Updated 3/20/2024: This article was updated with information about how to administer naloxone, in Question 2.
The life-saving opioid overdose reversal medication naloxone is now available to the public without a prescription. It is available under its brand name Narcan, which the U.S. Food and Drug Administration (FDA) approved for over-the-counter distribution earlier this year.
The FDA first approved naloxone in 1971, and it has since been traditionally used by first responders, law enforcement and emergency room staff to reverse overdoses from opioid drugs such as heroin, oxycodone and methadone. It is by far the most effective tool we have to reduce opioid overdose.
Today, because of the unprecedented and nationwide proliferation of the synthetic opioid fentanyl, which is 50-100 times more potent than heroin, people are often dying from overdose before first responders can get to them. That’s why it’s incredibly important that the FDA approved the over-the-counter naloxone product, so that roommates, parents or friends can easily possess and administer it if they witness an overdose. Additionally, due partially to the increased potency of illegal street drugs, the rate of fatal opioid overdose is more than 10 times higher now than it was 20 years ago. In other words, calling 911 may not be fast enough to save lives.
To better understand what naloxone is and how to use it, we posed a series of questions to John McIlveen, State Opioid Treatment Authority at OHA.
1: What forms does naloxone come in?
Naloxone comes in two basic forms, a nasal spray and an injectable liquid. Only the nasal spray has been approved as an over-the-counter product, and one still needs a prescription to get the injectable form.
2: How is naloxone administered?
The pre-filled naloxone nasal spray is safe and easy to use. Remove the nasal spray from the box. Peel back the tab with the circle to open it. Do not prime or test the nasal spray plunger. It contains a single dose of naloxone and cannot be reused. Hold the nasal spray with your thumb on the bottom of the plunger and your first and middle fingers on either side of the nozzle. Lay the person on their back. Put your fingers on either side of the nozzle and put the tip of the nozzle into one nostril until your fingers on either side of the person’s nose. Press the plunger firmly and completely to give the naloxone dose. Remove the nasal spray from the person’s nostril after giving the dose. Move the patient on their side into a recovery position after giving the naloxone. Watch the person’s breathing closely. While most people wake up or start breathing within a few seconds, it can take several minutes for the naloxone to work. If the person is not breathing at all, or the person is not breathing normally after three minutes, you can give a second dose of naloxone. The goal of giving naloxone is to restore breathing, and most people’s breathing will be restored with just ONE dose. Remember, naloxone only works on opioids. If the person has not taken opioids, naloxone will not hurt them, but it will also not restore their breathing.
Watch the video to the right on how to administer the nasal spray naloxone, and you can print out this one-page step-by-step guide to keep handy.
If you have the injectable form of naloxone, refer to this video and this one-page guide. It can be injected anywhere in the body, preferably into fatty tissue or muscle. This method also usually results in near-immediate overdose reversal, and there is also no risk associated with giving additional doses of injectable naloxone.
3: How does naloxone work?
When opioids enter the body, they attach to the “mu” or “opioid receptors” in the brain. These attachments, or connections, create a feeling of euphoria (or “high”) and analgesia (pain relief). If someone overdoses—that is, they take more opioids than their body can tolerate (each person is different in this respect)—the level of pain relief and euphoria can increase to a point where significant or life-threatening respiratory depression occurs. Breathing and heart rate will then slow down, and if that continues the body begins to shut down, starting with internal organs and then the brain. This can happen in matter of minutes, or even hours. (Learn more about overdose and how to recognize it here.)
When someone overdosing receives naloxone, that connection between the opioids and the receptors breaks, and the person should revive within seconds or a couple of minutes. They should become alert and lucid, but they may also become angry or annoyed because they might experience instant withdrawal symptoms such as nausea, vomiting and other flu-like symptoms. Also, the pain-relief effect of the opioid will have stopped, potentially causing the person physical pain.
4: Should I call 911 after giving someone naloxone?
ABSOLUTELY. If possible, call 911 before administering naloxone and then put the phone on speaker to free your hands while you talk with the 911 operator. The life-saving effects of naloxone will only last a short time, and as soon as the naloxone wears off the opioids may reattach to the receptors and potentially restart an overdose.
This is also why it’s a good idea to have more than one dose of naloxone on hand, if possible. Especially with the high potency of fentanyl, sometimes two or more doses are needed to keep the individual alive while you wait for the paramedics to arrive. And you should stay with the person until then.
Please note that if you call police or 911 to get help for someone having a drug overdose, Oregon’s Good Samaritan law protects you and the person who has overdosed from being arrested or prosecuted for drug-related charges or parole/probation violations based on information provided to emergency responders.
5: Can naloxone be used on any drug overdose, or just overdose of certain drugs?
Naloxone is strictly an anti-opioid medication and is only effective against overdose from opioids, which are sometimes referred to as opiates, painkillers or narcotics. About 75% of overdose deaths in the United States are caused by opioids, so the wide availability of naloxone is critically important.
Sometimes people take illegally manufactured opioids that are mixed with other, non-opioid drugs, such as the animal tranquilizer xylazine which makes the “high” from the opioid last longer. An overdose from mixtures like this can still be reversed with naloxone, but the naloxone won’t have any effect on the non-opioid components. This is another reason to call 911 as soon as possible, because the individual experiencing overdose could have other harmful substances in their body.
6: Who should carry naloxone?
In a perfect world everyone would carry naloxone on them, since just about anyone, anywhere, can be a witness to overdose. Certainly anyone who uses drugs or lives with people who use drugs should carry naloxone, even if the at-risk individual is not currently using but has a history of drug use. Even if someone doesn’t use opioids specifically, the proliferation of fentanyl used as a filler in illegally manufactured pills or powders makes just about any street drug potentially lethal.
Naloxone is often stocked in schools, public libraries and other places drug overdoses are known to happen, where staff is able to administer the medication.
7: How much does naloxone cost, is it covered by insurance, and how can I get it?
Most insurance policies cover the cost of naloxone, with a potential co-pay. Oregon Health Plan (OHP/Medicaid) provides free naloxone to its members, and those who are uninsured or underinsured may be able to pick up free naloxone at county health departments, some law enforcement and Department of Human Services offices, as well as many community based organizations that support substance use treatment, harm reduction and recovery. Most pharmacies carry it, but not all. Without insurance, the retail price of the nasal spray form of naloxone (under the brand name Narcan) varies widely, but some Walgreens, for example, are charging $45 for a two-dose box. You might call ahead to confirm availability and pricing.
You may also be able to have free naloxone mailed to your home, anywhere in the United States.
The availability of over-the-counter naloxone is so new that it may take some time for pricing and access to stabilize.
For more information on naloxone and other opioid resources, as well as how OHA is addressing the opioid crisis, visit our website. You can also explore our statewide initiative Save Lives Oregon, which provides harm reduction supplies and technical support to a variety of community based organizations and other groups which serve people in various stages of recovery and those at highest risk of overdose.