DMHAS: Naloxone

Opioid Overdose Prevention/Naloxone (Narcan) Initiative
 
For more information contact Susan Bouffard, Ph.D., 860-418-6993, susan.bouffard@ct.gov
Opioid abuse/misuse, whether of heroin or prescription painkillers (e.g., Vicodin, Percocet, Oxycontin), is at unprecedented levels and is exacting a huge toll in terms of dependence, addiction, overdose and death, in addition to the suffering of the individual involved and those that care about him/her. While access to naloxone (Narcan) won’t solve the opioid abuse/misuse problem, it will save lives. naloxone (Narcan) is the antidote to an opioid overdose. Medical professionals have used this safe medication for decades to reverse overdoses. The first naloxone distribution programs began in the US in 1996. As of June 2014, the CDC reported that the 644 naloxone distribution programs in existence had reversed over 26,000 overdoses. At present, 47 states have some sort of Narcan law. With enough prescriptions written for opiate painkillers in 2010 to medicate every adult American around the clock for a month, the accessibility of these powerful medications has resulted in more misuse, overdose, diversion (use without a prescription) and migration (from the more expensive medication to the cheaper heroin) than ever before.
 
Current CT Laws Related to Narcan:
  • In 2011, a “good Samaritan law” (Public Act 11-210) was passed in an attempt to address people’s unwillingness to call 911 for an overdose situation. This law protects people who call 911 seeking emergency medical services for an overdose from arrest for possession of drugs/paraphernalia. The law limits protection to this situation. It doesn’t protect someone from other charges or stop the police from serving a search or arrest warrant if that was already in process.
  • The 2012 Narcan law (Public Act 12-159) allows prescribers (physicians, surgeons, Physicians’ Assistants, APRNs, dentists, and podiatrists) to prescribe, dispense or administer Narcan to any person to prevent or treat a drug overdose and the prescriber is protected from civil liability and criminal prosecution.
  • In 2014, protection from civil liability and criminal prosecution was extended to the person administering the Narcan in response to an overdose (Public Act 14-61).
  • The 2015 legislation (PA 15-198) allows pharmacists who have been trained/certified to prescribe and dispense Narcan directly to customers requesting it. The pharmacist is required to educate the person on how to use the Narcan. The law also requires one hour of continuing education for physicians, PAs (Physicians’ Assistants), APRNs (Advanced Practice Registered Nurses) and Dentists in a risk management topic that includes prescribing controlled substances and pain management. Prescribers are required to check the electronic Connecticut Prescription Monitoring and Reporting System (CPMRS) before prescribing greater than a 72 hour supply of a controlled substance and, for those persons prescribed opiates long-term, at least every 90 days.
  • The 2016 legislation (Public Act 16-43) put a 7-day limit on all opioid prescribing for minors and for adults at their first outpatient visit, but exceptions could be made if documented by the prescriber. More real time data entry was required by pharmacies into the Connecticut Prescription Monitoring and Reporting System (CPMRS) for controlled substances dispensed. Veterinarians are now required to submit information weekly to the CPMRS if issuing controlled substance prescriptions. To make it easier for prescribers to check the CPMRS as required by previous legislation, the range of authorized agents who can check on their behalf was broadened. Insurers were prohibited from requiring pre-authorization for the opioid overdose antidote naloxone (Narcan).
  • Legislation passed in 2017 (Public Act 17-131) entitled An Act Preventing Opioid Diversion and Abuse made some modifications to earlier legislation and added some new items. Items are in effect from passage unless otherwise noted by a different effective date. Highlights are below:
    • DCP is allowed to share CPMRS data with other state agencies under certain circumstances
    • In an effort to reduce diversion by increasing removal of unwanted and excess controlled substances:
      • DCP can take custody of and destroy excess and unwanted controlled substances
      • Nursing Homes and Outpatient Surgery Centers can dispose of excess controlled substances if 2 or more of their leadership do so together
      • Home Health Care Agency RNs can destroy/dispose of controlled substances with permission of the patient’s designated representative
    • (effective January 1, 2018) Prescriptions for controlled substances must be electronically transmitted from the prescriber to the pharmacy with a few exceptions related to emergency situations, technological/electrical lack or loss, and potential negative impacts on patient care
