Naloxone for Opioid Overdose (FAQs)

Transcription

1 This Clinical Resource gives subscribers additional insight related to the Recommendations published in June 2018 ~ Resource # Naloxone for Opioid Overdose (FAQs) The number of overdose deaths in the U.S. from prescription and illicit opioids doubled from 2010 to in 2016, with over 42,000 deaths in In Canada, there were almost 3,000 opioid-related deaths in 2016 and at least 2,923 between January and September of More than 90% of these deaths were accidental. 29 These increases in overdose and death are partly linked to illegally made potent synthetic opioids (e.g., fentanyl). 19,28 These synthetic opioids are being mixed with heroin (sold as super-potent heroin), made into counterfeit prescription tablets (e.g., opioids, benzodiazepines), or are mixed with other illicit drugs (e.g., cocaine, methamphetamine). 1,28 Another contributing factor to opioid overdose deaths is an increase of higher doses of prescription opioids for long-term management of chronic pain. 28 Health Canada has removed naloxone from the Prescription Drug List to allow it to be sold without requiring a prescription in response to the growing number of opioid overdoses. 17 The FDA has approved two naloxone products for use by lay persons to treat someone known or suspected to have overdosed on opioids: Evzio, an auto-injector, and Narcan nasal spray. 2,3 In Canada, S.O.S. Naloxone Hydrochloride Injection and the Narcan nasal spray are labeled for administration by laypersons. 16,25 Even though these products are new, administration of naloxone by laypersons is not new; it has been used across the U.S. and Canada through takehome naloxone kit programs and administration by first-responders with reported success. 14,15,17,21 The chart below provides information on naloxone for opioid overdose. See our Naloxone Quick Start Guide for a simplified resource about identifying patients for naloxone and getting them started. Injectable naloxone for naloxone kits Continued Naloxone kits (U.S.): Naloxone for intramuscular injection is available from single-dose or multidose naloxone vials. For intramuscular use, it is recommended to give naloxone 0.4 mg (1 ml). 4 Each kit should contain: 24,44 o One multidose vial or two single-use vials. o One 3 ml syringe with an appropriate sized needle (22 to 25 gauge, 1 to 1.5 inches). Naloxone for intranasal administration using the injectable solution; each kit should contain: 24,45 o Two mucosal atomization devices (e.g., MAD 300). Examples of sources for ordering include: Common Cents EMS Supplies: or Teleflex Medical: o Two naloxone 2 mg/2 ml Luer-Lock prefilled syringes made by IMS/Amphastar (NDC# ) Some atomizers contain needles allowing naloxone to be drawn up from vials instead of attaching to syringes. Information on preparing naloxone rescue kits is available at: o Harm Reduction Coalition: o Prescribe to Prevent:

2 (Clinical Resource #340601: Page 2 of 13) Naloxone kits, continued With permission from the Prescribe To Prevent group, prescription forms with tear-off patient instructions are being made available to subscribers of Pharmacist s Letter/Prescriber s Letter: Naloxone for Overdose Prevention (Intramuscular) and Naloxone for Overdose Prevention (Intranasal). S.O.S Naloxone (Canada): Available as 0.4 mg/ml in 1 ml single-dose ampoules or vials, and as 1 mg/ml in 2 ml multidose vials. 16 The College of Pharmacists of British Columbia recommend dispensing at least two doses of 0.4 mg/ml naloxone plus at least two 3 ml safety syringes (e.g., Vanish Point, BD Integras) with 25 gauge, 1-inch needles. 20 Other supplies that might be helpful include a one-way barrier breathing mask for giving rescue breaths and an ampoule breaker. 20 o Gloves and alcohol swabs could be included but are not necessary, as the injection can be given through clothing. 16,32 Kits are also available from community-based programs (often called take-home naloxone programs in Canada). o In Canada, these programs provide kits and naloxone training. 21 o Kits typically consist of two 1 ml single-dose ampoules, needles, syringes, alcohol swabs, one-way barrier mask, instructions, and case. 21 For available programs see: o (U.S.) o (Canada). Naloxone auto-injector (Evzio [U.S. only]) Evzio (U.S.): can be given intramuscularly or subcutaneously. The 2 mg strength is currently manufactured. 2 Was previously available in two different strengths: 0.4 mg and 2 mg. o The 0.4 mg is no longer being manufactured, but available product can be used until its expiration date. 49 Each carton contains two active naloxone auto-injectors and one trainer. 2 o Active Evzio auto-injector is in a blue and purple outer case (2 mg) or purple and yellow outer case (0.4 mg). 2 o The trainer is in a black and white outer case. 2 The trainer is exactly like Evzio, except that it does not contain a needle or naloxone, and has no expiration date. 23 Unlike Evzio, the red safety guard on the trainer can be removed and replaced. 23 Each trainer can be used over 1,000 times. 23

