDC. Naloxone is available as part of the Take Home Naloxone kit through the BC THN program or can be ordered as per local medication ordering procedure. 1

2 DEFINITION Any person who uses an opioid is at risk of experiencing an overdose. Naloxone, an opioid antagonist, reverses an opioid overdose and restores breathing. [See Appendix 1 on more info about naloxone] INDICATIONS FOR DISPENSING Any person who uses opioids, who has received training and demonstrates understanding of opioid overdose prevention, recognition, and response is eligible to receive naloxone. The nurse must assess client s understanding and may use the Knowledge Checklist included in the BC THN Training Manual. When dispensing naloxone, Registered Nurses are required to meet the expectations for dispensing set out in CRNBC s Dispensing Medications Practice Standard and follow employer policy. These expectations include providing client education. A suggested training manual with relevant materials is available at Naloxone can be dispensed whether opioid use consists of prescribed, non-prescribed, criminalized, or non-criminalized opioids. Naloxone should be dispensed to opioid users, regardless of their reported or observed routes of consumption. Specific risk groups are outlined in appendix 2. CONTRAINDICATIONS FOR DISPENSING Naloxone is a prescription-only medication and should not be dispensed to individuals who do not have a history of previous or current opioid use. It cannot be dispensed to family members of an individual who uses opioids. CLINICAL ASSESSMENT Opioid Use History Current and past opioid use History of any previous overdoses History of substance misuse (including medications, alcohol, smoking) Assess current drug use, including prescribed medications, over-the-counter medications, herbal products, and illicit drugs 2

3 Physical Assessment Clients may not necessarily be demonstrating symptoms of an opioid overdose or drug intoxication at the time of assessment. Evidence of substance use may be present, including but not limited to: Signs of injection drug use (eg. track marks) Signs of inhalation in oral and nasal mucosa Evidence of intoxication during assessment (eg. alcohol, stimulants, depressants, other) MANAGEMENT AND INTERVENTIONS Goals of a Community Naloxone Program Reduce mortality Prevent complications from oxygen deprivation TREATMENT OF CHOICE Naloxone: Naloxone (2 x 1.0 ml ampules of 0.4 mg/ml naloxone) and accompanying equipment listed below Client education regarding overdose recognition, response, and prevention (detailed below) Notes: 1. Naloxone should not be dispensed to individuals who do not have a history of previous or current opioid use. 2. Please follow your agency guidelines for the storage, handling, and disposal of naloxone. 3

4 Appropriate equipment should be included when naloxone is dispensed. Equipment provided in a typical naloxone kit (as provided by the BC Centre for Disease Control s Take Home Naloxone Program) includes: 2 retractable VanishPoint safety syringes (3mL, 25G x 1 inch) 2 alcohol swabs 2 pairs of latex gloves 2 plastic ampoule breakers One-way rescue breathing mask THN Administration Information Form 1 set of instructions detailing steps to respond to opioid overdose MONITORING AND FOLLOW-UP Emphasize that clients should call 911 when suspecting an opioid overdose. When following up with clients regarding naloxone, perform the following tasks: Inquire regarding the use and condition of the naloxone ampules and additional supplies. Confirm that client has all the necessary equipment listed above. Identify and address any education needs regarding the use of naloxone in acute opioid overdose. Replace used, lost, stolen, or confiscated naloxone and accompanying equipment following the same process as for initial dispensing. If client has used the naloxone, please complete the following: Debrief overdose intervention and offer feedback. If client is part of the BCCDC THN program, complete the BCCDC THN Administration Form based on information from the client. This form is inside each kit and can also be found at Obtain used kit or any unused naloxone vials. Offer replacement naloxone and equipment as per agency policy. Offer opportunity for client to provide improvement suggestions about naloxone education and the THN program. 4