    • (effective October 1, 2017) A Voluntary Nonopioid Directive Form can be completed by any patient who doesn’t want to have opioids ordered or prescribed to them. The form will be accessible from the DPH website and must be filed with the prescriber. The form allows the patient to appoint another person to speak on their behalf who can override the form and either person may revoke the directive orally or in writing at any time
    • (effective July 1, 2017) The previous 7-day opioid prescribing limit for minors established in 2016 is modified such that it is reduced to a 5-day limit and the prescriber must discuss the following risks with the patient (and their caregiver if the patient is a minor and the caregiver is present when the prescription is issued):
      • Risks of addiction and overdose from opioids
      • Dangers of combining opioids with alcohol, benzodiazepines and other central nervous system depressants
      • Reasons the opioid prescription is necessary
    • (effective July 1, 2017) By October 1, 2017, DPH will post on its website how a prescriber can become certified to prescribe take-home medication to treat a person with Opioid Use Disorder
    • Activities related to the Alcohol and Drug Policy Council (ADPC), which was reconstituted by previous legislation, are highlighted in this section which describes how the council will:
      • By October 1, 2017, develop a fact sheet describing the risks of using opioids, symptoms of Opioid Use Disorder (OUD), and services available in Connecticut for persons with or affected by OUD. The fact sheet will be posted on the DMHAS website and should be distributed to persons with OUD symptoms or anyone being prescribed/administered opioids or naloxone (Narcan)
      • Investigate and report back by January 1, 2019 on the feasibility of a marketing campaign including public service announcements (PSAs) on various media sites to address opioid risks, symptoms of OUD, and availability of naloxone (narcan) and other services/treatments
      • Investigate and report back by January 1, 2019 on the feasibility of establishing an electronic single port of entry for information concerning the availability of treatment beds at detox and rehab and outpatient treatment slots for medication assisted treatment (methadone and Suboxone)
      • Create a workgroup to investigate and report back by February 1, 2018 on what statutory/regulatory/policy changes would allow for first responders/health care providers to dispose of a person’s opioid drugs upon their death
      • Create a workgroup to investigate and report back by February 1, 2018 on  programs established by police departments that refer people with OUD to substance use treatment to find out what is and isn’t working and determine if such programs can be expanded statewide
    • (effective January 1, 2018) Insurance companies covering persons with substance use disorders will be required to cover medically necessary inpatient detox services
    • (effective July 1, 2018) By October 1, 2017, each municipality will have at least one emergency medical services provider who is likely to arrive first on the scene of a medical emergency equipped with naloxone (narcan) and trained in its use (this provides clarification of 2016 legislation)
    • (effective October 1, 2017) A prescriber and pharmacy can agree to a standing order protocol which allows the pharmacist to dispense either the Narcan Nasal Spray or the Evzio Auto- injector formulations of naloxone (narcan) to anyone at risk of an opioid overdose or another person in a position to save them. The pharmacist dispensing the naloxone (narcan) under this standing order protocol has to have the naloxone certification
Naloxone (Narcan) Providers in your area

Pharmacists who have been trained and certified are now able to prescribe and dispense naloxone/Narcan to you from a pharmacy. A list of naloxone prescribing pharmacists in Connecticut is available by clicking this link. In addition to certified pharmacists, Connecticut law allows other prescribers, including physicians, surgeons, Physician Assistants (PAs), Advanced Practice Registered Nurses (APRNs), and Dentists to prescribe, dispense and/or administer the medication.     

 

Training materials:  Any of the following materials can be printed. For convenience, the one-page two-sided brochure listed below contains information for identifying and responding to an opioid overdose with Narcan.

Helpful Resources and Links


 
Frequently Asked Questions
 

What are the risks associated with naloxone (Narcan) use?

Naloxone (Narcan) is a safe prescription medication. Its sole purpose is to reverse an opioid overdose. Unless a person is known to be allergic to naloxone (Narcan), it is safe to administer.

 

How quickly does naloxone (Narcan) work?

Properly administered, naloxone (Narcan) usually works within 2 – 5 minutes. If there is no response during this time, a second dose should be administered.

 

Who in the state of CT is authorized to prescribe naloxone (Narcan)?

