Naloxone Factsheet for Drug Court Professionals
Approximately 1 in 5 people who use heroin will have an overdose each year and about 1 in 100 will die from an overdose. Pharmaceutical opioids such as morphine, codeine, oxycodone and methadone also are involved in many overdoses. With brief training, people who use heroin and other opioids and members of their family and social networks can effectively recognize and respond to an opioid overdose and successfully administer naloxone, the opioid overdose antidote. Distributing naloxone to laypersons has resulted in thousands of overdose reversals and many saved lives.
In 2015 the Board of Directors of the National Association of Drug Court Professionals passed a resolution supporting providing naloxone to people who may be present at an overdose. Drug courts are beginning to get involved in overdose education and making take-home-naloxone available to drug court participants.
This factsheet provides an overview of opioids, overdose, naloxone and considerations for implementing programing to provide overdose education and take-home-naloxone to drug court clients.
Naloxone Training Tool for Clients and Families
In partnership with the Center for Opioid Safety Education at the University of Washington, the National Drug Court Institute developed an online education program for treatment court professionals, clients and stakeholders on the safe use of naloxone. NDCI encourages all drug court clients recovering from an opioid use disorder, and their families, to review the video in the link below to educate themselves on the best way to combat a potentially fatal overdose.
What is an opioid overdose?
Opioids bind to opioid receptors in the body including the brain. In addition to reducing pain, opioids can also cause sleepiness or euphoria, and they can slow down and eventually stop breathing. Opioids include heroin and pharmaceutical medicines like:
- hydrocodone (Vicodin®)
- hydromorphone (Dilaudid®)
- morphine (MS Contin®)
- oxycodone (OxyContin®, Percocet®)
- fentanyl (and related illicitly manufactured drugs)
What are the signs and risks of opioid overdose?
An opioid overdose occurs when more opioids are consumed than the body can handle, slowing and then stopping breathing. Depending on which opioid and how much has been used, an opioid overdose can happen suddenly or slowly over a few hours. Without oxygen, a person loses consciousness, can get brain damage, and can die.
A person who has overdosed before is more likely to overdose again. However, their self-perception of risk decreases quickly.
Signs of an opioid overdose include:
- Person cannot be woken up
- Slow or no breathing
- Gurgling, gasping or snoring
- Clammy, cool skin
- Blue/grey lips or nails
The following factors increase the risk of an opioid overdose:
- Resuming opioid use after a break (i.e., while in jail, hospital, detox or treatment) when tolerance has dropped.
- Using opioids with other drugs like stimulants (cocaine or methamphetamine), depressants like benzodiazepines (Vailum®, Xanax®) or alcohol, or with additional opioids.
- Taking opioid medications more often or in higher doses that prescribed.
- Using someone else’s opioid medications.
- Unknown strength or contents of heroin or other opioids bought on the street.
- Any current or chronic illness that reduces heart or lung function.
Using alone also increases the chances a person will die from an overdose.
What is naloxone?
Naloxone is a prescription medicine that can temporarily stop the effect of opioids and help a person start breathing again. Naloxone is the generic name of the medication that is also sold under the brand names of Narcan® and Evzio®. Naloxone only works on opioids, so it has no effect on someone who is not using opioids. Naloxone does not work on other drugs or alcohol, but it can still be helpful in an opioid overdose where these other drugs may also be involved.
Because naloxone temporarily stops opioids from working and can cause withdrawal, it cannot be used to get high and is not addictive. Medical providers have used naloxone for decades and began being used by laypeople in 1996.
Naloxone can be sprayed into the nose or injected into a thick muscle like the thigh or upper arm. The four naloxone products currently available (as of August 2016) are similarly effective, but cost and availability may vary. A side- side-by-side comparison of these four products is available at www.PrescribetoPrevent.org
The 2 injectable and 2 intranasal products currently available.
How does naloxone work?
Naloxone displaces opioids from their receptors in the brain, which usually restores breathing and consciousness in about 2-5 minutes. However, naloxone only lasts 30-90 minutes. Some opioids can last for many hours. When naloxone wears off, any remaining opioids return to the receptors which can cause the person to go back into overdose.
After receiving naloxone and waking up, an overdose victim may feel symptoms of opioids withdrawal like pain, sweating, nausea and vomiting. The person may also feel confused, anxious or slightly agitated, but rarely combative or violent.
What are the laws about naloxone?
Medical prescribers been able to prescribe take-home-naloxone to their patients since it was approved by the FDA in 1971. Most states have passed laws that explicitly allow lay persons, such as those who use opioids and their friends, family or other potential overdose bystanders, to be prescribed, possess, and administer naloxone. Additional laws in some states also permit non-medical persons to distribute naloxone under a prescriber's standing order.
Most states have also passed Good Samaritan overdose laws to encourage people to call 911 to seek medical help during an overdose. These laws provide immunity from some civil liabilities to individuals who make a good faith effort to assist in an overdose and/or the person who has the overdose. The types of offenses for which immunity is granted varies widely across states.
When planning an overdose education and naloxone distribution program you should work with the relevant local entities such as your prosecutor’s office or health department to ensure alignment with relevant laws and coordinate with existing services. To review your state’s relevant naloxone and Good Samaritan laws, go to www.lawatlas.org.
How does someone get naloxone?
