NARCAN/NALOXONE FAQ

While Naloxone comes in an injectable form, it is never injected into the heart. Nothing should ever be injected directly into the heart. The injectable form of Naloxone (intramuscular or IM) is injected into a big muscle (thigh, shoulder, buttcheek). It can also be delivered intravenously in medical facilities.

Narcan is a form of Naloxone that is provided through the nose instead of via injection. Narcan has a stronger concentration of Naloxone (2mg/2ml versus the standard injectable naloxone concentration, .4mg/1ml) to compensate for the different mode of absorption into the body. There is research showing that Narcan is highly effective in successfully reversing opioid overdoses. Intranasal has the advantage of having no needle but it is more expensive.

Expired naloxone is better than no naloxone. If it is the only thing you have, use it. Like most other medication, naloxone will start to lose its effectiveness after its expiration date. According to a study on NEXT Distro’s page, naloxone has been found by one study to last 30 years past its expiration date. Using expired naloxone will not hurt, so use it, call emergency services, and continue to perform rescue breathing.

If you notice it has expired, get a new kit! Simply go to the place where you got the first one and get one that is unexpired. If you bring in the old kit, that’s great because the program can use it as a demonstration tool for training.

Buprenorphine (brand name Suboxone) diminishes cravings for opioids such as heroin, while naloxone (naloxone) counters “potential abuse” (meaning: injecting) of Suboxone. If the Suboxone is taken under the tongue, naloxone will not get absorbed into the body. If Suboxone is injected, the naloxone will beat the buprenorphine to the opioid receptors, delaying and lessening the high.

Using buprenorphine to reverse an overdose is not something that has been scientifically studied. However, there are reports of this working. This is probably because the buprenorphine has a stronger affinity or attraction to the opioid receptors than heroin or other opioids, so it displaces the opioids. The reason Suboxone may reverse an overdose is probably not because of the naloxone in it—it is a very small amount—and it is most likely the buprenorphine that causes the person to wake up. Remember: during an overdose it is all about time and oxygen. Anything that is done to reverse an overdose should not sacrifice time or oxygen. Preparing a Suboxone to inject takes precious time, and waiting for the pill to dissolve in the mouth takes even longer.

NO, naloxone only works for opioid overdoses. If it is an alcohol overdose that also involves opioids, it may help by dealing with the opioid part of the OD.

No- speedballing does not cancel out OD risk- it actually increases risk, especially cocaine which can also numb the urge to breathe.

Speedballing is any combination of a stimulant (upper) and a depressant (downer) taken together, especially a mixture of heroin and cocaine or heroin and methamphetamine injected into the bloodstream.

Stimulants actually constrict blood vessels, and cause the heart to beat faster, which can depletes the body of much-needed oxygen, which makes the overdose worse.

The more different drugs someone’s body has to process, the harder it is on their body. People who speedball usually use much more frequently that people who use only heroin- this increases OD risk.

Naloxone will not work on a cocaine overdose. Although, fentanyl and other synthetic opioids are being cut into the stimulant supply, in which case naloxone would be necessary. It is always best to test any substance for fentanyl.

If it is a cocaine overdose that also involves opioids, it may help by reversing the opioid part of the OD. Cocaine overdoses are dangerous because they are not dose-dependent and they are a complicated medical emergency- call 911.

Neither (do not confuse with Klonopin, which is a benzo). It can be used to relieve withdrawal symptoms from opioids, alcohol & nicotine. When combined with opioids recreationally it increases the high. It lowers blood pressure, heart rate, causes dizziness & drowsiness. Lowering the blood pressure raises the risk of falls. There is a higher risk of overdose with a clonidine/opioid combo than with opioids alone, but less than with a benzodiazepine/opioid combination. It is not as long lasting as benzos, no amnesiac effects (short-term memory loss). Stopping regular use does cause mild physical withdrawal symptoms and in people using it for high blood pressure it can cause very high blood pressure.

It’s used to combat nausea, as a sedative, allergy medication, for motion & morning sickness, and to increase the activity of opioids. For example, someone on high doses of opioid pain medication could lower dose of pain med and take Phenergan to get the same effect. Similarly, the effects of heroin would be increased. There is a higher risk of overdose with a phenergan/opioid combo than with opiods alone, but less than with a benzodiazepine/opioid combination. It is not considered to be habit-forming or cause withdrawal.

Fentanyl is an extremely concentrated/potent opioid. Some heroin dealers mix Fentanyl powder with larger amounts of heroin in order to increase potency or compensate for low-quality heroin. If it is not well mixed a small bit of highly potent Fentanyl could cause an OD in a user that is expecting just heroin. Fentanyl patches can also be used by either slapping them on the skin to get the time released medication, and then using other drugs on top of that, or by placing the patch inside the cheek, which allows the medication to release quicker, or by shooting or snorting the gel inside the patch (a bit of a process to get it into injectable form, but it can be done!). Very risky in terms of overdose, Fentanyl is extremely potent and short-acting and can flood the receptors in the brain very quickly. Fentanyl is designed to treat pain for people who are already dependent on opioids for pain management, so it is designed to be very strong to handle the pain someone experiences despite already taking sometimes high doses of opioids.