In CT, authorized prescribers are physicians, surgeons, PAs, APRNs, dentists, podiatrists and, with the 2015 legislation, Pharmacists who have been trained and certified.

 

Where can I go for training and a prescription kit?

Any pharmacist who has been trained and certified can prescribe and dispense naloxone (Narcan). The pharmacist will educate the person requesting the naloxone (Narcan) on its use. Additionally, your primary care provider (physicians, surgeons, PAs, APRNs, dentists, and podiatrists) would be able to prescribe naloxone (Narcan) to you. Many programs providing treatment for substance use also have mechanisms in place to provide education and access (through prescriptions or kits) to naloxone (Narcan). You may also check the map of pharmacies with pharmacists approved to prescribe naloxone on the Department of Consumer Protection's website.

 

Will I be arrested if I call 911 when there’s been an overdose?

Public Act 11-210 An Act Concerning Emergency Medical Assistance for Persons Experiencing an Overdose and the Designation of Certain Synthetic Stimulants as Controlled Substances concerns consequences for possession of different substances, but makes an exception in section g, for persons who in good faith seek medical assistance for a person that they reasonably believe is overdosing. Consequently, you should be protected from arrest by this “Good Samaritan” law.

 

What do I do if I come across someone who has overdosed?

If someone you are close to uses opiates, you could, in fact, find yourself in this situation. The first step is to determine whether the person has overdosed on Opioids. Look for the following signs:

  • Person is unresponsive or limp
  • Person is awake but unable to talk
  • Their breathing is slow or erratic or they are not breathing
  • Their pulse is slow or erratic or they have no pulse
  • Their skin is pale gray or blue, especially around the fingernails and lips
  • They are making deep, slow snoring, choking or gurgling sounds
  • They are vomiting
If you cannot wake or get a response from the person, call 911. If they aren’t breathing, start “Rescue Breathing” by moving them onto their back, tilting their head back and lifting their chin, and giving them 2 normal breaths. Give one breath every 5 seconds after this until they begin breathing on their own or help arrives. If you have a naloxone (Narcan) kit, have someone bring it to you and administer the naloxone (Narcan). If you have to leave the person for any reason, put them into the “Recovery Position” by rolling them onto their side so that they won’t choke if they begin vomiting.
 
How does naloxone (Narcan) work?
In the brain, naloxone (Narcan) competes with the opioids the person used for the same receptor sites. Since naloxone (Narcan) has a greater affinity for the binding sites, the opioids the person used are replaced by the naloxone (Narcan) which reverses the overdose effects of the opioids.
 
What increases/decreases risk of an opioid overdose?
These factors increase risk of an opioid overdose:
  • Using too much (because you haven’t used that amount before or because it was stronger than what you are used to, or because your tolerance decreased while you weren’t using or were in a detox/program/jail/hospital)
  • Using alone
  • Mixing opiates with alcohol, pills or cocaine
  • Other health issues (Hepatitis, HIV, infections, malnutrition/dehydration, liver disease, kidney disease, heart disease or respiratory disease, asthma, sleep apnea, etc.)
  • Previous overdose
  • Mode of administration (Smoking and IV use are riskier)
  • Age (older people and those with longer histories of drug use are more likely to die as a result of an overdose)
These factors decrease risk of an opioid overdose:
  • Using a consistent source/supplier
  • Testing a small amount first
  • Using a less rapid mode of administration (snorting)
  • Using with someone else
  • Using less if you haven’t used in some time, for any reason
  • Not letting anyone else prepare your drugs for you
What are commonly used opioids?
Heroin, Oxycontin, fentanyl, morphine, Vicodin, and Percocet. Methadone is also an opioid.
 
Can a person overdose on a prescription opioid?
Certainly a person can overdose on any opioid, regardless of whether it is a prescription medication or not.
 
Where can a person go for treatment of an addiction?
People who need treatment for an addiction have a number of choices. If they have insurance, they should call the number on the insurance card for a referral. Those who don’t have insurance or who have a program like Husky or Medicaid LIA should check the DMHAS website for a list of programs. All programs receiving funding from DMHAS must take some clients without insurance. Also, some programs are designed to treat individuals without insurance (like Blue Hills and CVH Merritt Hall).  Programs range from detox to outpatient to inpatient. Most programs should begin by asking you about your substance use so they can try to match you to the level of care that best meets your needs. DMHAS has a 1-800 number for persons struggling with opioids who want to be connected to services: 1-800-563-4086.
 