3 (Clinical Resource #340601: Page 3 of 13) Naloxone nasal spray (Narcan nasal spray) When should naloxone be administered? How should an intranasal naloxone kit (using injectable naloxone) be administered? Narcan nasal spray is available in two different strengths (2 mg strength is approved, but not marketed). The 4 mg nasal spray carton contains TWO blister-packed, single-use nasal sprays, each containing 4 mg of naloxone. 3,25 The 2 mg nasal spray carton contains FOUR blister-packed (two in Canada), single-use nasal sprays, each containing 2 mg of naloxone. 3,25 o In the U.S., restrict the use of the 2 mg product to opioid-dependent patients at risk for severe opioid withdrawal and at LOW RISK for accidental or intentional opioid overdose. 3 Be careful of mix-ups between the new Narcan nasal spray and an older, no longer available Narcan brand injection. For some, Narcan has become synonymous with injectable naloxone. An indication to use naloxone is respiratory and/or central nervous system depression in a situation where opioids may be present. 2,16,25 o Naloxone should be given if a patient is excessively sleepy and cannot be aroused with a loud voice or sternal rub. 2,3,25 o Other indications include slow, shallow, or no respirations, or pinpoint pupils in a patient who is difficult to arouse. 2,3,25 o Other signs of overdose include blue or purple fingernails or lips, death rattle, slow heartbeat, or low blood pressure. 6,25 Follow these steps to administer naloxone injectable solution intranasally: 5,30 (There are three parts: the atomizer device, a plastic tube, and the naloxone vial.) Remove the two yellow caps from the plastic tube AND remove the red cap from the naloxone. Hold the atomizer device by its plastic wings and attach it to the plastic tube by twisting it into place. Screw the naloxone into the barrel of the tube. Place atomizer into one of the patient s nostrils. Deliver first-half of the naloxone dose (1 ml [1 mg]) by giving a short, vigorous push on the naloxone vial Move the atomizer into the patient s other nostril. Deliver the second-half of the naloxone dose (1 ml [1 mg]) by giving a short, vigorous push on the naloxone vial. How should an injectable naloxone kit be administered? Continued Follow these steps to administer naloxone intramuscularly: 16,30 Remove the cap from the naloxone vial or break the naloxone ampule neck. Uncover the needle. If using a naloxone ampule: o Insert the needle into the liquid within the ampule. o Pull back the plunger to draw 1 ml (0.4 mg) into the syringe.

4 (Clinical Resource #340601: Page 4 of 13) Intramuscular administration, continued If using a naloxone vial: o Hold the vial upside down and insert the needle through the rubber plug. o Pull back the plunger to draw 1 ml (0.4 mg) into the syringe. Inject the naloxone into the muscle of the shoulder, thigh, or upper outer buttocks at a 90 angle. o Feel comfortable giving the injection through clothing. 16 Repeat doses can be given every two to three minutes if there is no change in patient s status. Naloxone needles used for intramuscular injection should be disposed of in a sharps container. 7 o Emergency medical personnel might do this. 16 How should Narcan nasal spray be administered? How should Evzio (U.S. only) be administered? Continued Keep the spray in the original packaging until use. 3,25 The person to receive the spray should be lying on their back. 3,25 Remove the spray from its packaging and hold it with the thumb on the bottom of the plunger and the first and middle fingers on either side of the nozzle. 3,25 The patient s head should be tilted back gently and the tip of the nozzle inserted into one nostril until the fingers holding the nozzle are on either side of the person s nose. 3,25 o In young children, if the nozzle does not fit completely in the nostril, make sure the nozzle seals the nostril before administration. 25 The plunger is then pressed firmly, spraying the naloxone into the nostril. 3,25 The nozzle is then removed from the nostril. 3,25 Each carton contains a trainer. 2 o Patients and anyone who may need to help the patient in the event of an overdose should practice with the trainer. 2 o Product labeling recommends that the patient and caregivers practice daily for the first week, then weekly. 2 Evzio has a speaker that provides voice instructions. Even if the voice instructions don t work, Evzio will still work. Users should follow the written instructions on the label. 2 To use Evzio: 2 o o o o Remove Evzio from its case. Remove the red safety guard and place the black end of the injector against the outer thigh. Evzio can be injected through clothing. The red safety guard CANNOT be replaced. To administer the dose, press the injector firmly and hold for five seconds. For infants less than 1 year old, give the injection into a pinched-up area of the middle of the outer thigh muscle. The injector makes a click and hiss noise during injection.

