Fitting naloxone into community pharmacy practice

We are in the midst of an opioid crisis in Canada. In Ontario over the past 2 decades, there has been a 2-fold increase in opioid-related deaths, mostly in younger people aged 25 to 54 years.¹ Of particular concern in these deaths is the increasing role of prescription opioids such as fentanyl and illicit opioids such as heroin and fentanyl analogues. In fact, every 3 days, at least 1 Canadian dies from a fentanyl overdose.²

The dramatic increase in opioid deaths is raising serious concerns about how we can and should prevent overdoses from fentanyl and other opioids.

One option is to make the opioid antidote naloxone widely available, as recommended by the World Health Organization.³ Naloxone is an old drug that has historically been used in hospital emergency departments and intensive care units to rapidly reverse opioid overdoses.

In recent years, take-home naloxone kits have started to be made available by prescription or through public health programs. In most cases, the naloxone kits could only be distributed to current and past users of opioids. Friends and family members—those most likely to administer the drug during an overdose—were excluded.²

By making naloxone available without a prescription, pharmacists can now sell the antidote to anyone who provides support to current and former opioid users, including parents, partners, family, friends and even community supports such as shelters and group homes.

Now that naloxone is no longer restricted to public health programs, pharmacists will likely find themselves making their own naloxone kits for sale in the pharmacy. A typical naloxone kit costs about $50 and includes 2 ampoules of single-dose naloxone (0.4 mg/1 mL), three 25-gauge 1- to 1.5-inch safety syringes, and 2 alcohol swabs. The 3-mL syringes are preferred over the 1-mL syringes as they provide inexperienced users with extra space to draw up a single dose without accidentally pulling out the plunger completely.

Recently, several public insurance payers have announced that they will pay for naloxone for their members, including the Canadian Armed Forces, the National Indian Health Board and the provinces of Alberta and Ontario.

To support pharmacists in dispensing naloxone, we have created an infographic that can be used to educate patients about naloxone and can be printed and posted in a pharmacy waiting area to raise awareness. We developed the infographic in partnership with the Region of Waterloo Public Health Department.

Looking at the infographic, there are a few points to emphasize when educating patients. Naloxone is a temporary antidote that lasts only 30 minutes. If someone administers naloxone to reverse an overdose, it is critical that they call 9-1-1 immediately, as the duration of some opioids may exceed that of naloxone. If the person who has overdosed does not respond to the first dose, a second dose can be administered in 2 to 3 minutes.

To give naloxone, start by breaking off the top of the 1-mL ampule. Insert the needle and slowly draw the naloxone into the syringe to avoid getting air in the syringe—too much air and there won’t be enough room for a full dose. A dose of naloxone can be injected into a muscle in the person’s arm or leg. It is not necessary to remove their pants or shirt, although it is difficult to inject through heavy coats and pants.

According to public health, the times someone is most at risk of overdose include when they are starting a new or different opioid, when they first buy from a new or unfamiliar source, when they restart drug use after a period of cessation (e.g., incarceration or detoxification) and when they mix an opioid with other depressants such as alcohol or benzodiazepines.

Naloxone is a safe drug, but it does have some side effects. When someone uses opioids for a long time, naloxone can cause fast and strong withdrawal symptoms, also known as being “dope sick,” that include irritability, anger, sweating, shivering, muscle pain, vomiting and diarrhea.

Finally, witnessing an overdose can be very traumatic. Individuals who have responded to an overdose by administering naloxone may want to seek support or counselling. If someone is picking up a replacement naloxone kit, ask how they are doing and encourage them to talk and share their story. ■