Event 3: Follow-up with Owen

Owen presents to your clinic following a recent trip to the emergency department.

Select a naloxone product for Owen

Intranasal

Nalxone nasal spray would make a reasonable choice for Owen.

Narcan nasal spray apparatus — Narcan Nasal Spray

Insurance coverage may be a barrier
Approximately $75 for 2 doses
Easy to use
One pack comes with two doses
Educate that applicator should be placed into nostril deep enough for fingers to touch patient's nose
Additional information on administration of nasal naloxone

Intramuscular

Naloxone for intramuscular (IM) injection would make a reasonable choice for Owen.

IM naloxone is cost-effective and generally covered by most private and Medicaid payers
Average cost for 0.4 mg / mL 1 mL vial is $20
IM naloxone requires education of the patient and potential caregivers, friends, and family
IM naloxone is available in pre-filled syringes

Auto-injector

Naloxone auto-injector (Evzio) is a reasonable choice for Owen:

Naloxone auto-injector (AI) is simple and easy to use
Voice prompts direct the user step by step
Naloxone AI may be administered directly through thin layers of clothing
Naloxone AI is provided in box with two live 2mg auto-injectors and one trainer
Insurance coverage may be significant barrier (estimated cost of $2,400 for each AI unit)

Nasal Atomizer

Naloxone nasal atomizer would not be a reasonable choice for Owen.

Lacks FDA approval
Requires multiple steps to assemble
Cost for pre-filled cartridge and nasal atomizer approximately $50
Insurance coverage may be barrier to use

RIOSORD Risk Factors

The Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) is a tool with separate validated screens for use in veteran and civilian patient populations. Discover Owen's risk by selecting the buttons you believe to apply to him.

In the past six months, Owen has had a health care visit (outpatient, inpatient, or emergency department) involving:

Substance use disorder (abuse or dependence): +25 points

Owen consumes the following:

Extended release or long-acting opioid: +5 points

Prescription anti-depressant: +8 points

Owen's Overall RIOSORD Score

Owen's overall RIOSROD risk score falls in the 26-41 range.

Owen scored 38 points on the civilian RIOSORD tool. His predicted probability of experiencing serious opioid-induced respiratory depression or overdose is around 55%.

Table shows the average predicted probability of opioid-induced respiratory depression or overdose depending on score. A score of 0-4 has a probability of around 2%, a score of 5-7 a probability of around 5%, a score of 8-9 a probability of around 8%, a score of 10-17 a probability of around 15%, a score of 18-25 a probability of around 30%, a score of 26-41 a probability of around 55%, and a score of greater than 42 a probability of around 83%

RIOSORD Risk Factors that Did Not Apply to Owen

Bipolar disorder or schizophrenia (+10 points)

Stroke or cerebrovascular disease (+10 points)

Clinically or significant renal impairment (+10 points)

Heart failure (+7 points)

Non-malignant pancreatic disease (+7 points)

Chronic pulmonary disease (+5 points)

Recurrent headache (+5 points)

Consuming fentanyl (+3 points)

Consuming morphine (+11 points)

Consuming methadone (+11 points)

Consuming hydromorphone (+7 points)

Consuming benzodiazepine (+9 points)

Reference

Zedler, BK, et al. Pain Med 2018;19:68-78.

When to Administer Naloxone

Question: When to Administer Naloxone?

Review the following to answer common questions about administering Naloxone.

Slow Breathing

Slow breathing (less than 8 breaths/minute), blue lips or fingertips, limp body, or choking, gurgling, and snoring noise may all be indicative of opioid overdose. Additionally, patients unresponsive to yelling their name or sternal rub may be in opioid overdose. Administration of naloxone is warranted.

Naloxone Administration through Clothing

Naloxone may be administered through clothing if the length of the needle and the thickness of the clothing allows. The auto-injector may also be administered through clothing.

Recovery Position

The recovery position involves the overdose patient being placed on his or her side, not on their back.

Contacting Emergency Services

Always instruct the person who will be administering the naloxone to an overdose patient to always contact emergency services following the first administration.

Follow Up

Always stay with a patient following administration of naloxone for opioid overdose until emergency medical services arrive.

Number of Naloxone Doses

When prescibing the nasal naloxone, 2 doses of 4mg naloxone nasal applicators will be provided. When prescribing naloxone auto-injector, 2 doses of 2mg injectors and a demonstration device will be provided. Co-prescribing naloxone requires delineating a quantity of 2 0.4mg/mL 1 mL vials with syringes.

Administration of Second Dose of Naloxone

Some opioid overdose patients may require a second dose of naloxone if no response after 3 minutes. Remember that the effects of naloxone may wear off before the drug ingested causing the overdose wears off.

Conclusion

This concludes the Opioid Overdose Risk and Naloxone educational module.

Event 3: Follow-Up