Nasal Naloxone 101
Overdoses can happen anywhere and to anyone. Knowing what to do during a possible overdose can be the reason that person survives. Naloxone is an opioid antagonist that blocks opioid receptors, which are some of the same parts of the brain that control your breathing. By blocking the opioid receptors in the brain, the effects of opioids are reversed. This allows the individual to regain the ability to breathe on their own again.
There are several different routes of administration for naloxone. The two most popularly used are nasal naloxone and intramuscular naloxone. This document will outline how to properly administer nasal naloxone, what is an appropriate dose of naloxone to administer, and what are the general steps to follow during a possible overdose.
Symptoms of a possible opioid overdose:
• Blue, gray, or purplish fingernails, lips, or face
• Unresponsiveness to painful agitation, like rubbing knuckles on the sternum or shin
• Snoring, rattling, gurgling sounds
• Rigidity/stiffness: indicative that fentanyl is involved
• Pinprick pupils
• Slowed, shallow, erratic, or stopped breathing
• Awake but unable to speak
Appropriate Dosing
Because of how naloxone works, it’s possible to send opioid dependent people into precipitated withdrawal. Precipitated withdrawal is very uncomfortable and usually painful for folks who use opioids. This can cause a negative experience for both the person who has experienced the overdose and the person providing naloxone. We go into precipitated withdrawal, its negative effects, and how to care for individuals after an overdose in our Post-OD Care Plan.
Administering microdosed intramuscular naloxone has successfully reversed overdoses without putting the individual into withdrawal. Unfortunately, with the nasal formulation there is no way to measure out a microdose. We recommend administering one full nasal spray and performing rescue breaths. Most times, one dose of nasal spray naloxone combined with rescue breathing is more than enough to bring someone out of an overdose. If the individual has not begun to breathe again on their own and you have waited a full five minutes since the first dose, another dose of nasal naloxone should be given.
With the rise of xylazine in the drug supply, opioid overdoses have changed. People who overdose from an opiate containing xylazine are more likely to remain unresponsive even if they’ve regained the ability to breathe on their own. Once someone is breathing on their own, please try to avoid oversaturating them with more nasal naloxone, as it can cause negative and sometimes dangerous side effects.
How to properly administer nasal naloxone:
Nasal naloxone is absorbed into the bloodstream through the lining of the nose. Because of this, it’s important to work with gravity when administering it. Ideally, the overdosed person can easily be placed on their back (preferably on a solid surface in the event that CPR is needed), given a chin lift (depicted below), and then given nasal naloxone.
It is possible for someone to experience an overdose in the upright sitting position or standing due to rigidity from fentanyl. In these cases it’s important to try to focus on lifting the chin to get the naloxone down into their nose. Once a proper chin lift is achieved, put the nasal applicator all the way inside the nose before spraying.
Responding to an Overdose
1. You’ve identified symptoms of a possible overdose.
2. If possible, the person is placed on their back on a solid surface. In any scenario, a proper chin lift is done to set up for the nasal spray.
3. Fully place the applicator into their nose and spray.
4. At this point, if possible, do a time check or set an alarm to ensure you’ve given that first dose five full minutes to have an effect.
5. Administer rescue breaths. We have a step-by-step guide for rescue breathing on our website
6. While you are waiting for the naloxone to take effect, observe the individual’s lip color, finger color, chest movement for possible breathing, or any sounds that person is making. If you have a pulse oximeter, you can put it on their finger now.
7. Continuous and appropriate agitation such as sternum or shin rubs should be given to encourage responsiveness. Examples of inappropriate agitation include slapping, shaking, dropping, splashing cold water, or screaming in the individual’s face. Experiencing an overdose is already very overwhelming to the individual; do not add stress or trauma to the situation.
8. If five full minutes have passed, administer another dose of naloxone and continue with rescue breaths.
Rescue breathing, CPR, and calling 911 are all tools that can assist during an overdose. However, we recognize that calling 911 increases the chances of law enforcement involvement. Many overdoses can be reversed without medical intervention but it is crucial to call 911 if the person is experiencing:
1. Seizures
2. Bleeding from nose, mouth, or ears
3. Symptoms of a possible stroke (droopy face, non-responsive)
If the Individual does not regain the ability to breathe on their own or has no pulse, 911 can provide CPR instructions. If you need to leave the scene before the ambulance arrives, put the person in the recovery position to prevent the possibility of them choking on their vomit. The recovery position Is depicted at right.
Responding to an overdose can be jarring but having a plan in place is the best way to prepare for a possible emergency. It’s important to always carry naloxone and if possible, refrain from using alone.
