Naloxone – Opioid Antagonist (Nursing)

00:00 Now, I want you to be aware as a nurse what would you recognize with the patient, what are the classic triad of signs if someone has had an opioid overdose.

00:09 Well, the first one is going to seem kind of obvious. Oh, hello, coma. Yeah.

00:14 Hopefully you would recognize if a patient is in a comma, that means they're unresponsive, there's a problem.

00:21 If they have respiratory depression and here's the one to remember most, pinpoint pupils.

00:28 If I've got somebody who's not responsive, they're not breathing very quickly, respiratory depression, and their pupils are tiny, then I will start thinking about opioid overdose.

00:38 Now, we can treat this. Remember if we have an opioid overdose, we can treat it with naloxone because it's an opioid antagonist.

00:46 But you'll see this refer to in the literature, as the classic triad of signs of opioid overdose, just meaning the classic 3 signs of opioid overdose.

00:56 They're not responsive, they're in a coma, their respiratory rate will be slow and shallow, and they have pinpoint pupils.

01:04 Now, the trade name for naloxone is Narcan and I wanted to include that in this one.

01:09 I don't normally put those in our presentations, but I want you to recognize that because this is the name that you see in the news a lot.

01:17 Naloxone is the generic name, Narcan is one of the trade names.

01:22 Now, it is a very strong competitive, pure opioid antagonist at the receptors.

01:29 Okay, I said that slowly because I want it to sink in. This drug saves lives.

01:37 If someone has taken an overdose of a pure opioid agonist, (remember those are the medications, strongest ones, these are the ones that are most likely for abuse) this drug can literally save their lives.

01:50 Now, it's not just limited to someone who individually takes an overdose.

01:54 Sometimes in the hospital when we give opioids to a patient, it's a little much for them.

01:59 So we can give that to a patient to back off on that rather quickly.

02:03 Doesn't mean we intended to overdose them or they intended to overdose, but this is a drug that we also use in the hospital setting for anyone who gets a little bit too sleepy or a little too much of an opioid agonist.

02:16 This drug reverses the effects of the opioids because it's an antagonist so it's going to reverse the coma, they're going to wake up.

02:24 It's going to reverse the respiratory depression. It's going to reverse the pain relief and the euphoria.

02:29 So when they wake up in the ER, they're not particularly happy if they thought they had taken a drug to get that euphoric kind of feeling, they get into ER, we hit them with the naloxone, they wake up, and it's usually not a real happy awakening but we have saved their lives.

02:48 Here's another reason why they're not really excited.

02:50 Be aware, if somebody has significant physical dependence on opioids, they will have an immediate withdrawal response.

02:59 Okay, that should kind of give you a picture why when someone rolls in the ear with an overdose of opioids, we hit them with naloxone, they wake up, come right out of that coma, they start breathing faster, they have no pain relief, they have no euphoria, and they start feeling horrible.

03:17 There is nothing fun about withdrawal responses.

03:21 Now, the patient had been on opioids whether prescription or they were abusing them, we would gradually wean those down to avoid the withdrawal symptoms.

03:31 But clinically significant dependence can develop after just 20 days or more of high opioid doses.

03:38 So, you may be a patient who has a prescription and you've been taking it for 20 days.

03:43 That would be perfectly appropriate. That's why it's so important that we wean the medication down instead of abruptly discontinuing it.

03:51 Hey, Narcan is abruptly discontinued. If we're using Narcan, we're trying to save your life and so we'll deal with the withdrawal symptoms.

03:59 But someone else who had been on an opioid, that's why we wean the medications.

04:03 We give them gradually lower and smaller and smaller doses over a longer period of time so they don't deal with those withdrawal symptoms.

04:12 But that's what you're dealing with in an ER situation or out in the street.

04:15 If you give somebody Narcan, they're going to wake up immediately and if they have a very strong physical dependence, they are going to start feeling horrible pretty quick.

04:25 Now, I want you to think about opioid withdrawal symptoms kind of like flu-like symptoms.

04:29 And nobody feels good with the flu, but that's kind of how they feel.

04:34 Let me break it down for you. Instead of that euphoria, they have this dysphoria and they feel terrible.

04:41 They have this weird kind of yawning, they have a runny nose. That's a rhinorrhea.

04:46 Their pupils were dilated and they'll be tearing kind of that parasympathetic response.

04:51 Their hairs stand on under. They bristle. Their muscles hurt. They have nausea, vomiting, and diarrhea.