Are all overdoses the same?
All overdoses are not the same. An overdose on a stimulant like Cocaine would potentially have some of the same signs like difficulty breathing, vomiting and loss of consciousness, but unlike an opioid overdose, might also have: chest pain, dizziness, foaming at the mouth, lots of sweating or no sweating, racing pulse and seizures.  naloxone (Narcan) will not work on a cocaine overdose and there is no comparable naloxone (Narcan)-like medication to reverse it.
 
Where do I store the naloxone (Narcan)?
Naloxone (Narcan) should be stored at room temperature (neither too hot nor too cold) and should be kept out of sunlight; but not in the refrigerator.
 
What is an overdose “kit”?
Overdose kits are a handy way to be prepared by having everything needed in one place. A container of some sort is necessary to keep all the pieces together. The kit should include 2 doses of naloxone (Narcan), 2 alcohol wipes for cleaning the injection site, a pair of gloves, and a set of instructions. Some kits include other items, such as a Rescue Breathing mask.
 
Who do I call if I use my prescription or if my naloxone (Narcan) expires and I need a refill?
Prescriptions for naloxone (Narcan) are generally written in multiples of two, because of the possibility that the first dose may not work and a second dose may need to be given. Prescribers will vary in terms of how many refills they will be willing to write. Those individuals currently in a program should be able to get refills where they are receiving services. They could also ask their primary care physician. This website also has a list of providers who can write prescription refills.
 
Should I report if I use the naloxone (Narcan) and reverse the overdose?
If you reverse an opioid overdose, congratulations! You can report this good news to the agency where the naloxone (Narcan) was prescribed and/or email susan.bouffard@ct.gov.
 
Will insurance cover the cost of the naloxone (Narcan)?
Insurance may very well cover the cost of the prescription. You can check with your insurance company. If you have Husky C or Medicaid LIA, the cost is covered by these plans.
 
Will naloxone (Narcan) work if the person overdosed on something other than an opioid
Naloxone (Narcan) will only work to reverse the effects of opioids.
 
Will the person who recovers from an overdose be violent?
People who overdose generally don’t realize what has happened to them. They just come out of it feeling sick. They may misinterpret the situation to think that someone took their drugs and be agitated or upset. The best thing to do is to explain what happened.
 
Can a person re-overdose after the naloxone (Narcan) has been given?
Yes, depending on how much the person used. The naloxone (Narcan) lasts for about 30 – 90 minutes, so it is possible that at the end of that time, the person could re-overdose. The other possibility is that the person will want to use more drugs now that they are feeling sick after the naloxone (Narcan). Under no circumstances should they do this as it will increase the chances of re-overdosing.

My family doctor won’t prescribe me naloxone (Narcan). What are my options? 
Sometimes doctors aren’t familiar with naloxone (Narcan) or are unwilling to prescribe it. You can still obtain naloxone by going to one of the pharmacies in the state with a pharmacist who has been trained/certified to prescribe and dispense it. Just click on the Naloxone Prescribing Pharmacists link. The list is organized in alphabetical order by name of pharmacy. If you click the tab across the top of the page labeled “more views”, you can access a map with each red dot identifying a pharmacy in that location. If you click on the red dots near your location, you can see which pharmacies in your area have pharmacists willing to prescribe and dispense it to you. Most insurance will cover naloxone, although a co-pay or deductible may apply. The pharmacist will educate you on how to use the Narcan.

What is fentanyl?
Fentanyl is both an opioid medication that can be prescribed to treat pain (it can be prescribed as a transdermal patch worn on the skin) and an illicitly manufactured opioid that can be created in a lab similar to how methamphetamine is created in “meth labs”. It’s the illicitly manufactured fentanyl that is playing a significant role in the current opioid epidemic. Fentanyl and its many analogues are dangerous because they are much stronger than heroin and can be pressed into pills and passed off as other medications or mixed into heroin without the user’s knowledge. Many overdoses now involve fentanyl or fentanyl analogues.
 




Content Last Modified on 8/14/2017 8:37:03 AM