What do you need to know about naloxone before the day you have to use it?
What would you do if someone in your home stopped breathing after taking an opioid? Would you call 911 and wait? Or, would you have naloxone within reach, and know how to use it?
Naloxone, best known by the brand name, Narcan, is the drug that reverses an opioid overdose. It is now sold on store shelves without a prescription, and you do not need medical training to use it. If someone near you cannot be woken, or is not breathing normally right now, stop reading and call 911.
I first wrote this article in March of 2020, when Narcan was kept behind the pharmacy counter. A lot has changed since then, yet the five things that every family should understand about naloxone have not changed at all.
First, naloxone is a rescue drug that reverses an opioid overdose.
When a person overdoses on an opioid, such as heroin, fentanyl, or a prescription pain medication, their breathing slows down and can stop. Slowed breathing leads to low oxygen levels and, eventually, death.
The way that naloxone works is that it blocks opioid receptors. It is such a potent blocker that it knocks opioid molecules off of the receptors, and it keeps them away by continuing to block. When the receptors are blocked, the person wakes up and starts to breathe again.
They also wake up in opioid withdrawal. While opioid withdrawal is rarely life-threatening, it is very unpleasant, and withdrawal caused by a blocker is especially hard because it starts all at once. This sudden form is known as precipitated withdrawal.
So, do not expect to be thanked. The Narcan label warns that some people wake up shaking, sweating, nauseated, or angry, and that this is to be expected. Stay with them anyway.
Second, naloxone has been around for a long time, and you no longer need a prescription to buy it.
You may believe that naloxone is a new drug, invented in response to fentanyl. The fact is that naloxone was patented in 1961, and the U.S. Food and Drug Administration (FDA) approved it to treat opioid overdoses ten years later. We have had this overdose reversal drug for decades.
What is new is where you can find it. On March 29, 2023, the FDA approved Narcan 4 mg nasal spray for over-the-counter sale.
Over-the-counter, or OTC, means that you can take it off the shelf and pay for it at the register, along with your milk, eggs, and butter. There is no prescription, no paperwork, and no disapproving look from across the pharmacy counter.
A second OTC spray, RiVive, which contains 3 mg, was approved in July of 2023, and generic 4 mg sprays are sold as well. The nasal spray has no needle and nothing to assemble. Each device holds a single dose, so do not press the plunger to test it.
If you or a family member takes a prescribed opioid, or uses street opioids, you should have naloxone in your home at all times. You should also know how to use Narcan before the day that you need it.
How much does Narcan cost now, and can you get it for free?
In 2020, a box of Narcan cost around $150, and I predicted that OTC approval would bring the price down to $10 or less per spray. I was wrong about the number. When OTC Narcan reached stores in 2023, a box of two doses cost far less than $150, and far more than $10.
Fortunately, many people do not have to pay for it at all. Many state and county health departments give naloxone away at no cost. So do harm reduction programs, which are community organizations that work to keep people who use drugs alive and healthy, and some of them will mail it to your home.
A prescription is no longer needed, yet it may allow your insurance plan to pay for naloxone, so it is worth asking your pharmacist.
Should you still ask your doctor about naloxone?
Yes, you should. In July of 2020, a few months after this article first appeared, the FDA began requiring the labels of opioid pain medications, and of the medications that treat opioid use disorder, to tell doctors to discuss naloxone with their patients.
I believe that doctors should have this conversation with every patient who takes an opioid, and with every family that keeps opioids at home. If your doctor does not bring it up, bring it up yourself.
Keeping naloxone in the medicine cabinet does not mean that anyone in your home has an addiction. A person who takes a prescribed opioid for pain may be physically dependent on it, and physical dependence is not addiction. Yet, that person can still overdose by accident, and so can a grandchild who finds the bottle.
Third, naloxone does not last for very long.
Since you may one day have to give Narcan to someone who has just overdosed, you must understand that naloxone wears off quickly. It starts working within minutes. Yet, a dose only keeps working for about 30 to 90 minutes.