5 (Clinical Resource #340601: Page 5 of 13) Evzio administration, continued What is the maximum recommended naloxone dose? What happens after a dose of naloxone is administered? Once the injector has been used, the needle will retract into the base, the base will lock, the voice instruction will state that the injector has been used, a red light will blink, and a red indicator will show in the viewing window. 2 o The used injector should be placed in its case and disposed of in a sharps container, following any state or local laws about disposal of auto-injectors or perchlorate-containing batteries (California). 2 There is not a well-established maximum naloxone dose. 41 Product labeling indicates initial doses of 0.4 mg to 4 mg (dose based on route of administration), with repeat doses as necessary. 41 Typically patients will respond to the first dose. 41 o Second doses are often supplied as a backup. 41 o Additional doses may be needed, especially when emergency help is delayed and initial naloxone doses wear off. 41 Healthy volunteers have received 24 mg without experiencing toxicity. 41 The duration of most opioids is longer than that of naloxone (30 to 90 minutes). 6,30 o Emergency medical help should be requested (call 911) immediately, even if the patient wakes up. 6 If symptoms return or if the patient doesn t respond or achieve the desired response (i.e., adequate spontaneous breathing), and emergency medical help has not yet arrived, repeat doses of naloxone can be given every two to three minutes. 2,3,16,25 o When giving additional doses of Narcan nasal spray, alternating nostrils should be used. 3,25 Rescue breathing may be required, and ideally, patients experiencing opioid overdose should be given oxygen. 6 Patients who have overdosed on partial agonists and mixed agonist-antagonists (e.g., buprenorphine) may not respond well to naloxone. 2 Naloxone use may precipitate withdrawal in opioid-dependent patients. (See details below in section What should you tell patients, caregivers, and families about naloxone?) If naloxone is given to a patient who is not opioid-dependent or is not opioid-intoxicated, it has no clinical effects. 6 How should naloxone be stored? Continued Naloxone should be stored at room temperature and protected from light. 8 Narcan nasal spray and Evzio (U.S.) should be stored in the original packaging and provided case, respectively, between 59 F and 77 F (15 and 25 C), although excursions are allowed as follows: 2,3,25 o Evzio: Excursions down to 39 F (4 C) and up to 104 F (40 C) are allowed. o Narcan nasal spray: Excursions up to 104 F (40 C) are allowed. It is a good idea for patients to carry naloxone products with them, and to tell family, friends, co-workers, and others who may need to administer naloxone where it is kept. 2,3