The salt shot causes pain (1. the injection & 2. saltwater will sting/burn) so if the person CAN respond to pain, they WILL. Fixing a salt shot wastes precious time that could be spent on calling 911, rescue breathing & giving naloxone. While salt shots may have appeared to have worked sometimes, they could also cause damage. Naloxone is a safer alternative.

You really do not want to kick, slap, punch, drag anyone…you might hurt them. The sternal rub basically does the same thing as hitting, but we want to cause pain but without causing harm. If someone doesn’t respond to a sternal rub, move on! Call 911, do rescue breathing and give naloxone.

Ice down the pants or a cold shower might work and it might not. Ice down the pants or cold showers can slow down the respiratory system and can send someone into shock or hypothermia.

A safer, quicker, more likely to work action is: Call 911, do rescue breathing and give naloxone.

No. Naloxone knocks opioids off the opioid receptors, but the drug is still floating around in the body (AND urine!)

Your naloxone rescue kit is yours like any other possession. It should not be confiscated. Please tell someone at the naloxone distribution program where you got it if it does get confiscated. Some programs and shelters have policies about needing to check prescription medications- you can expect to have to follow individual program guidelines as naloxone is a prescription medicine. Sometimes people like police or probation officers might assume that the only people who have naloxone rescue kits are people who might overdose themselves, so they might assume that it is a flag for illegal activity.

There is no easy answer to this question because it depends. It depends on the policies and culture of your local police department and community. For example some departments have unwritten policies to never arrest people at the scene of an overdose just for calling for help. Other regions, cities and communities take a much more punitive stance, and the chance of getting searched and arrested at the scene of an overdose is higher. Some states have passed laws (or are trying to) that are called 911 Amnesty or Good Samaritan bills. These bills offer protections that make it unlawful for police to arrest you, or at least to charge and prosecute, at an overdose if you called for help. HOWEVER, consider: Are you on probation? Do you have warrants/open cases?

South Carolina has a Good Samaritan Statute found here and explained better here.

Plan in advance! Remove all paraphernalia from view- if no reason for a search is obvious, it might not happen. Police’s first priority is the safety of the scene. The smoothest interactions will happen when it is calm and under control.

It is probably a higher dose of naloxone than therapeutically necessary. It is likely the person will experience more severe withdrawal symptoms as a result. Injecting ~1/4 of the naloxone in the vial is a good amount to start. Since it is the same medication as in the injectable version, it will work to reverse an opioid overdose.

Try to keep the nasal spray piece attached to the naloxone box with a rubber band or attach it ahead of time so it’s ready to go. Two things have been done successfully (only to be done in an emergency): Inject the naloxone in the vial; or squirt it up the person’s nose anyway without the nasal adapter. It will come out in more of a stream than a spray, so make sure the head is tilted back far enough so it doesn’t all drain out the nose! When making a decision about which to do, remember time and oxygen!

This is not ideal, because muscle syringes have longer points, which are better for getting the naloxone into the muscle where it is better absorbed. Regular insulin syringes have shorter points, so you’re not getting the naloxone all the way into the muscle. They are better than nothing! Some studies have shown that subcutaneous injections (under the skin, but not all the way into the muscle) are just as effective as shooting it into the muscle. Be sure to pay attention to the measurements. You want to inject 1cc of naloxone to start, which will be a FULL syringe if you are using a 1cc syringe, and it will be TWO full syringes if you are using a ½ cc syringe.

It depends on: the person’s metabolism (how quickly the body processes things); how much drug they used in the first place; the half-life of the drug they used (i.e. methadone has a much longer half-life than heroin), how well the liver is working; and if they use again. Naloxone is active for about 30 – 90 minutes in the body. So if you give someone naloxone to reverse an opioid overdose, the naloxone may wear off before the opioids wear off and the person could go experience another overdose. Because naloxone blocks opioids from acting in the brain, it can cause withdrawal symptoms in someone that has a tolerance. After giving someone naloxone, they may feel dope sick and want to use again right away. It is very important that they do not use for a couple of hours because they could overdose again once the naloxone wears off.

Ideally, people should receive medical attention, but many people who use drugs are uncomfortable with medical staff and decline the need for medical care. That is okay. Encourage the person to stay with another person for the next 2 hours in case of another overdose.

The new guidelines are aimed primarily at cardiac arrest, not respiratory arrest. In cardiac arrest, respirations are not as important as compressions -particularly in the first few minutes. In respiratory arrests (like overdoses), respirations are the key. If the respiratory arrest progresses to a full cardiac arrest the patient should get both chest compressions and rescue breathing. The situation with an opioid overdose where the primary problem is lack of oxygen because of decreased breathing is different than a heart attack. With any signs of life, such as gasping breaths or a pulse with inadequate breathing, then rescue breathing is likely sufficient.

