As the world of post-acute care continues to evolve, and we are faced with a quickly evolving landscape of new challenges, perhaps an especially unexpected (and unwelcome) one is the increasing prevalence of opioid drug use (and abuse) in our residents. This issue is one is of keen interest in the non-LTC world, so it is no surprise that it has now become a point of contention for us.

The state of California has taken a proactive stance in addressing this issue by promulgating guidance on the use of NARCAN (naloxone hydrochloride), which is used to reverse the effects of opioid toxicity.  For patients who have been identified as having any of the following conditions, a prescriber shall OFFER a prescription of Narcan (or other approved “reversal” agent):

1. A prescription for 90 or more morphine milligram equivalents/day;
2. An opioid prescribed concurrently with a benzodiazepine;
3. An increased risk for overdose, i.e. a history of overdose, a history of substance abuse, or a risk of returning to a high dose of opioid to which the patient is no longer tolerant.

This seems like pretty straight-forward guidance, and it should not be too difficult for our IDT to be able to determine which residents should be “offered” this option. However, this is a requirement that begins with the prescriber and ends with the patient; non-prescriber members of the IDT can certainly take part, but are not required to do so.

It should be also noted that Narcan can be administered in two ways: injection, or nasally. It is important that physicians prescribe the administration route that they prefer. Obviously, this is a “PRN,” emergency drug, analogous to the way Glucagon is used, so if the injectable Narcan is prescribed, it can be stored in and pulled from the e-kit on an “as needed” basis (and not cost the facility any undue expense). If, however, the prescriber chooses to prescribe the nasal formulation, the script will be filled like any other script: individualized for the resident it was prescribed for, and kept in the med cart. This could get somewhat expensive for a product that will (hopefully) never be used, as our resident population is not self-administering opioids. It is also important to establish what is to be used and communicate it to the hospital which fills your bed.  If the discharge hospital uses inhaled Narcan you will have to have the order changed on admission. 

It is important that we recognize this additional challenge in treating our residents, while at the same time protecting our facilities from undue financial burden.  Accompanied with this article is a video for nasal administration of Narcan in case that is what you choose to use.