6 (Clinical Resource #340601: Page 6 of 13) Storage, continued While counseling patients about naloxone storage consider reminding them to keep their prescription opioid secure; divulging opioid use to others might invite theft. Patients should periodically check the appearance of their naloxone. 2 o Visually inspect naloxone vials or pre-filled syringes. There is a window in the Evzio (U.S.) auto-injector. 2 o If the solution is discolored, cloudy, or contains particulates it should be replaced. 2 Naloxone products (and syringes, if applicable) should be replaced before the expiration date. 8 o If stored properly, naloxone products should be effective at least until the manufacturer s expiration date. Typically, the shelf-life is 12 to 18 months. 8 o It has been suggested that pharmacists dispense naloxone with at least a six-month shelf-life at time of sale, and ideally longer than one year. 20 Who should naloxone be considered for? Consider naloxone for people: o With a history of opioid intoxication or overdose. 9,26 o With a suspected history of substance abuse or nonmedical opioid use. 9,26 o Taking methadone or buprenorphine for opioid use disorder. 9,22,26 o Taking high opioid doses (e.g., 50 mg or more of oral morphine or its equivalent) daily. 18,26 Tools to calculate daily morphine equivalents can be found at: (app also includes helpful opioid prescribing info) o Being rotated from one opioid to another (due to risk of incomplete cross-tolerance). 9 o Taking an opioid who: 9,26 Smoke or have a respiratory illness (e.g., COPD, sleep apnea, asthma). Have renal, hepatic, or heart disease, or human immunodeficiency virus (HIV). Use alcohol or a benzodiazepine, sedative, or antidepressant. o Who live in a remote location (consider providing more than one kit or dose due to potential for delays with emergency response personnel in remote areas). 9 o Who request it. 9 o Who may be in a position to help some at risk of an opioid overdose. 26

7 (Clinical Resource #340601: Page 7 of 13) Can naloxone be provided to a third party? Is naloxone available without a prescription? Providing naloxone to a third-party (e.g., to a caregiver or family member) as opposed to a patient may be permitted. o In the U.S., to find out about providing naloxone to a third-party, consult either of the following: Your state medical board. Patient-specific insurance programs, including Medicaid and Medicare. o In Canada, naloxone falls in the schedule II category. This means it is available for purchase by anyone, but it must be dispensed or sold at a pharmacy under the supervision of a pharmacist. 27 U.S.: Naloxone is available without a prescription. 33,50 o A chart comparing the naloxone formulations available in the U.S. is available at o To understand specific laws about naloxone in your state (e.g., protocol, standing order): Consult your state pharmacy board. Go to the National Alliance of State Pharmacy Associations: Go to Canada: Naloxone is available without a prescription. 31 o To find where to get naloxone in your province or territory go to o Naloxone resources from the College of Pharmacists of British Columbia are available at How much does naloxone cost in the U.S.? Continued Evzio (includes two auto-injectors and a trainer) o Evzio 2 mg/0.4 ml: a $4,100 For specific information regarding their individual coverage, patients should contact their insurance provider directly by calling the number on the back of their insurance card. Prior authorization may be necessary. o Patients with private insurance may be eligible to have Evzio mailed directly to their home without a copay. o Information on the Evzio patient assistance programs is available at Narcan nasal spray 4 mg (includes two nasal sprays): a $125 (at time of publication pricing not available for 2 mg) o For qualified public interest groups (e.g., first responders, community naloxone programs, etc) the cost is $37.50 per device through Adapt Pharma distributors. 36 o Adapt Pharma also provides two free cartons (four doses) to high schools and four free cartons (eight doses) to eligible colleges and universities. 36

8 (Clinical Resource #340601: Page 8 of 13) Naloxone costs in the U.S., continued How much does naloxone cost in Canada? Naloxone kits (U.S.): 34,35,43 o Naloxone kit (for nasal administration): ~$80 o Naloxone kit (for IM administration): ~$30 o Check with your local health department, as some may offer naloxone at no charge o Some insurance plans, including Medicaid and Medicare in some states, will cover the kits or some components. 10 Naloxone is not on most provincial or territorial public drug plans. 39 Naloxone (medication only) may be covered by extended healthcare plans. If cost is an issue, consider referring patients to a community-based program, which might provide a kit for free. o See Injectable naloxone for naloxone kits section above for contact information. Narcan nasal spray: a $157 o Available free of charge through the Ontario Naloxone Program for Pharmacies (ONPP). 37 o Available as an open benefit through the Non-Insured Health Benefits (NIHB) Program. 37 S.O.S. Naloxone (Canada): a Naloxone 0.4 mg/ml vials or ampoule (~$14 to $15.33/0.4 mg dose) BD Integras syringe: $0.55/syringe In Ontario, the Ontario Public Drug Program provides a fee to pharmacies to cover the cost of the naloxone kit, dispensing and training. Recipients of the naloxone kit are not charged. 39 How do I bill for naloxone-related counseling (U.S.)? Continued Prescribers (U.S.) Use the codes for Screening, Brief Intervention, and Referral to Treatment (SBIRT) to bill for counseling a patient about how to recognize overdose and how to administer naloxone. 6 o Use these billing codes for SBIRT: 32 CPT (commercial insurance, 15 to 30 minutes) CPT (commercial insurance, longer than 30 minutes) G0396 (Medicare, 15 to 30 minutes) G0397 (Medicare, longer than 30 minutes) H0050 (Medicaid, per 15 minutes) o For counseling and instruction on the safe use of opioids, including the use of naloxone, outside of the context of SBIRT services, the prescriber should document the time spent and use the E&M code that accurately captures the time and complexity. For example, in new patients deemed appropriate for opioid pharmacotherapy, when a substantial and appropriate amount of additional time is used to provide a separate service such as behavioral