However, the newest AHA guidelines for Basic Life Support do include instructions to do rescue breathing for opioid overdose prior to cardiac arrest, but this has not been publicized as widely as the new recommendations for cardiac arrest. Read Harm Reduction Coalition’s alert on the guidelines here.

Naloxone has no effect on someone who has no opioids in their system. It will not help anyone who is not experiencing an opioid overdose, but it will not hurt them either. For example. if someone is having a heart attack, naloxone will not impact their health.

It is not possible to give too much naloxone so as to harm a person. However, if a person has opioid tolerance (including people without substance use disorders but on chronic pain medication), the more naloxone they get the more uncomfortable they will feel because of withdrawal symptoms. Vomiting is a possibility - once the person is breathing again, be sure to put them in the recovery position to prevent aspiration (inhaling vomit into their lungs).

If the person is given too much naloxone, the withdrawals or dopesickness will fade anywhere between 60-90 minutes. It is possible to overdose again after the naloxone wears off.

No, people will not develop immunity to naloxone. It can be used as effectively on the first overdose as on the 8th overdose, for example. However, someone who overdoses a lot might start to wonder what is going on with their body if they rarely overdosed before and now seem to be overdosing more frequently. Some examples of reasons that have been discovered are:

• Untreated asthma

• Seasonal allergies

• Changes in medications for depression, anxiety, sleep, HIV

• Disassociation because of trauma= not remembering amount of drugs used

• New environment, new friends, new practices

• Suicidality

Naloxone acts as an opioid antagonist and has no adverse effects. It simply kicks opioids off brain receptors temporarily to allow breathing, thus reversing an opioid overdose.

Naloxone is safe for children older than 6 weeks of age and is also safe for animals who have ingested opioids.

While the medication itself does not pose a risk to children, it’s important to keep naloxone and other medicines out of reach of children. The small parts of the naloxone kit may pose a choking hazard. The vial is made of thin glass that can be easily broken and there is a sharp needle inside the plastic tubing of the applicator.

It depends. OD trainers should ask this question specifically of programs (example: detox, shelter) before doing group trainings. Some programs are simply unable to get around this internal policy and are not allowed to have Naloxone on-site to respond to overdoses or to give out Naloxone for program participant use.

In this case, focus on helping the program create a policy for on-site overdoses that includes identifying the overdose, calling 911, rescue breathing and recovery position, to help find ways staff can still train program participants about overdose prevention and response. It is also possible to refer staff and participants to outside organizations to obtain Naloxone and training. Some cities and states have regulations or laws to allow “3rd party administrators” of Naloxone. This provides protections for staff to have and use Naloxone at their programs. Learn what your local regulations are concerning this before the training.

Naloxone itself does not evoke ‘violent’ reactions from folks. There are many reasons a person may behave unexpectedly or aggressively after being administered Naloxone.

Naloxone simply replaces the opioid from the receptor that allows us to breathe, therefore allowing breathing and consciousness again. When someone has a tolerance for opioids, receiving too much Naloxone can send them into precipitated withdrawal which is often incredibly painful and uncomfortable. Additionally, consider the circumstance. Someone who has overdosed is unaware of the overdose, they were unconscious. To be awoken in a shocking way, possibly surrounded by EMS, strangers, and/or law enforcement, would be unpleasantly surprising, to say the least.

The person who overdosed may be angry to that their high was ruined or taken away. Many people are living lives that center around substance use. They spend an incredible amount of time gaining the resources to be able to get high. When that high they worked so hard for is taken away, it can be emotionally and physically overwhelming.

Being uncomfortable and/or disoriented is certainly a combination that could cause someone to act in unexpected and aggressive ways, even if you or another bystander may have just saved their life. Even if angry at the time, people often come to gratitude after taking time to process the situation.

There are multiple barriers to people seeking treatment for substance use. Sometimes people are not interested, willing, ready or able to go to treatment; Financial barriers; Waiting lists/availability; Stigma; Untreated underlying mental health or trauma issues; Acceptability of treatment models, hours of operation, staff, abstinence requirements, etc. Overdose Response and naloxone trainings are a practical strategy to focus on what is, as opposed to what “should be”. If this question is raised in a group setting, one successful strategy is to turn this question around to the group. Usually group members elucidate the reasons why treatment is only sometimes a viable option for some people who use drugs.

The liver processes all drugs in a person’s body. If the liver is damaged or not functioning properly, it could cause a back-up of drugs in the body, causing an OD. A person whose liver isn’t functioning properly could have a longer overdose in addition to more frequent overdoses.

The death of a peer or a near death experience does not “teach a person who uses drugs a lesson”. Increased psychological distress or trauma can actually increase substance use. The actual definition of addiction (called “dependence” or “abuse” by the American Psychological Association’s DSM IV-TR) includes one important criteria that relates to this issue: Use continues despite knowledge of adverse consequences (e.g., failure to fulfill role obligation, use when physically hazardous). This means that someone who is addicted by definition may not modify behaviors based on bad outcomes such as overdose.