04:58 Their gut is just going crazy and they have a fever and they're sweating.

05:03 So think of it as like an overall horrible case of the flu and you want to watch them very closely for severe dehydration because of the nausea, vomiting, diarrhea, fever, and sweating.

05:15 So, opioid withdrawal is no fun, but let's stop for just a minute and I want you to see if you can think of 2 reasons a patient would go through opioid withdrawal symptoms.

05:29 Okay, here are some examples of why a patient would go through opioid withdrawal symptoms.

05:34 They have overdosed and they have a physical dependence on opioids and we gave them naloxone.

05:41 Oohhh, they're going to wake up and they're going to wake up feeling horrible.

05:46 Another reason patients would go through an opioid withdrawal symptoms is they may have had a prescription, they are following exactly the doctor's orders, but for some reason they stop taking the medication abruptly and they have been taking it for 3 weeks.

05:59 They are going to experience opioid withdrawal symptoms.

06:02 Always remember when it's appropriate to wean the medication.

06:07 Now, the routes that we can give naloxone, this is what is so cool.

06:10 You can give it intranasally. That means anyone can give it in a nose spray.

06:15 So you spray it in 1 nostril with the person lying on their back. In about 2-5 minutes, you'll start to see the effect.

06:22 Now, lots of EMT, first responder, police officers, or even family members of people who we know have problems with drug addiction can carry a nose spray with them and it's easy for anyone to administer.

06:36 Parenteral, IV or IM has to be given by somebody who's trained.

06:40 So, IV, the effects take effect almost immediately but they only last for about an hour.

06:46 So if you think about that patient that's in the ER, they are all in the opioid overdose, we give them an IV dose of medication, boom they wake up almost immediately but it only last for an hour.

06:56 So we might have to give them more than 1 dose. You can also give it like thru the EpiPen.

07:02 You can give this injected directly into the thigh with an autoinjection device.

07:06 That also will kick in in about 2-5 minutes and it will last for several hours.

07:12 So, I want you to be really clear on what drugs naloxone reverses. It's opioids only. Okay? Opioids only because remember naloxone is an opioid receptor antagonist.

07:27 I want to give you an example of commonly abused types of opioids. Fentanyl.

07:33 That drug is a hundred times more potent than morphine.

07:37 It's a really powerful drug, has a high black market value.

07:42 Methadone, dilaudid, Norco, and Lorcet. Now, all of these are considered prescription drugs. The last one is heroin.

07:52 So, naloxone will also work on a heroin overdose which is clearly a street drug but I wanted you to be aware that that's one of the medications that it will also work on.

08:02 Now, this isn't a complete list. Again, I just gave you the commonly abused examples plus heroin.

08:10 Now, I want to also clarify what drugs naloxone does not reverse.

08:15 Non-opioids like benzodiazepines. But wait a minute, if somebody took a true benzodiazepine overdose, how does it look different? Well, you know they're still going to be out of base so might be able to respond to them but if they have taken something like diazepam, alprazolam, or midazolam, you can give them the naloxone, but it's not going to help anything.

08:35 It won't hurt them but it also won't help them. Same thing for stimulants.

08:39 If they're on amphetamines, cocaine, crystal meth, methamphetamines, naloxone is not going to help them.

08:46 If they have other sedatives like phenobarbital or clonazepam, ___ it's not going to help.

08:51 So be very clear. Naloxone only works on medications that are opioids.

08:57 Also if you have someone who has an alcohol overdose, naloxone will effect it.

09:03 The good news about naloxone, like I said on those other medications it won't help the patient but it won't hurt them.

09:08 You can't overdose on naloxone and you don't ever develop a dependence to it or tolerance. It works every time.

09:17 So there are certain patients that have had naloxone multiple times with overdoses.

09:22 So, larger doses are more likely to cause withdrawal symptoms if the patient is physically dependent on opioids.

09:28 So, when they get a big dose of Narcan, that's likely what's going to happen.

09:32 Remember, if the patient hasn't taken opioids, naloxone will not have any effect, won't hurt them but it sure won't help them.

09:40 So if the person has taken opioids and other medications, let's say that the person took an opioid plus they took a benzodiazepine and we give them naloxone, it will only reverse the opioid medication effects.

09:54 So, they're still going to have to deal with the overdose of the benzodiazepine and if they had taken a benzodiazepine and alcohol and opioids, again naloxone will only reverse the opioid effects so you're still going to have to deal with the CNS depressant effects of the benzodiazepines and alcohol.