How to write an order for intramuscular (IM) administration of Naloxone (Narcan)?

From the Guidelines

To write an intramuscular naloxone (Narcan) order, specify "Naloxone (Narcan) 0.4 mg IM once, may repeat every 2-3 minutes as needed for respiratory depression or suspected opioid overdose, up to a maximum of 2 mg". This recommendation is based on the 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1.

Key Considerations

• The initial dose of 0.4 mg IM is recommended to avoid provoking severe opioid withdrawal in patients with opioid dependency, as stated in the guidelines 1.
• The dose may be repeated every 2-3 minutes as needed, with a maximum dose of 2 mg, to effectively reverse CNS and respiratory depression without provoking severe opioid withdrawal 1.
• It is essential to monitor the patient for re-sedation, as the duration of action of naloxone is 30-90 minutes, which may be shorter than the opioid effect 1.
• Airway management equipment should be available, as precipitated withdrawal can cause vomiting and other complications 1.

Administration Parameters

• Route: Intramuscular (IM)
• Site preference: Deltoid or vastus lateralis
• Parameters for administration: Respiratory depression or suspected opioid overdose
• Parameters for notification: Continued respiratory depression after administration of naloxone The guidelines emphasize the importance of naloxone administration in opioid-associated resuscitative emergencies, highlighting its excellent safety profile and ability to rapidly reverse CNS and respiratory depression 1.

From the FDA Drug Label

Intramuscular or subcutaneous administration may be necessary if the intravenous route is not available. To write an intramuscular Narcan order, the dose is not explicitly stated for intramuscular administration in the provided text.

• The initial dose for intravenous administration is 0.4 mg to 2 mg of naloxone hydrochloride.
• Intramuscular administration is mentioned as an alternative route, but the dose is not specified.
• It is mentioned that supplemental intramuscular doses have been shown to produce a longer lasting effect, but the dose is not provided. Since the FDA label does not explicitly state the dose for intramuscular administration, no conclusion can be drawn about the specific dose to use for an intramuscular Narcan order 2.

From the Research

Intramuscular Narcan Order

To write an intramuscular Narcan order, consider the following points:

• The typical dose of intramuscular naloxone is 0.4 or 0.8 mg, as seen in a study by 3
• The choice of dose may depend on the patient's clinical presentation, with unconscious patients or those in respiratory arrest more likely to receive 0.8 mg naloxone 3
• Multiple doses may be necessary, with 15% of patients receiving multiple doses in the study by 3

Administration Route

• Intramuscular administration is a common route for naloxone, with 91.9% of patients in the study by 3 receiving intramuscular naloxone
• Other routes of administration, such as intravenous, may also be used, but the study by 4 suggests that intravenous administration should be titrated slowly to avoid precipitating withdrawal symptoms

Dosing Considerations

• The dose of naloxone may need to be titrated based on the patient's response, with the study by 4 suggesting that doses of 20-100 µg be administered every two minutes as needed
• The study by 5 found that intramuscular naloxone doses of 0.26 mg were effective in inducing opioid withdrawal, but the optimal dose for reversal of opioid overdose may be higher

Safety Considerations

• Naloxone is generally considered safe, but the study by 6 found that there was no disproportionate reporting of adverse cardiovascular events associated with naloxone
• The study by 7 found that opioid overdose prevention training with naloxone was effective in increasing knowledge and preparedness to respond to opioid overdoses, but additional training may be needed to improve attitudes towards patients with substance use disorders