What is the proper procedure for writing a Naloxone (Narcan) order?

From the Guidelines

To write a Narcan (naloxone) order, specify the medication name, dose, route, frequency, and indication, with a standard order being: "Naloxone 0.4 mg IV push for respiratory depression (rate less than 8 breaths per minute) or suspected opioid overdose, which is based on the most recent guidelines from 2015 1. The dose and route of administration should be tailored to the individual patient, taking into account their level of consciousness, respiratory rate, and potential for opioid dependence. For patients with known or suspected opioid dependence, consider starting with a lower dose of 0.1-0.2 mg to reduce the risk of precipitating severe withdrawal, as recommended in the 2010 guidelines 1. For intranasal administration, order "Naloxone 4 mg intranasal spray, one spray in one nostril, which is a common dose used in studies 1. May repeat in alternate nostril after 2-3 minutes if no response, as the ideal dose of naloxone is not known and may vary depending on the clinical scenario 1. Include parameters for monitoring (respiratory rate, oxygen saturation, level of consciousness) and instructions for post-administration care, as the duration of action of naloxone (30-90 minutes) may be shorter than many opioids, so patients require continued monitoring for recurrence of respiratory depression after initial improvement 1. Naloxone works by competitively binding to opioid receptors, displacing opioids and rapidly reversing respiratory depression, with an excellent safety profile and minimal risk of harm when administered to patients who are not opioid-intoxicated or dependent 1.

Some key points to consider when writing a Narcan order include:

• The patient's medical history and current condition, including any potential allergies or sensitivities to naloxone
• The potential for opioid dependence and the risk of precipitating severe withdrawal
• The need for continued monitoring and potential repeat dosing, as the duration of action of naloxone may be shorter than many opioids
• The importance of providing clear instructions for post-administration care and monitoring, as recommended in the 2015 guidelines 1.

Overall, the goal of writing a Narcan order is to provide a clear and effective treatment plan for patients with suspected opioid overdose, while minimizing the risk of harm and ensuring the best possible outcomes, as supported by the most recent and highest quality evidence 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Naloxone Hydrochloride Injection, USP may be administered intravenously, intramuscularly, or subcutaneously. Opioid Overdose - Known or Suspected: An initial dose of 0. 4 mg to 2 mg of naloxone hydrochloride may be administered intravenously. If the desired degree of counteraction and improvement in respiratory functions are not obtained, it may be repeated at two- to three-minute intervals If no response is observed after 10 mg of naloxone hydrochloride have been administered, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned.

To write a Narcan order, the following should be considered:

• Initial dose: 0.4 mg to 2 mg of naloxone hydrochloride administered intravenously for known or suspected opioid overdose in adults.
• Repeat doses: may be administered at two- to three-minute intervals if the desired degree of counteraction and improvement in respiratory functions are not obtained.
• Maximum dose: if no response is observed after 10 mg of naloxone hydrochloride have been administered, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned. 2

From the Research

Naloxone Administration

To write a Narcan order, it is essential to consider the optimal initial dose and route of naloxone administration for successful opioid reversal.

• The optimal initial dose of naloxone is unclear, with variations in recommended doses spanning an order of magnitude 3.
• A systematic literature review found that 2 mg intranasal (IN) is the most popular dosing for initial naloxone for successful opioid reversal 4.
• The most common route of naloxone administration for successful reversal could not be determined, but most studies revealed successful initial naloxone dosing in IN equivalents 4.

Dosing Considerations

When writing a Narcan order, healthcare professionals should be aware of the potential risks and benefits of different dosing strategies.

• Higher doses of naloxone may precipitate opioid withdrawal, posing acute risks to the patient and medical personnel 3.
• Lower doses of naloxone may be ineffective for adequate opioid overdose reversal 4.
• The American College of Medical Toxicology and the American Academy of Clinical Toxicology recommend that nalmefene should not replace naloxone as the primary opioid antidote at this time due to the potential for more prolonged and severe opioid withdrawal 5.

Alternative Antidotes

Nalmefene is a potent opioid antagonist that has recently been reintroduced in the United States to treat known or suspected opioid overdose.

• Comparative effectiveness data regarding naloxone and nalmefene are sparse, and it is unclear if the inherent properties of nalmefene are beneficial in opioid overdose 5.
• A translational model study found that intranasal nalmefene produced a substantially greater reduction in the incidence of cardiac arrest compared to intranasal naloxone following a synthetic opioid overdose 6.
• However, existing data highlight the effectiveness of already available naloxone products as a safe and effective standard of care, and stronger, longer-acting agents may be unnecessary and potentially harmful 7.