9 (Clinical Resource #340601: Page 9 of 13) U.S. billing, continued Does naloxone availability encourage opioid misuse? Are there liability issues related to naloxone? How is naloxone used in hospitals and emergency departments? counseling (e.g. opioid overdose risk assessment and naloxone administration training), consider using modifier 25 in addition to the E&M code. 6 Complete the DAST-10 drug abuse questionnaire (available at 10_Institute.pdf) and refer to a substance abuse treatment program if applicable. 11 For pain patients consider using one of these tools: 11 o Current Opioid Misuse Measure (COMM; for patients already on opioids). o Screener and Opioid Assessment for Patients with Pain (SOAPP; for patients new to opioids). o These tools are available at When using an evidence-based opioid misuse/abuse screening tool, CPT Code (administration and interpretation of health risk assessment instrument) can be used for patients with commercial insurance. 32 Surveys of heroin users in the late 1990s suggest they do NOT use more heroin if naloxone is available. o This may be because they do not want to experience withdrawal precipitated by naloxone. 12 In one naloxone program for heroin users, the frequency of heroin injection (p=0.003) and number of overdoses (p=0.83) actually decreased. 13 In communities where naloxone distribution programs exist, opioid overdose deaths decrease. 14,15 Monitor patients for opioid dose escalation and discuss the risks with patients. 12 The medico-legal risks of prescribing and dispensing naloxone to opioid users are low. 11,12,40 In the U.S., laws are being drafted and passed to protect prescribers, dispensers, and bystanders who administer naloxone. o See for information by state. Good Samaritan Laws may require reasonable care (e.g., calling 911, rescue breathing). In Canada, the Good Samaritan Drug Overdose Act became law in May of o Witnesses are protected and encouraged to carry and provide naloxone during suspected opioid overdoses. 38 Given the high prevalence of substance abuse, prescribers working in an emergency department have an opportunity to prevent opioid overdose deaths. IM and subcutaneous naloxone are the most likely methods of administration in hospitals and emergency departments. o Subcutaneous and IM doses have a similar onset of action and are less expensive than intranasal naloxone. 41 o The onset of action for subcutaneous and IM naloxone is likely quicker than obtaining intravenous access. 41 Follow your facility policies for proving naloxone at discharge. Options may include: o Providing naloxone or naloxone kits directly to patients, families, or caregivers. o Give a written order for patients, families, or caregivers to obtain naloxone (e.g. pharmacy, health department).

