Frequently asked questions about naloxone: Part 3

Myths

Does naloxone break down if it is not stored properly?

Naloxone should be kept between 15 to 30°C and away from direct light, but studies have shown that it is stable even when not stored in perfect conditions, ¹ such as when individuals carry naloxone with them or have a kit in a vehicle. Naloxone has been shown to be stable when frozen and thawed between the temperatures of −20 to 4°C or at high temperatures of 80°C. ² Although naloxone dosage forms normally carry an expiry date of 2 years, a recent study showed that naloxone for injection that had been expired for 30 years still contained more than 90% of active naloxone with limited degradation. ³ Pharmacists should routinely offer replacement kits to patients as their kits expire. However, tell your patients that in an emergency situation, an expired or improperly stored naloxone kit can still be effective and is unlikely to cause harm.

If I call 911 during an overdose, could I be arrested?

No: Due to the Good Samaritan Act, individuals are protected against most charges when reporting an overdose situation. ⁴ Everyone, including the individual who is experiencing an overdose, is protected against being charged with drug possession. ⁴ The Act does not protect against outstanding warrants, production and selling of controlled substances or other charges not mentioned within it. ⁴ Data collected between 2013 and 2016 showed that in 30% to 65% of cases, laypeople responding to an overdose did not call 911. ⁵ Fear of law enforcement due to the illicit nature of opioids is a factor in calling 911 in an overdose situations, as bystanders fear that they will be reprimanded if they call for help. It is important to educate your patients so that they are aware of the Good Samaritan Act and understand the Act’s protections. They can share this information with others present and can remove the barrier to calling 911.

Does naloxone access increase and promote opioid use?

Although more studies are needed, current evidence does not support a link between naloxone and more or riskier opioid use. One study of individuals who used heroin and individuals receiving opioid agonist therapy showed that there was no increase in opioid use when the participants were trained and given a naloxone kit. ⁶ One study did find an increase in emergency calls about overdoses associated with a naloxone distribution program, but calling 911 is an integral part of naloxone training. ⁷

Do unregulated fentanyls mean that standard naloxone kits are insufficient?

Some overdoses have been reported to require multiple doses or repeated administration of naloxone. ⁸ In one study, the response rate to naloxone for heroin overdoses was 80% but was only 57% for overdoses involving fentanyl. However, in another study, naloxone response rates were 90% to 95%, even as the unregulated opioid supply changed from 3% to 68% fentanyl during the study period. ⁹ An individual’s response to naloxone depends on the opioid involved, the dose, other substances used and the individual’s tolerance. Although some overdoses may require more naloxone than is included in a standard kit, many victims will still respond to 1 or 2 doses.

Are there “naloxone-resistant” fentanyls?

There is no pharmacological evidence that fentanyl or its analogs are pseudo-irreversible or noncompetitive agonists at opioid receptors. The apparent failure for naloxone to reverse an overdose is more likely to be caused by other factors, such as errors in administration, higher potency fentanyls, high opioid doses, or contamination of a fentanyl with another central nervous system depressant, such as benzodiazepines. ¹⁰ Always administer naloxone if you suspect an opioid overdose. Even if there is no apparent response, getting naloxone doses into a patient provides a head start to additional doses and interventions provided by emergency personnel.

Can I experience a fentanyl overdose via accidental exposure?

Individuals may be concerned about exposure to fentanyl when helping victims of overdose. However, experiencing opioid toxicity from accidental exposure to fentanyl is highly unlikely. A joint task force of the American College of Medical Toxicology and the American College of Clinical Toxicology concluded that fentanyl pills and powder did not pose any risk of causing overdose. ¹¹ Absorption of fentanyl through the skin is very slow and would require pharmaceutical-grade patches or dissolved fentanyl to be absorbed over a large surface area. ¹¹ Absorption through mucous membranes (eyes, mouth) may be greater. ¹² Pulmonary absorption of heated or aerosolized fentanyl is possible but can be prevented through standard respiratory protection. ¹¹ ■