What is the proper use of Narcan (naloxone) in an opioid overdose?

Proper Use of Naloxone (Narcan) in Opioid Overdose

For suspected opioid overdose, immediately activate the emergency response system, provide rescue breathing or CPR as needed, and administer naloxone while not delaying standard resuscitation measures. 1

Initial Assessment and Response

1. Recognition of opioid overdose:

   • Unresponsiveness
   • Respiratory depression or arrest (slow, shallow, or absent breathing)
   • Pinpoint pupils (miosis)
   • Cyanosis
   • Evidence of opioid use nearby

2. Immediate actions (in order):

   • Activate emergency response system (call 911) 1
   • Assess breathing and pulse 1
   • If no normal breathing but has pulse: Begin rescue breathing 1
   • If no pulse: Begin high-quality CPR with compressions plus ventilation 1
   • Administer naloxone while continuing resuscitation efforts 1

Naloxone Administration

Routes of Administration

• Intranasal (IN): Preferred for lay responders and first aid providers

  • Spray directly into one nostril (2-4 mg) 2
  • No assembly required with FDA-approved devices

• Intramuscular (IM): Alternative when IN not available

  • Inject into large muscle (thigh or upper arm)
  • Standard dose: 0.4-2 mg 3

• Intravenous (IV): Fastest onset, typically used by healthcare providers

  • Initial dose: 0.4-2 mg 3
  • May be titrated in smaller increments (0.1-0.2 mg) for postoperative opioid depression 3

Dosing Considerations

• Initial dose:

  • For suspected overdose: 2-4 mg IN or 0.4-2 mg IM/IV 1, 3
  • For respiratory depression with known pulse: Same as above

• Repeat dosing:

  • If inadequate response, repeat dose every 2-3 minutes 1, 4
  • Multiple doses are often necessary, especially with potent synthetic opioids like fentanyl 5
  • 78% of community reversals required ≥2 doses of naloxone 5

Post-Administration Care

1. Monitor response:

   • Most patients respond within 5 minutes (73.5% of cases) 2
   • Continue rescue breathing/CPR until spontaneous breathing returns 1
   • Be prepared for possible opioid withdrawal symptoms

2. Observation period:

   • All patients must be observed in a healthcare setting after naloxone administration 1
   • Duration of naloxone (30-45 minutes) is shorter than many opioids 1, 4
   • Recurrent respiratory depression may occur as naloxone wears off 1

3. Potential for withdrawal:

   • Common symptoms include agitation, nausea, vomiting, sweating, and tachycardia 1
   • Use lowest effective dose to minimize withdrawal severity 1
   • Withdrawal symptoms are rarely life-threatening 1

Special Considerations

• Potent synthetic opioids (e.g., fentanyl):

  • May require higher total doses or multiple administrations 4, 5
  • 95.4% of community reversals involved heroin; 5.2% involved fentanyl 2

• Polysubstance overdose:

  • Naloxone only reverses opioid effects, not other substances 4
  • Continue supportive care regardless of naloxone response

• Lay responder training:

  • Training in opioid overdose recognition and naloxone administration is beneficial 1
  • Hands-on training is more effective than video-only instruction 1

Common Pitfalls to Avoid

1. Delaying CPR while searching for naloxone - Always prioritize standard resuscitation measures 1
2. Premature discharge - Observation is required due to naloxone's shorter duration of action 1
3. Focusing on consciousness rather than adequate ventilation - The primary goal is to restore breathing 1
4. Inadequate dosing - Modern synthetic opioids may require multiple doses 4, 5
5. Not activating emergency services - All overdose patients need medical evaluation 1

Effectiveness and Safety

• Successful reversal reported in 98.8% of community-administered cases 2
• Intranasal administration is effective and avoids needlestick risks 6, 7, 8
• Naloxone has an excellent safety profile even if administered to someone without opioid intoxication 1