10 (Clinical Resource #340601: Page 10 of 13) What should you tell patients, caregivers, and families about naloxone? Help patients, caregivers, and families be prepared. o Provide resources for them to get trained to administer naloxone. U.S.: Canada: Training will cover the essential steps to take if an opioid overdose is suspected: 42 o Call for help (dial 911). o Check for signs of an opioid overdose (e.g., pinpoint pupils, slowed breathing, or loss of consciousness). o Address breathing. o Give naloxone and monitor response. Encourage patients, caregivers, and families to get naloxone. o Encourage patients, caregivers and families to talk with prescribers or pharmacist about getting naloxone. o Patient instruction sheets from the College of Pharmacists of British Columbia are available at o Patient instructions are included with Evzio, Narcan nasal spray, and S.O.S. Naloxone. 2,3,16,25 o With permission from the Prescribe To Prevent group, prescription forms with tear-off patient instructions are being made available to subscribers of Pharmacist s Letter/Prescriber s Letter: Naloxone for Overdose Prevention (Intramuscular) and Naloxone for Overdose Prevention (Intranasal). Reinforce that naloxone can save a life. o Naloxone is easy to use, has a low risk of adverse effects, and is not harmful if the person didn t really need it. o Naloxone is like a seatbelt: most people don t need it, but it s there just in case they need it. Warn family and caregivers to expect opioid withdrawal symptoms. o Common opioid withdrawal symptoms include sweating, goose bumps, achiness, shivering, gastrointestinal symptoms, tachycardia, irritability, and increased blood pressure. 2 o Other signs and symptoms of opioid withdrawal may include fever, runny nose, sneezing, and yawning. 6 o Patients may become agitated, combative, or vomit after naloxone is given. 6 To prevent aspiration, the patient should be positioned on their side after naloxone is given. 6 o This recovery position is illustrated in the Narcan nasal spray and S.O.S Naloxone patient labeling, and in the patient instruction sheets available at Most patients respond to naloxone and return to spontaneous breathing with only mild withdrawal symptoms. 6 o Opioid withdrawal is not typically life-threatening in adults. 6 a. Costs for are based on wholesale acquisition cost (WAC). U.S. medication pricing by Elsevier, accessed May 2018.

11 (Clinical Resource #340601: Page 11 of 13) Users of this resource are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication. Project Leader in preparation of this clinical resource (340601): Beth Bryant, Pharm.D., BCPS, Assistant Editor References 1. Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med 2015;372: Product information for Evzio. Kaleo. Richmond, VA October Product information Narcan nasal spray. Adapt Pharma. Radnor, PA February Prescribe to Prevent. Naloxone for overdose (intramuscular) Prescribe to Prevent. Naloxone for overdose prevention (intranasal). content/uploads/2012/11/naloxone-one-pager-in-nov pdf. 6. Substance Abuse and Mental Health Services Administration. SAMHSA opioid overdose prevention toolkit. HHS publication no (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, (Accessed May 1, 2018). 7. FDA. Best way to get rid of used needles and other sharps. Last updated January 24, calprocedures/homehealthandconsumer/consumer Products/Sharps/ucm htm. (Accessed May 1, 2018). 8. College of Psychiatric & Neurologic Pharmacists. Naloxone access: a practical guideline for pharmacists. Updated February (Accessed May 1, 2018). 9. Prescribe to Prevent. Instruction for healthcare professionals: prescribing naloxone Prescribe to Prevent. Pharmacy basics. Billing. Updated February Prescribe to Prevent. FAQ. (Accessed May 1, 2018). 12. Burris S, Norland J, Edlin B. Legal aspects of providing naloxone to heroin users in the United States. Temple Law School Working Papers. ibing.pdf. (Accessed December May 1, 2018). 13. Seal KH, Thawley R, Gee L, et al. Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study. J Urban Health 2005;82: CDC. Community-based opioid overdose prevention programs providing naloxone-united States, MMWR Morb Mortal Wkly Rep 2012;61: Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 2013;346:f Product monograph for S.O.S. Naloxone Hydrochloride Injection. Sandoz Canada, Inc. Boucherville, QC JB 7K8. April College of Pharmacists of British Columbia. Naloxone now available in BC without a prescription. (Accessed May 1, 2018). 18. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-united States, MMWR Recomm Rep 2016;65: Canadian Centre on Substance Abuse. Deaths involving fentanyl in Canada, CCENDU Bulletin. August CCENDU-Fentanyl-Deaths-Canada-Bulletin en.pdf. 20. College of Pharmacists of British Columbia. Community pharmacy distribution of naloxone. Naloxone_Training.pdf. 21. Canadian Centre on Substance Abuse. The availability of take-home naloxone in Canada. CCENDU Bulletin. March CCENDU-Take-Home-Naloxone-Canada en.pdf. 22. Prescribe to prevent. Substance use disorder treatment Trainer for Evzio. Instructions for use. Updated October Trainer-Information.pdf. 24. Harm Reduction Coalition. Naloxone kit materials.

