It’s not always obvious as to who might be at risk of an accidental opioid poisoning
The articles and videos below may inspire you to incorporate small changes into your practice that can help make a difference in the Canadian opioid crisis.
Indications and clinical use: NARCAN® NASAL SPRAY is a pure opioid antagonist indicated for emergency use to reverse known or suspected opioid overdose, as manifested by respiratory and/or severe central nervous system depression.
NARCAN® NASAL SPRAY can be administered by a bystander (non-health care professional) before emergency medical assistance becomes available, but it is not intended to be a substitute for professional medical care. Emergency medical assistance (calling 911) should be requested immediately when an opioid overdose is suspected, before administering naloxone.
Do prescription opioids play a role in the crisis?
While prescription opioids offer benefits, they also come with some risks.2 In fact, in Ontario, 53% of patients hospitalized due to opioid-related reasons had an active opioid prescription.9 As the most accessible healthcare professionals in Canada, you can help make a difference.19
The opioid crisis in communities
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The opioid crisis is a complex issue; while illegal drugs have caused many of the opioid-related harms, prescription drugs have also contributed.2 Despite patients intending to take their prescribed medication as instructed, there are a multitude of factors that can contribute to the risk of patients experiencing an overdose.8
Accidental opioid poisoning can happen to any of your patients taking opioids
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Uncovering all the factors that could lead to opioid-induced respiratory depression is difficult which is why anyone using opioids may be at risk of having an accidental opioid poisoning.1
You have the power to help prepare patients in case of an accidental opioid poisoning. Think of take-home naloxone kits as a powerful tool in your toolbox, and explain to patients that it’s analogous to any other emergency device or technique.20
Who is at risk of accidental opioid poisoning? It’s not always obvious
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Typically, patient selection guidelines for take-home naloxone kits recommend using key risk factor criteria.1-4 However, risk factor information isn’t always easy to acquire. Patients may not be fully forthcoming about their history, especially considering the stigma associated with opioid use.5
Everyone has bias—including patients and pharmacists.21,22 When it comes to opioid use, we may already have pre-conceived notions about the type of people who are at risk of opioid poisoning.7,20,23 This can have an impact on our conversations.22 Here are some ways to break-free from bias and tackle stigma.
Is the opioid stigma affecting your practice?
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As a pharmacist, you may have seen the impact of the opioid crisis firsthand. By acknowledging the social stigma associated with opioid use, and giving patients a positive experience at the pharmacy, you can help make a real difference.1
There are many types of opioids. But risk is still risk.
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Patients taking fentanyl or fentanyl analogues may be at an increased risk, but patients taking medications containing codeine, on its own or in combination (e.g., acetaminophen/codeine tablets), may also be at risk for an accidental opioid poisoning.24,25
The length of opioid use may be different. But risk is still risk.
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Whether opioids are prescribed to treat chronic or acute pain, there are still risks associated with each treatment plan.3,26 Despite best efforts in educating and counselling patients on opioid use, accidents may still occur.
Let’s talk about prescription opioids: Starting the conversation with your patients
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Communication is key! Keep in mind that some people may have been influenced by the negative connotations that media coverage has given to opioid use.7 Remind your patients that anyone using opioids may be at risk of having an accidental opioid poisoning.1
There are a few key words that come to mind when thinking about opioids: “overdose”, “accident”, “epidemic”, “addiction”, “death”. When talking to patients, your role as a pharmacist is to find a balance between the benefits and risks of prescription opioids, and to help keep the conversation positive.
Liam is a patient who was injured at work and has been suffering from chronic back pain
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How do you communicate with patients who may be uncomfortable having a conversation about naloxone over the counter and who may have already been taking opioids without naloxone?
Always offer a take-home naloxone kit–available as either a nasal spray, like NARCAN® Nasal Spray, or an injection–to any patient receiving an opioid prescription.1,3
Safety information10
Indications and clinical use: NARCAN® NASAL SPRAY is a pure opioid antagonist indicated for emergency use to reverse known or suspected opioid overdose, as manifested by respiratory and/or severe central nervous system depression.
NARCAN® NASAL SPRAY can be administered by a bystander (non-health care professional) before emergency medical assistance becomes available, but it is not intended to be a substitute for professional medical care. Emergency medical assistance (calling 911) should be requested immediately when an opioid overdose is suspected, before administering naloxone.
Contraindications: Patients who are hypersensitive to this drug or to any ingredient in the formulation or component of the container.
Serious warnings and precautions:
Call 911: Emergency medical assistance (calling 911) should be requested immediately when an opioid overdose is suspected, before using naloxone.
Continued surveillance: Individuals with a satisfactory response to an initial dose of naloxone should be kept under continued surveillance.
Aggressive reactions: Caregivers administering naloxone should be prepared to act in response to or assist the patient in cases of potential adverse reactions such as aggressive reactions, convulsions and vomiting. Special attention is warranted if naloxone is administered to a neonate or a pregnant woman.