Many opioids stay in the body longer than that. Fentanyl, methadone, and extended-release pain medications can all outlast a dose of naloxone.
That means that a successful rescue may only be temporary. While the person may look fine after waking up, they can slip back into the overdose as the naloxone wears off, sometimes after everyone in the room has relaxed.
Naloxone is not a cure for an overdose. It is a bridge to the ambulance.
What should you do when you give Narcan to someone?
The Narcan label lays out the steps in order. First, check for an overdose by shouting and shaking the person. If they do not wake up, lay them on their back, give one spray into one nostril, and then call 911.
Next, wait 2 to 3 minutes. If the person has not woken up, give a second dose from a new device, and keep giving a dose every 2 to 3 minutes until they wake up. With fentanyl, one dose may not be enough. There is also a prescription 8 mg spray, and the steps are the same.
Finally, stay. The label says to stay until the ambulance arrives, even if the person wakes up. If the person is breathing but not awake, roll them onto their side, so that they do not choke.
Call 911 right away if a person who may have taken an opioid:
- cannot be woken, or does not respond to your voice or your touch
- is breathing very slowly, breathing irregularly, or not breathing at all
- is making gurgling, choking, or snoring sounds
- has lips or fingernails that are turning blue, gray, or purple
- has woken up after a dose of naloxone, because the naloxone may wear off before the opioid does
Give naloxone if you have it, and do not wait to see whether it works before you call. If you are in crisis or having thoughts of suicide, call or text 988, the Suicide and Crisis Lifeline, at any hour.
Fourth, naloxone has no potential for abuse, so never lock it away.
In medicine, we sometimes take our knowledge for granted, assuming that most people already understand the basics. So, to be clear, naloxone has no potential for abuse. A person with an opioid addiction, or any other addiction, has no way to get high from naloxone.
Why is it so important to be aware of this fact? I have spoken with family members of people with opioid use disorder about keeping Narcan in the house. Even after hearing what it is for, some families have locked up the Narcan, to keep it from being misused.
Imagine that your loved one overdoses in the house. You do not want to be fumbling with the key to a locked box or a safe while your family member is unconscious, on the floor, and not breathing.
Keep naloxone out in the open, in a place that everyone in the house knows about. The same goes for a rehab or a sober living home, where there is no reason to keep the Narcan locked up.
Fifth, naloxone is just one component of effective harm reduction.
Harm reduction means to help people stay safe, healthy, and alive during the time that they continue using drugs. While naloxone is a vital part of harm reduction, there is more to it than carrying Narcan.
People who use heroin or fentanyl with a needle should have access to sterile syringes and needles, and some communities in the U.S. have programs that provide them. In some countries, there are supervised consumption sites, where staff are ready to reverse an overdose and to help people get treatment when they are ready.
Another rule of harm reduction is to never use alone. People tend to use drugs secretly and in private, and often, by the time they are found, it is already too late. Naloxone cannot help a person when there is no one there to give it.
Tough love does not work.
For many years, families have been taught to practice “tough love.” It means that if you have a loved one who cannot stop using drugs, you do not feed them, you do not let them in your home, and you do not give them money.
The idea is that they will hit their “bottom” faster, and then they will finally be ready to accept help. Unfortunately, tough love does not work, and it is more dangerous than ever now that the street supply is full of fentanyl.
If your family member is out on the streets using drugs, who will be there to give them Narcan? Tough love gets people killed.
Harm reduction starts at home.
Harm reduction is nearly the opposite of tough love. Yet, it does not mean that you are enabling someone to continue using drugs. It does not include buying drugs for your loved one or handing them drug money.
What it might consist of is allowing your loved one to keep living at home, eat meals with you, and remain a part of the family. It also means that there is naloxone in the house, and that everyone knows where it is.
When you stay connected with a family member who has an addiction, and you let them know that you are there to help, they can turn to you when they are ready to quit.
