A NURSE CARES FOR DX at a skilled nursing facility. DX is excited when her adult grandson, GD, arrives for a visit. The nurse leaves the room to give them privacy but later hears DX yell for help. After her grandson went to use the restroom, DX heard a thud against the door and he would not respond to her calls. When the nurses get the door open, they find GD unresponsive with an empty bottle of oxycodone nearby. His respirations are slow and shallow, and he is cyanotic. While a colleague calls for emergency medical services, the nurse gathers nasal naloxone from the nearest location.

Opioids include prescription medications such as oxycodone, hydrocodone, morphine, methadone, tramadol, and fentanyl, as well as illicit drugs such as heroin.1 In the US, 130 deaths from opioid overdoses occur daily on average. In 2017, the number of overdose deaths related to opioids was six times higher than similar figures from 1999.2

Many nurses are accustomed to caring for patients experiencing an opioid overdose, but what if the victim is not a patient, as in the scenario above? This article discusses the challenges of managing nonpatient opioid overdoses in healthcare settings, the logistics of providing care for these individuals, and ways organizations can prepare to address this scenario effectively.

Legal duties and protections

Most US states have passed some variation of a Good Samaritan law. These laws provide immunity for both the person experiencing an overdose and the individual who calls 911 or administers naloxone, including immunity from arrests, charges, prosecution related to possession of an illicit substance, and paraphernalia offenses.3 Multiple states, including Arizona, Tennessee, Vermont, and Mississippi, also provide immunity for those awaiting trial, on probation and parole, or facing restraining order violations, although they do not negate other crimes committed at the scene of an overdose.3,4 These laws function on the understanding that the individual who is helping is doing so "in good faith," meaning that the individual believes a person is experiencing an overdose and is not interfering in an arrest or active search warrant.3,5

Good Samaritan laws offer civilians protection against liability for ordinary negligence, which describes failure to act in regards to the appropriate care in a specific circumstance.3 On the other hand, gross negligence describes conscious, voluntary disregard for the appropriate care and is not protected.3 Criminal liability, or crimes committed throughout the process of administering emergency care, is not always protected under these laws.3,6

For healthcare professionals, however, these laws may be more applicable outside of work.3 For example, in some jurisdictions, healthcare professionals may be subject to an affirmative duty, or legal obligation, to respond to patient and visitor emergencies in clinical settings for which the healthcare organization should have an action plan in place.7,8 Additionally, all facilities with an attached ED or within 250 ft of one are required to examine, transport, and treat individuals with emergency medical conditions by the Emergency Medical Treatment and Active Labor Act.7,9

Although naloxone administration is often considered in the context of outpatient scenarios, this situation may also occur in healthcare settings, such as the ED. But what about those who overdose while visiting patients in a healthcare facility? For example, at the main campus of Brigham and Women's Hospital in Boston, Mass., a middle-aged male visitor was found in a locked bathroom with drug paraphernalia around him after an undetermined period of time. A code blue was activated, and the emergency medical response team administered naloxone I.M. to no avail. The patient was rushed to the ED for further treatment, which was unsuccessful. He did not survive. Subsequently, the hospital made several process changes, including having emergency medical response nurses bring nasal naloxone to codes.10

Healthcare considerations

The opioid epidemic has left many questions unanswered, and treating visitors who overdose within the healthcare facility is a situation that remains vague. Each hospital system dedicates its own policies and protocols regarding overdoses. But how can healthcare organizations store naloxone to make it readily available in emergencies involving individuals who are not current patients?

In the authors' experience, storage in an automated dispensing cabinet (ADC) is one option, but accessing ADCs typically requires patient information. As visitors are not active patients, this would complicate the process. Although nurses may be the most likely candidate to administer naloxone in this setting, it could be helpful to store the drug in a permanent location, such as the crash cart. Further research is necessary.

Another consideration is the ideal route of administration (see How naloxone works). I.V. administration of naloxone is the quickest and most effective route, but visitors are not likely to have vascular access. The nasal spray is easy to administer and protects rescuers from accidental needle sticks. However, it has the longest onset of action and is more expensive than the other options at approximately $75 per nasal spray. I.M. or subcutaneous injections fall in the middle in terms of onset and cost approximately $20 per dose.11

Life-or-death interventions

Nurses may unexpectedly encounter visitors, including patient friends and family members, who overdose on opioids within the healthcare facility. Prompt administration of nasal or I.M. naloxone can determine whether these individuals live or die.

Nurses should be familiar with their organization's policies and be prepared to intervene. Healthcare facilities should create policies, procedures, and training that enable nurses to intervene quickly with naloxone in critical situations.

How naloxone works1,12

Administered to reverse opioid overdose, naloxone is an opioid antagonist that displaces opioids at their receptor sites. It can be administered via multiple routes, including I.M. or subcutaneous injection, I.V. push or continuous infusion, and intranasal spray. Additional off-label routes may include inhalation via nebulization or endotracheal administration for patients for whom establishing I.V. access has been difficult.

Naloxone reverses the effects of opioids only; it has no effect on nonopioid drugs. Given via the I.V. route, it is effective within 2 minutes of administration. Given via I.M., subcutaneous, and endotracheal routes, it begins working in 2 to 5 minutes. Response to administration via inhalation can take up to 5 minutes, and between 8 and 13 minutes via the intranasal route.

Because opioids typically have a longer duration of action than naloxone, multiple doses may be necessary. Possible adverse reactions include allergic reactions and opioid withdrawal symptoms. Additionally, individuals can become agitated or combative as they respond to naloxone.

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