Other relevant warnings and precautions:
In opioid dependent people, naloxone may trigger an acute opioid withdrawal syndrome; this may be life-threatening in opioid dependent neonates
Preterm labour or fetal distress in opioid dependent pregnant women
Rebound opioid toxicity, including respiratory depression, following the temporary reversal of the opioid overdose
Ineffective against respiratory depression due to non-opioid drugs
Cardiovascular risks including rare cases of cardiac arrest, tachycardia and ventricular fibrillation
Post-operative considerations including hypotension, hypertension, ventricular tachycardia and fibrillation, dyspnea, pulmonary edema and rare cases of cardiac arrest. Death, coma, and encephalopathy have been reported as sequelae of these events
Convulsions or seizures
Irritability and aggressive behaviour
Gastrointestinal reactions including diarrhea, nausea, vomiting and abdominal cramps
The product monograph is also available by calling 1-844-898-0657.
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Frequently Asked Questions
Can NARCAN® Nasal Spray be used on pregnant women?
NARCAN® Nasal Spray should only be used in pregnant women when clearly needed.10
Giving NARCAN® Nasal Spray to anyone who is physically dependent on opioids may induce an acute opioid withdrawal syndrome causing a reaction such as becoming aggressive, shaking and/or vomiting. You will need to pay special attention when giving NARCAN® Nasal Spray to a pregnant woman because some of these reactions may cause preterm labour or can be life threatening to the fetus. Emergency medical assistance (calling 911) should be requested immediately when an opioid overdose is suspected, before administering NARCAN® Nasal Spray.10
Please see the product monograph and patient information for a full list of warnings and precautions:
Newborns: You may need to help the person who received NARCAN® Nasal Spray. The patient may have a reaction such as becoming aggressive, shaking and/or vomiting. You will need to pay special attention when giving NARCAN® Nasal Spray to a newborn who is less than four weeks old or a pregnant woman. Some of these reactions can be life-threatening for a newborn or a fetus. Emergency medical assistance (calling 911) should be requested immediately when an opioid overdose is suspected, before administering NARCAN® Nasal Spray.10
The pharmacist may recommend using an alternate form of naloxone in newborns or children under two years old. This is because smaller doses can be given with the injectable form of naloxone.10
Children: When administering NARCAN® Nasal Spray in young children, the nozzle of the device may not fit inside the child’s nostril. In this case, make sure that the device nozzle forms a seal with the nostril before giving NARCAN® Nasal Spray.10
Please see the product monograph and patient information for a full list of warnings and precautions:
Can NARCAN® Nasal Spray be used past its expiration date?
NARCAN® Nasal Spray should be used before the expiration date on the box. However, if only expired NARCAN® Nasal Spray is available in an overdose situation, it should be used.10
What are the withdrawal symptoms that occur when you use NARCAN® Nasal Spray? What should you be prepared for?
NARCAN® Nasal Spray should be administered with caution to patients who are known or suspected to be physically dependent on opioids. In such cases, an abrupt reversal of opioid effects may precipitate an acute opioid withdrawal syndrome. The severity of such a syndrome will depend on the degree of physical dependence, the dose and potency of the opioid that induced the overdose, and the dose of naloxone administered.10
The signs and symptoms of an acute opioid withdrawal syndrome include, but are not limited to: body aches, pain, fever/pyrexia, sweating/hyperhidrosis, runny nose, sneezing, piloerection, yawning, weakness, asthenia, shivering, chills, tremor/trembling, convulsions/seizures, nervousness, restlessness, irritability, aggressive behavior, diarrhea, nausea, vomiting, abdominal cramps, increased blood pressure, and tachycardia. In the dependent neonate, signs also include excessive crying as well as hyperactive reflexes and the acute withdrawal may be life-threatening if not recognized and properly treated.10
Emergency medical assistance (i.e., calling 911) should be requested immediately when an opioid overdose is suspected. Monitor the patient for the development of the signs and symptoms of opioid withdrawal. Caregivers administering naloxone to any patient should always be prepared for potential reactions associated with acute opioid withdrawal syndrome and to assist the patient to minimize harm when experiencing these reactions. For example, a patient should be positioned in lateral decubitus to prevent choking if vomiting occurs; sharp or dangerous objects should be moved away in case of convulsions to protect the patient from injury, but the patient should not be restrained.10
How does reimbursement work? Can you give it to someone without ID?
NARCAN® Nasal Spray is available at pharmacies in Ontario as part of the Ontario Naloxone Program for Pharmacies (ONPP), and in Quebec as part of the Program for Free Access to Naloxone and Certain Related Supplies implemented by the Ministère de la Santé et des Services sociaux.11,12
NARCAN® Nasal Spray is also available for Veteran Affairs Canada clients, Non-Insured Health Benefits (NIHB) program clients, and First Nations Health Authority (FNHA) clients in British Columbia.13-15
Patients can request NARCAN® Nasal Spray without providing a prescription or an ID, helping them protect their privacy.16
In Ontario, for anonymous patients or those without an Ontario health card, use the following information:11 First and last name: HARM REDUCTION Gender: blank DOB: 20000101 Proxy patient ID: 89999 999 91
In Quebec, a health card may not be required to receive it; it can be supplied anonymously, especially in case of emergency.12,17
Do you need to call 911 if using NARCAN® Nasal Spray?