Naloxone is a prescription medication, and there are many ways to obtain naloxone:
- Any prescriber can write a prescription for naloxone. Some Medicaid and commercial health insurance plans cover at least one form of naloxone, although coverage and co-pays vary widely.
- Many pharmacists have the ability to directly prescribe naloxone on behalf of a health care provider under an arrangement called a collaborative drug therapy agreement. Like getting a flu shot, a customer can obtain naloxone directly at the pharmacy without seeing a health care provider.
- Most states also have community organizations like syringe exchange programs that distribute naloxone under a health care provider’s standing order. A list of these programs can be found at www.prescribetoprevent.org. Using this same model, many organizations like housing providers, substance use treatment centers, jails, and drug courts also distribute naloxone to clients at risk for overdose.
Should all drug court clients get naloxone?
Any drug court clients who have used or are currently using heroin or pharmaceutical opioids (either illicitly or under a health provider’s care for pain or treatment of opioid use disorder) should consider having naloxone. Similarly, many drug court clients may know others in their family or social networks who use opioids and may want to have naloxone in case they witness an overdose.
Many drug court clients, however, may not believe they are at overdose risk and may not be interested in naloxone. Clients may minimize their opioid use for fear of legal consequences or feel confident they have stopped drug use completely and permanently and therefore perceive themselves to not be at risk for overdose. It can be helpful, therefore, to share messages like these below with all drug court clients:
- Opioids are widespread in the community and overdoses are at record levels. Getting overdose response training and naloxone is no different than learning how to do CPR so you can be ready to help someone.
- If you or others have opioids for pain or opioid use disorder treatment, those opioids are a potential overdose risk to anyone in the household. Have naloxone around “just in case” like a fire extinguisher.
- Relapse happens, even among those who are most committed to their recovery. Using after a break in use is also one of the riskiest times for overdose.
The essential goal of distributing naloxone and educating people about how to prevent, recognize and intervene in overdoses is to prevent deaths. Other goals, such as decreasing/stopping drug use, can only be accomplished if the person is alive.
How can we connect clients with overdose education and naloxone?
Drug court staff have an important role to play in educating clients about overdose prevention and response and helping them access naloxone. Drug court staff can:
- Refer clients to outside organizations who can provide overdose education and naloxone or encourage clients to ask their health care provider for a prescription for naloxone.
- Provide basic overdose prevention education to clients and them refer them to places to get naloxone (e.g. health care provider, community program, pharmacy).
- Provide “in-house” overdose prevention education and naloxone to clients (assuming local laws permit direct naloxone distribution this way). This can be done by drug court staff or by partnering with a community organization or local health department to provide those services regularly on site.
Research has found that making naloxone available does NOT encourage people to use opioids more. In fact, distributing naloxone often opens the door to discuss other client needs such as treatment or social services.
Years of collective experience among medical- and community-based naloxone distribution programs has shown that referrals to naloxone are not usually effective. Whenever possible, it is best to get naloxone directly into clients’ hands at the time overdose education is given.
To determine which approach might work best for your organization:
- Determine what local laws apply distributing naloxone in your state.
- Identify what local options for naloxone exist in your area and which community naloxone programs might be willing to partner to provide overdose education/naloxone at your site
- If your agency decides to provide its own overdose/naloxone training, develop a naloxone distribution policy and training curriculum and have it reviewed by legal and medical experts. Also find a funding source for the naloxone.
How do we provide overdose response and naloxone training?
Training can be offered in a variety of ways and does not require significant time. Under 15 minutes is usually sufficient for most people. Options for training include:
- 1:1 conversation, usually within the context of a regular meeting with drug court staff
- Group “classroom” sessions
- Client self-directed training, usually by video or online
Training can include overdose education only or overdose education plus take-home naloxone. Some programs also offer brief behavior change counseling/motivational interviewing to help clients change overdose risk behaviors.
It can also be helpful to designate a “point person” for questions and refresher training on overdose and naloxone at each site that carries naloxone.
Training in basic overdose response and naloxone administration should cover the following topics:
- Risks for opioid overdose
- Recognizing the signs of an opioid overdose
- Steps of overdose response: Try to wake the person up-Call 911-Give naloxone- Give rescue breathing until the person wakes up or medical help arrives.
- How to administer naloxone
- How to perform rescue breathing
- Local Good Samaritan laws and other relevant laws/policies
Are there training resources available?
There are a number of excellent training curricula, print materials, training videos, evaluation tools and other resources at:
Always supplement these with local information e.g. local laws, services, resources
How do we pay for the naloxone?
Agencies must find internal resources to pay for naloxone they purchase for clients. Your state, county or city may have designated funds for community naloxone distribution. Check with your local health department if there are funds in your area. Some state Medicaid programs will cover the cost of naloxone for Medicaid recipients. To provide naloxone for their clients who receive Medicaid, some agencies have worked with a pharmacy who can directly bill Medicaid for the naloxone.
Working with community partners.
When implementing an overdose education and take-home-naloxone program it is important to inform your stakeholders and the community:
- Law enforcement
- Public health
- Treatment and health care providers
- Community prevention coalitions/Churches/non-profits
Communicating to the public increases awareness of your program and the need for community awareness around overdose prevention and intervention more generally:
This fact sheet was prepared by the Alcohol and Drug Abuse Institute, University of Washington under contract with the National Association of Drug Court Professionals. This fact sheet is for educational purposes and does not constitute legal or medical advice.