Use caution with higher doses of Narcan
Narcan, or naloxone, is a fast-acting opioid overdose reversal medication. It works by blocking the effects of opioids on the brain, particularly those related to breathing. Narcan can quickly restore normal breathing in someone experiencing an overdose, potentially preventing death. This lifesaving substance is now available over the counter at many pharmacies, local health departments and other organizations.
In 2021, the FDA approved an 8-milligram naloxone spray to combat the rise of potent opioids — doubling the original 4-milligram dosage. However, a recent report from the U.S. Centers for Disease Control and Prevention found that administering an 8-milligram dose of intranasal naloxone does not increase the odds of surviving an opioid overdose; a higher dose than the usual 4 milligrams may result in a greater risk for onset of opioid withdrawal symptoms.
Opioid overdoses occur when a person takes too much of an opioid drug, overwhelming the body and causing a dangerous slowing of their respiratory system.
This can happen due to prescription misuse, which includes taking more medication than prescribed or using someone else’s prescription. Similarly, illicit drug use, where the potency of the opioid may be unknown or mixed with other substances such as fentanyl, can lead to an accidental overdose. People in recovery who relapse may have a decreased tolerance, putting them at higher risk of overdose.
If you or someone you know may be struggling with opioid overdose, there are a few key signs to look out for, such as:
● Decreased level of consciousness.
● Slowed, shallow or stopped breathing.
● Pinpoint pupils: The pupils of the eyes will be very small and constricted.
● Pale clammy skin.
● Purple or blue lips or fingernails.
● Vomiting or gurgling noises.
● Slowed or undetectable pulse.
How do you use Narcan?
Narcan, or naloxone, is a crucial tool in the fight against opioid overdose. It acts as an antidote, quickly reversing the effects of opioids on the brain. By binding to opioid receptors, naloxone essentially blocks the drug, allowing the person to return to regular breathing.
Follow these steps to administer naloxone:
1 Lay the person flat on their back, making sure nothing is in their mouth or blocking their airway.
2 Open the outer carton of Narcan and peel back the inner packaging to remove the nasal spray device.
3 Hold the device with your thumb at the bottom of the plunger and your pointer and middle fingers on either side of the nozzle.
4 Tilt the person’s head back and insert the nozzle into one nostril until both your pointer and middle fingers touch the bottom of the person’s nose.
5 Firmly press the plunger to deliver the spray dose into the person’s nose and remove the device once it’s delivered.
6 Call 911 to report the suspected overdose.
7 Once you give them the first dose of Narcan, you should support their breathing by starting CPR or doing hands-only CPR until they begin breathing on their own or until emergency services arrive. If the person starts breathing again and becomes responsive in two to three minutes, the Narcan worked. You can rotate them onto their side in the recovery position and sit with them until emergency services arrive.
If in two to three minutes the person is still unresponsive or not breathing, or if breathing trouble resumes after they’ve started breathing, you can administer the second dose of Narcan in the opposite nostril. If they stop breathing again at any point, continue to support their breathing until emergency services arrive.
In my work as a recovery coach at Mountainside Chappaqua in Westchester County, New York, I often talk with people about how they might get impatient while they are waiting for the individual to wake up and give the second dose of Narcan before two minutes has passed. Doing so can cause the person to go into severe withdrawal when they wake up.
This can be a scary and chaotic process, but try your best not to panic. If you need help keeping track of time, I suggest first calling 911 and placing your phone on the ground and don’t hang up. You can then proceed to give the affected person the naloxone and do rescue breathing. Your phone will show the time you have been on call, and this is an effective way to monitor time.
Did the dosage change?
Although the original 4-milligram Narcan is still available, there is now an 8-milligram naloxone medication sold under the brand name Kloxxado.
During the CDC study mentioned above, New York State Police troops were supplied with both the 8-milligram and 4-milligam intranasal naloxone. Individuals who received the 8-mg intranasal naloxone product had 2.51 times the risk of opioid withdrawal signs and symptoms, including vomiting, than did those who received the 4-milligram intranasal naloxone product.
Still, more research is needed to determine whether higher-dose intranasal naloxone would provide added benefit.
Why should we talk about this?
Opioid overdoses in the U.S. claim over 80,000 lives annually. The administration has increased naloxone accessibility to fight synthetic opioids, but I worry that the higher 8-milligram naloxone dosage is not quite the answer to curb the epidemic. Many people who receive an overload of naloxone or too much of the substance all at once will wake up feeling awful and agitated with unbearable pain.
Furthermore, this may prompt them to immediately seek more of the drug to stop the discomfort and put them at risk of another overdose, perpetuating a deadly cycle.
Although it comes from a place of being helpful, I believe it’s crucial to find a balance between effectively reversing the overdose while avoiding causing intense withdrawal symptoms that can leave patients in pain when they regain consciousness.
I hear people make comments like “Why are we catering to the addicted person?” or “Why are we worried about killing the pleasurable effects of their high?” We need to remember these individuals are going through an extremely difficult time — we should be caring for them with a health care, person-centered approach.
What can we do?
Ensuring comprehensive training for those administering naloxone is key. While current training programs provide a good foundation, there’s room for improvement. Training should be more rigorous, delving deeper into the nuances of naloxone use.
Equipping trainers with a thorough understanding of all important details, like recognizing subtle overdose signs and proper administration techniques, can make a significant difference in saving lives. Furthermore, increasing public education about opioid use disorder and readily available support resources for those seeking recovery can empower individuals and communities to prevent deaths and support pathways to a healthier future.
Mountainside treatment center, with locations in New Jersey, New York and Connecticut, offers free virtual and inperson support groups as well as recovery-friendly events in the surrounding communities. Visit mountainside.com/resources/support-groups for more information.
Katherine Reynolds is a certified addiction recovery coach at Mountainside Chappaqua in Westchester County, New York.