5 CLIENT EDUCATION Counsel client: Regarding the risks of opioid overdose. Regarding opioid overdose recognition and calling 911 immediately. Regarding naloxone administration and safekeeping. Regarding post-opioid overdose care. Regarding further resources about opioid overdose and prevention at towardtheheart.com/naloxone. CONSULTATION OR REFERRAL Consult physician or nurse practitioner if clients do not meet the outlined criteria and you still have concerns re client safety. DOCUMENTATION Document as per CRNBC Practice Standard Documentation Standards and retain records as per your agency policies. A suggested Naloxone Dispensing Record is included in Appendix 2 for reference. REFERENCES Banjo O, Tzemis D, Al-Qutub D, Amlani A, Kesselring S, Buxton J. A quantitative and qualitative evaluation of the British Columbia Take Home Naloxone program. CMAJ Open, 2014, 2(3): E153-E161. BCCDC. Training Manual: Overdose prevention and response Retrieved July 26, 2014, from: BCCDC. DST for Use of Naloxone in the Management of Suspected Opioid Overdose in Outreach and Harm Reduction Settings. (2012). Retrieved July 26, 2014, from: 5

6 Compendium of pharmaceutical and specialties, online version (e-cps). Naloxone CPhA monograph. (2011) Retrieved Sept 11, 2014, from: vm3. Dasgupta N, Brason FW, Albert S, Sanford K. Project Lazarus: Overdose Prevention and Responsible Pain Management. NCMB Forum. 2008, 13(1):

7 DST Authors: Jessica Bridgman, Street Nurse, North Okanagan Youth and Family Services Tim Gauthier, Clinical Coordinator, Insite & Onsite, VCH Kirstin McLaughlin, Registered Nurse, Royal Inland Hospital, IHA Christine Halpert, Senior Practice Lead, BCCDC Ashraf Amlani, Harm Reduction Epidemiologist, BCCDC Erica Tsang, Medical Student, University of British Columbia Janine Stevenson, STBBI Coordinator, FNHA DST Co-Authors, Contributors, and Reviewers: Alison Swalwell-Franks, Collaborative Practice Leader, PHSA Dr. Jane Buxton, Physician Epidemiologist, BCCDC Joyce Seto, Manager, Vaccine and Pharmacy Services, BCCDC Erin Gibson, Regional Harm Reduction Coordinator, FH Sharlene Lively, Regional Director, Public Health, NH Reanne Sanford, Public Health Nurse/Street Nurse, Quesnel Public Health, NH Misty Bath, Clinical Practice Leader, Primary Care, VCH Melanie Kalbfleisch, Medical Elective Student, University of Toronto Sonya Ishiguro, Epidemiologist, Harm Reduction program, BCCDC 7

8 APPENDIX 1 INFORMATION ON NALOXONE HCL (NARCAN) Classification Mechanism Indications Contraindications Dose Route of Administration Onset Duration of Action Metabolism and Excretion Side Effects Drug Interactions Synthetic opioid antagonist Competes with and displaces opioids from their receptor sites. Naloxone has no pharmacologic effect on patients who have not received opioids. Opioid-induced collapse; hemodynamic instability and respiratory depression due to suspected opioid overdose; cardiovascular collapse with airway compromise due to suspected opioid overdose. Hypersensitivity to naloxone or to any ingredient in the formulation Initial dose 0.4 mg (one ampoule) dose followed by repeat doses of 0.4 mg every 2 to 5 minutes if needed. Each kit contains 2 ampoules at 0.4mg each Intramuscular (IM), subcutaneous (SC) 2 to 5 minutes (IM or SC) minutes (depends on route of administration and person s medical condition) Metabolized in liver, excreted in urine; half-life of minutes CNS: Excitation due to abrupt reversal of opioid or narcotic induced analgesia; Tremulousness, seizures, coma CVS: Tachycardia; hyper/hypotension; arrhythmias RESP: Pulmonary edema, hyperventilation SKIN: Sweating, hot flashes (flushing), shivering EMOTIONAL STATE: Irritability; agitation; confusion/feeling startled, nervousness GI: Nausea; vomiting; diarrhea; cramping OTHER: Pain/pain crisis (if opioids used for pain crisis), yawning There are no known significant drug-drug interactions with naloxone. Special Considerations Naloxone may cause abrupt state of opioid withdrawal in the physically dependent participant. This may present as pain, hypertension, sweating, agitation and aggressiveness Naloxone s half life (30 to 90 minutes in adults) is shorter than that of all opioids; therefore, a participant must be observed until the opioid effect has worn off Special attention should be given to clients that may have ingested long acting opioids such as methadone, since their overdose may return and they may require additional doses of naloxone 8