Why do heroin and fentanyl overdoses happen in the first place?
Most overdoses are accidents. The person did not intend to take too much.
Don’t people who use heroin know how much is too much? Unfortunately, they cannot know, because street drugs are not regulated at all. There is no label on the bag, and there is no way to tell what is in it.
With other street drugs, a dealer makes more money by adding an inactive filler. With heroin, the added ingredient is fentanyl, and fentanyl is not inactive. It is a synthetic opioid that is far more potent than heroin, and a very small difference in the amount can be the difference between getting high and dying.
In an operating room, measured and given by an anesthesiologist, fentanyl is safe and useful. On the street, stirred into a powder or pressed into counterfeit pain pills, it is one of the deadliest drugs that there is.
How can an opioid overdose be prevented?
Naloxone treats an overdose after it has started. It does nothing to prevent the next one. The real prevention is medical treatment for the opioid addiction itself.
Fortunately, there are two medications with a long track record, methadone and buprenorphine. Methadone is dispensed through licensed clinics. Buprenorphine, the main ingredient in Suboxone, ZubSolv, and their generics, is prescribed from a doctor’s office.
Congress eliminated the special federal waiver that doctors once needed to prescribe buprenorphine at the end of 2022. That changed the answer to the question of who can prescribe Suboxone.
Treatment with buprenorphine is known as medication-assisted treatment, or MAT. Buprenorphine relieves the withdrawal sickness, and it reduces the cravings.
A person who is not sick, and not craving, has far less reason to buy an unknown powder from a stranger. That is how treatment prevents an overdose. It starts with a doctor who does not judge you, and who takes the time to listen.
Is the naloxone in Narcan the same naloxone that is in Suboxone?
Yes, it is the same drug, doing a very different job. Suboxone is a brand-name medication that contains buprenorphine and naloxone, and it is taken under the tongue.
Remember that naloxone throws a person who is dependent on opioids into sudden withdrawal. It also has little to no effect when a person swallows it or puts it under their tongue. Because of these properties, it was added to Suboxone as an abuse-deterrent, meaning an ingredient that is there to discourage misuse.
The idea is that if someone tries to inject their Suboxone, the naloxone will make them sick. Taken under the tongue as prescribed, it does almost nothing.
Should I be worried about naloxone side effects from my Suboxone?
For the vast majority of patients who take Suboxone as directed by their doctor, naloxone side effects are not an issue. Very little of it is absorbed under the tongue.
Is naloxone effective as an abuse-deterrent? Realistically, it is unclear. It has not been clearly shown to work as a deterrent, and yet the combination remains the usual prescription.
If you believe that you are reacting to the naloxone in your medication, tell your doctor. Buprenorphine can be prescribed without it, and the difference between Suboxone and Subutex is smaller than most people think.
Remember that naloxone is an opioid overdose rescue drug first.
Please do not be distracted by the other uses of naloxone. Naloxone should be seen, first and foremost, as a rescue drug that saves lives.
Have you ever looked at the wall in a public building and seen a box labeled AED? An AED is an automated external defibrillator, which is a life-saving device for people whose hearts suddenly fall out of rhythm. Why are these machines on the walls of airports, gyms, and schools? Because they save lives.
While this is not a perfect analogy, naloxone belongs on that wall, right beside the AED.
You can do your part as well. Carry naloxone with you, in your handbag or your backpack. Naloxone is far cheaper than an AED.
How do I treat opioid dependence in my practice?
I provide buprenorphine treatment, with Suboxone and its film and tablet generics, to new patients in Florida by telemedicine, with in-office visits available in Fort Lauderdale. Patients start at home with phone support, and when fentanyl is involved, I use a low-dose start when needed.
Visits are monthly, or weekly when needed, and there are no mandatory group meetings. The patient decides whether the goal is long-term maintenance or a gradual taper. An overdose is always a reason to call 911.
To ask about buprenorphine treatment, contact my office through the contact form.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