Yes, NARCAN® Nasal Spray can be administered before emergency medical assistance becomes available, but it is not intended to be a substitute for professional medical care. Emergency medical assistance (calling 911) should be requested immediately when an opioid overdose is suspected, before administering NARCAN® Nasal Spray.10
How much time between doses does there need to be?
Multiple doses of NARCAN® Nasal Spray may be required until emergency medical assistance becomes available.10
If the patient responds to the first dose of NARCAN® Nasal Spray but relapses back into respiratory depression before emergency assistance arrives, administer repeated doses of NARCAN® Nasal Spray as necessary. If the patient does not respond to the first dose of NARCAN® Nasal Spray after 2-3 minutes, administer repeated doses using alternate nostril as necessary.10
How do you order NARCAN® Nasal Spray kits?
Orders for NARCAN® Nasal Spray can be made by calling Emergent BioSolutions Canada Inc. at 1-844-898-0657 or by emailing customerservicecanada@ebsi.com.
How many NARCAN® Nasal Spray kits can you hand out to a person?
In Ontario, up to two NARCAN® Nasal Spray kits can be given to a patient at a time.11 In Quebec, up to four NARCAN® Nasal Spray kits can be given to a patient at a time.18
Is one dose of NARCAN® Nasal Spray sufficient to reverse an opioid overdose?
Not always, some patients may need multiple doses. The requirement for repeat doses of NARCAN® Nasal Spray depends upon the amount, type, and route of administration of the opioid being antagonized.10
If the patient does not respond within 2-3 minutes to the first dose of NARCAN® Nasal Spray, administer an additional dose of naloxone every 2-3 minutes (if additional doses are available), using a new NARCAN® Nasal Spray device for each dose using alternate nostril, until the desired response is obtained.10
Emergent BioSolutions, Emergent, NARCAN® and any and all Emergent BioSolutions Inc. brands, products, services and feature names, logos and slogans are trademarks or registered trademarks of Emergent BioSolutions Inc. or its subsidiaries in the United States or other countries.
Meet Liam
Liam is a patient who was injured at work and has been suffering from chronic back pain
Meet Liam
Age: 42
Job: Construction worker
Condition: Liam injured his back while lifting a heavy load at work. He has also been suffering from chronic back pain for the past two years.
Treatment plan: Liam takes acetaminophen/codeine tablets twice a day for his chronic back pain.
Other: Liam has two teenage boys at home, the oldest of which is 16.
References: 1. Alberta College of Pharmacists. Helping you navigate change: The communication issue. The Transition Times. October 2008. Available at: https://abpharmacy.ca/system/files/TransitionTimes_Oct08.pdf, Viewed September 2, 2021. 2. Antoniou T, Pritlove C, Shearer D et al. A qualitative study of a publicly funded pharmacy-dispensed naloxone program. International Journal of Drug Policy. 2021:103146. 3. Dassieu L, Heino A, Develay É et al. “They think you’re trying to get the drug”: Qualitative investigation of chronic pain patients’ health care experiences during the opioid overdose epidemic in Canada. Canadian Journal of Pain. 2021. 4. Jeunesse sans drogue Canada. Help your teens before they help themselves. Available at: https://www.jeunessesansdroguecanada.org/prevention/pleins-feux-sur-les-drogues/medicaments-dordonnance/. 5. Finkelstein Y, Macdonald EM, Gonzalez A et al. Overdose risk in young children of women prescribed opioids. Pediatrics. 2017;139(3):e20162887. 6. Government of Canada. Opioids. Viewed at: https://www.canada.ca/en/health-canada/services/opioids.html. 7. Government of Canada. Opioid overdose. Viewed at: https://www.canada.ca/en/health-canada/services/opioids/overdose.html8. Mueller SR et al. Attitudes toward naloxone prescribing in clinical settings: a qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. Gen Intern Med. 2016;32(3):277-283. 9. Monograph of NARCAN® Nasal Spray. Emergent BioSolutions Canada Ltd. 5 mars 2021. 10. Ontario Pharmacists Association. Pharmacist clinical tool for initiating naloxone discussions. Available at: https://opatoday.com/wp-content/uploads/Practice/Tools/Naloxone/Pharmacist-Clinical-Tool-for-Initiating-Naloxone-Discussions.pdf. Viewed July 27, 2021. 11. Tsuyuki R et al. Canadian national consensus guidelines for naloxone prescribing by pharmacists. Canadian Pharmacists Journal. 2020;153(6):347-351.
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