12 (Clinical Resource #340601: Page 12 of 13) prevention/tools-best-practices/od-kit-materials/. 25. Product monograph for Narcan nasal spray. Adapt Pharma Canada. Hamilton ON, L8N 2Z7. March American Medical Association. AMA opioid task force. Help save lives: co-prescribe naloxone to patients at risk of overdose. August FINAL.pdf. 27. Canadian Agency for Drugs and Technologies in Health. Funding and management of naloxone programs in Canada. March (Accessed May 1, 2018). 28. U.S. Department of Health & Human Services. Surgeon General s advisory on naloxone and opioid overdose Government of Canada. Apparent opioid-related deaths. Updated March 27, Harm Reduction Coalition. Administer naloxone: overdose response. (Accessed May 2, 2018). 31. Government of Canada. Naloxone. Updated March 31, (Accessed May 2, 2018). 32. Substance Abuse and Mental Health Services Administration. Reimbursement for SBIRT. ent_for_sbirt.pdf. (Accessed May 2, 2018). 33. Prescription drug abuse policy system. Naloxone overdose prevention laws. Updated July 1, (Accessed May 9, 2018). 34. Naloxone (Narcan) fact sheet (IL PA ). (Accessed May 2, 2018). 35. Common Sense EMS Supply. aloxone. (Accessed May 2, 2018). 36. Adapt Pharma. Adapt Pharma expands program offering free Narcan (naloxone HCl) nasal spray to eligible schools and universities. March 19, adapt-pharma-expands-program-offeringfree-narcan/. (Accessed May 2, 2018). 37. Adapt Pharma. Adapt Pharma welcomes Canadian & Ontario government programs providing Narcan (naloxone HCl) nasal spray free of charge to NHIB clients and all Ontarians through pharmacies. April 9, (Accessed May 2, 2018). 38. Government of Canada. About the good samaritan drug overdose act. March 6, (Accessed May 2, 2018). 39. Canadian Agency for Drugs and Technologies in Health. Funding and management of naloxone programs in Canada. March (Accessed May 2, 2018). 40. Davis C, Carr D. State legal innovations to encourage naloxone dispensing. J Am Pharm Assoc (2003) 2017;57:S Pammett R. Naloxone for opioid overdose virtual Q&A. Canadian Pharmacy Association: pharmacy practice webinar. (Accessed May 7, 2018). 42. SAMHSA opioid overdose tool kit: five essential steps for first responders FirstResponders.pdf. (Accessed May 10, 2018). 43. Personal communication (written). Alexander Y. Walley, MD, MSc. Clinical Addiction Research and Education. Boston Medical Center/Boston University School of Medicine. Boston, MA May 8, Prescribe to Prevent. Prescription & dispensing instructions for injectable naloxone with tear-off patient instructions. (Accessed May 8, 2018). 45. Prescribe to Prevent. Prescription & dispensing instructions for nasal naloxone with tear-off patient instructions. content/uploads/2012/11/naloxone-one-pager-in-nov pdf. (Accessed May 8, 2018). 46. Indiana State Department of Health. Naloxone resource guide for local health departments. (Accessed May 8, 2018). 47. New York City Health. Naloxone. (Accessed May 8, 2018). 48. Baltimore City Health Department. Opioid Overdose. (Accessed May 8, 2018).

13 (Clinical Resource #340601: Page 13 of 13) 49. Personal communication (verbal). Lisa. Medical Information. Kaleo. Richmond, VA May 16, Omaha World Herald. Stewart K. Local first responders carry opioid overdose antidote naloxone recommended by Surgeon General. April 5, (Accessed May 15, 2018). Cite this document as follows: Clinical Resource, Naloxone for Opioid Overdose (FAQs). Pharmacist s Letter/Prescriber s Letter. June Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA ~ TEL (209) ~ FAX (209) Copyright 2018 by Therapeutic Research Center Subscribers to the Letter can get clinical resources, like this one, on any topic covered in any issue by going to PharmacistsLetter.com, PrescribersLetter.com, PharmacyTechniciansLetter.com, or NursesLetter.com