Administration of Nasal Naloxone Narcan

Pursuant to section 195.206, RSMo.,

• Any licensed pharmacist may sell and dispense naloxone.
• It is permissible for any person to possess naloxone.
• Any person who administers naloxone to another person who the person believes is suffering from an opioid overdose, who acts with good faith and reasonable care and who contacts emergency personnel immediately after administering the drug, is immune from criminal prosecution and civil liability and is not subject to disciplinary action from his or her professional licensing board based on the administration of the drug.

Pursuant to 338.205:

• Notwithstanding any other law or regulation to the contrary, any person or organization acting under a standing order issued by a health care professional who is otherwise authorized to prescribe an opioid antagonist may store an opioid antagonist without being subject to the licensing and permitting requirements of this chapter and may dispense an opioid antagonist if the person does not collect a fee or compensation for dispensing the opioid antagonist.

Considerations:

• Given that when a student is having a possible opioid overdose, it can be a stressful situation, it is highly recommended that you familiarize yourself with the district naloxone plan or if student specific, their emergency care plan beforehand.
• Signs of opioid overdose include:
  • Small, constricted “pinpoint pupils;”
  • Falling asleep or losing consciousness;
  • Slow, weak, or no breathing;
  • Choking or gurgling sounds;
  • Limp body;
  • Cold and/or clammy skin; and
  • Discolored skin (especially in lips and nails).
• Naloxone is a safe medicine. Give naloxone even if you do not know what kind of drug the student took.
  • It only reverses overdoses in people with opioids in their systems.
• Store the naloxone in a location that is easily accessible during a suspected overdose.
• Secured, but accessible storage of the medication should be considered in the school’s emergency response plan.
• The school nurse should develop a plan to systematically check the expiration date on the medication to ensure the medication has not expired.
• Be sure to ensure the student’s privacy and confidentiality when calling for assistance. 
• Do not say the student’s name over the PA system or walkie-talkie.
• If possible, have someone assist with removing onlookers and other students to provide the student with privacy.
• Do not remove the naloxone nasal spray until you are ready to use it.
  • Do not test the device prior to use.
• The naloxone nasal spray does not need to be primed prior to administration.
• Each naloxone nasal spray has one dose and cannot be reused.

Supplies:

• Medication
• Gloves
• Gauze or paper towel
• Health care provider’s order/Standing Order/Protocol
• Parent/Guardian authorization form, if needed
  
  

Procedure:

1. Call for assistance, if you have not already done so
   • Ask that another school staff person call 911 or emergency medical services
2. Determine that the signs of an overdose are present
3. Check the student for a response
   • Shake the student and shout to them to wake up
   • Grind your knuckles into their chest bone for 5-10 seconds
4. Hold your ear close to the student’s nose, listen and feel for signs of breathing
5. Explain to the student that you are going to administer naloxone
6. If possible, wash your hands
7. Assemble the needed supplies
8. Review the six rights of medication administration to be sure it is:
   • The right student
   • The right medication
   • The right dose
   • Being given at the right time
   • Being given by the right route
   • Being given for the right reason
9. Check the medication expiration date
10. Review student’s allergy status
11. Ensure proper documentation of parent/guardian authorization to administer medication, if needed
12. Put on gloves
13. Review the six rights again to be sure that it is:
    • For the right student
    • The right medication
    • The right dose
    • Being given at the right time
    • Being given by the right route
    • Being given for the right reason
14. Place the student on their back to receive the medication
15. Remove naloxone from packaging
16. Hold the nasal spray with your thumb on the plunger and your first and middle fingers on either side of the nozzle
17. Tilt the student’s head back and provide support under the student’s neck with your hand
18. Gently insert the tip of the nasal spray into either nostril of the student until your fingers are touching their nose
19. Firmly press the plunger to release the entire dose of the medication into the nose
20. If the student is not already lying on their side, place the student on their side
21. If EMS/911 has not been called yet, call 911 or EMS services 
22. Stay with the student, monitoring breathing
23. Attempt to keep the student awake and breathing
24. If breathing stops, begin rescue breaths
25. Have someone bring an AED, if available
26. If breathing and heartbeat stop, begin CPR
27. If there is no response in 2-3 minutes and the health care provider’s order allows, give an additional dose in the other nostril, if one is available
28. Once rescue squad arrives, inform them of medication administered, including type of medication, dosage, and time
29. Remember to dispose of all used equipment and medicine safely out of the reach of students
30. Remove gloves
31. Wash hands
32. Document the date, time, and dose of medication given
33. Follow up with the parent or guardian and health care provider, as needed

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References:

Adapt Pharma, Inc. (2020, August). Instructions for use NARCAN (nar´ kan) (naloxone hydrochloride) nasal spray. Retrieved June 23, 2023, from https://www.narcan.com/wp-content/uploads/2021/10/Gen2-Instructions-For-Use.pdf

Center for Disease Control and Prevention. (n.d.) How to use naloxone nasal spray. . Retrieved June 23, 2023, from https://youtu.be/odlFtGNjmMQ

Centers for Disease Control and Prevention. (2023, April 21). Lifesaving naloxone. Reverse opioid overdose with naloxone. Retrieved June 23, 2023, from https://www.cdc.gov/stopoverdose/naloxone/index.html

Missouri Department of Health and Senior Services. (n.d.) Questions to consider in development of naloxone protocol in Missouri school programs. Retrieved June 23, 2023, from https://health.mo.gov/living/families/schoolhealth/pdf/naloxone-toolkit.pdf

Missouri Department of Health and Senior Services. (n.d.) Use naloxone for a drug overdose. Retrieved June 23, 2023, from https://health.mo.gov/living/families/schoolhealth/pdf/naloxone-admin.pdf

Missouri Revised Statute: 195.206 RSMo. (2022, August 28). Opioid antagonist or addiction mitigation medicine, sale and dispensing of by pharmacists, possession of — administration of, contacting emergency personnel — immunity from liability, when. Retrieved June 23, 2023, from https://revisor.mo.gov/main/OneSection.aspx?section=195.206#:~:text=Notwithstanding%20any%20other%20law%20or%20regulation%20to%20the%20contrary%2C%20it,the%20drug%2C%20contact%20emergency%20personnel.

Missouri Statute 338.205 RSMo. (2016, August 28). Opioid antagonist, storage and dispensing of without a license, when. — Retrieved June 23, 2023, from https://revisor.mo.gov/main/OneSection.aspx?section=338.205&bid=33134&hl=

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Page last updated: March 19, 2024

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Acknowledgement of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Debra Funk, BSN, RN
Director of Practice
Missouri State Board of Nursing

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

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