9 Participants treated with naloxone should be encouraged to go to hospital Storage Store naloxone in a secure location, preferably locked and at a height that small children cannot reach Naloxone should be stored between C and away from light 9

10 APPENDIX 2 SUBPOPULATIONS WHO MAY BENEFIT FROM NALOXONE PRESCRIPTION TO PREVENT OPIOID OVERDOSE Potential Indication/Participant Risk Factor for OD Population 1 Recipient of emergency medical care for acute opioid poisoning Increased risk for subsequent accidental poisoning or self-harm 2 Suspected illicit or nonmedical opioid user Risk for polydrug use; continued polydrug use; reduced opioid tolerance (due to abstinence) 3 High-dose opioid prescription (i.e. over 100 mg of morphine equivalence per day) Participant incorrectly administers opioid resulting in higher risk of toxic levels 4 Any methadone prescription to opioid naïve Low threshold for OD; inexperience with participant 5 Any opioid prescription to participant with respiratory illness or obstruction (e.g. asthma, emphysema, bronchitis, smoking) 6 Any opioid prescription for participants with renal dysfunction and/or hepatic disease 7 Any opioid prescription and known/suspected concurrent alcohol use 8 Any opioid prescription and concurrent benzodiazepine prescription 9 Additive effect of multiple central nervous system depressants 10 Released prisoners from correctional facilities 11 Released participants from opioid detoxification or mandatory abstinence program 12 Participants entering methadone maintenance treatment programs for addiction or pain long-acting opioids Increased risk of respiratory depression due to co-morbidities Prolonged and/or increased serum concentrations of opioid due to decreased metabolism and/or excretion Additive effect of multiple central nervous system depressants Additive effect of multiple central nervous system depressants Increased toxicological risk for opioid poisoning; higher risk for substance use and self-harm Relapse to or initiation of nonmedical opioid use; reduced opioid tolerance; risk for multiple substance use Relapse to nonmedical opioid use; reduced opioid tolerance; risk for multiple substance use Increased risk for poisoning in first month; risk for multiple substance use 13 Participant may have difficulty accessing Emergency medical services may have 10

11 emergency medical services difficulty reaching residents of remote areas quickly 14 Voluntary request Perceived risk for opioid exposure 11

12 APPENDIX 3 TAKE HOME NALOXONE: SUGGESTED DISPENSING RECORD FOR NURSES This form should only be used by nurses dispensing naloxone kits without a physician s order as allowed by the Decision Support Tool for Nurses. Dispensing Date: Name of THN Site: Last Name: Date of Birth: Street Address: Gender: Known Allergies: YYYY / MM / DD PATIENT DETAILS First Name: PHN: City & Postal Code: Phone Number: MEDICATION DETAILS Kit Number: Expiration Date: YYYY / MM / DD Type of kit dispensed: 1 st Kit Replacement for Kit # Reason for replacement: Used Expired Lost Stolen Confiscated Medication Dispensed Indication Repeats Full Name: Title: Signature: Naloxone 0.4mg (=1mL) IM q 5 minutes prn x 2 doses For reversal of opioid overdose No repeats DISPENSER DETAILS MSP # (if applicable): WHEN COMPLETE, FAX THIS FORM TO THE BC HARM REDUCTION PROGRAM AT