Digital Repository Doctoral Projects Fall 2022 Establishing a Narcan Protocol in a Rural Mental Healthcare Center Melissa Slaugh Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Slaugh, M. (2022) Establishing a narcan protocal in a rural mental healthcare center Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 1 Establishing a Narcan Protocol in a Rural Mental Healthcare Center by Melissa Slaugh A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 Project Consultant: Robert Hall, Clinical Director, LCSW _______________________________ ______________________________ Melissa Slaugh, DNP-FNP, BSN, RN Date _______________________________ _____________________________ DNP Project Faculty Project Lead Date 12/16/2022 _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Cynthia Beynon, PhD, RN, CNE 12/16/2022 Melissa Slaugh 12/16/2022 NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 2 Table of Contents Abstract ........................................................................................................................................... 4 Establishing a Narcan Protocol in a Mental Healthcare Center in a Rural Community ................. 5 Background and Problem Statement ............................................................................................... 6 Diversity of Population and Project Site ..................................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership .............................................. 7 Search Methods ............................................................................................................................... 7 Literature Review............................................................................................................................ 7 Opioid Use Disorder.................................................................................................................... 8 Risk Factors ............................................................................................................................. 8 Addiction ..................................................................................................................................... 9 Cost .......................................................................................................................................... 9 Treatment ............................................................................................................................... 10 Barriers to Treatment ......................................................................................................... 1212 Opioid Overdose ................................................................................................................... 1313 Populations at Risk/Risk Factors ....................................................................................... 1313 Consequences .................................................................................................................... 1414 Solutions…………………………………………………………………………………….14 Changing the Culture…………………………………………………………………….15 Narcan……………………………………………………………………………………15 Expanding Access to Narcan…………………………………………………………….16 Narcan Prevention Protocol……………………………………………………………...17 Discussion ............................................................................................................................. 1717 Implications for Practice ....................................................................................................... 1818 Framework……………………………………………………………………………………….20 Project Plan ............................................................................................................................... 2121 Project Design ....................................................................................................................... 2121 Needs Assessment of Project Site and Population ................................................................ 2222 Cost Analysis and Sustainability of Project .......................................................................... 2323 Project Outcomes .................................................................................................................. 2323 Consent Procedures and Ethical Considerations ................................................................... 2424 NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 3 Instruments to Measure the Effectiveness of Intervention ....................................................... 2424 Project Implementation ............................................................................................................. 2525 Interventions .......................................................................................................................... 2525 Interventions Align with Long and Short-term Outcomes ....................................................... 2626 Project Timeline ........................................................................................................................ 2727 Project Evaluation ..................................................................................................................... 2727 Data Maintenance and Security………………………………………………………………..27 Data Collection and Analysis ................................................................................................ 2828 Findings ..................................................................................................................................... 29 Strengths ................................................................................................................................ 3030 Weaknesses ........................................................................................................................... 3030 Quality Improvement Discussion ............................................................................................. 3030 Translation of Evidence into Practice ................................................................................... 3131 Implications for Practice and Future Scholarship ................................................................. 3232 Sustainability ..................................................................................................................... 3232 Dissemination .................................................................................................................... 3232 Conclusion ............................................................................................................................. 3333 References ................................................................................................................................. 3434 Appendix A (Staff Narcan Presentation) .................................................................................. 4242 Appendix B (Intranasal Narcan Administration Video) ............................................................... 49 Appendix C (Narcan Handout) ................................................................................................. 5050 Appendix D (Narcan Pretest/Posttest) ...................................................................................... 5252 Appendix E (Narcan Post-Test Answer Key) ........................................................................... 5353 Appendix F (Narcan Tracking Sheet) ....................................................................................... 5454 Appendix G (Project Timeline) ................................................................................................ 5555 NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 4 Abstract Purpose: Narcan is a life-saving drug proven to reverse an opioid-related overdose if administered promptly. There is a need to improve distribution rates of intranasal Narcan to reduce high overdose rates. This Doctor of Nursing Practice (DNP) project aimed to increase Narcan awareness among Northeastern Counseling Center (NCC) employees, thereby aiming to increase the distribution rates of Narcan kits handed out by NCC staff to community members at risk for opioid overdose. Methodology: Northeastern Counseling Center employees were provided Narcan education and training at a staff meeting. Pretest and post-test surveys were used to evaluate knowledge of Narcan and how it should be administered. The survey directly assessed the employee’s comfort level with delivering intranasal Narcan for an opioid-related overdose. In addition, a Narcan distribution sheet was used to track the number of intranasal Narcan kits handed out six months before and six months after employee Narcan education and training. Results: Narcan education and training proved to be an effective intervention in a) increasing Narcan awareness, b) increasing the confidence to intervene in an opioid-related overdose event, and c) increasing the number of Narcan kits distributed to patients and community members. Staff education and training increased the comfort level in educating the patients and their family members. The Narcan distribution rate also increased, as evidenced by the data collected via the distribution sheet. Implications for Practice: Narcan education and training is an effective intervention that increases the confidence of staff members to administer intranasal Narcan in an opioid-related event. Narcan education and training increase staff awareness, and staff members feel better prepared to distribute Narcan kits to patients at risk for an opioid-related overdose. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 5 Establishing a Narcan Protocol in a Mental Healthcare Center in a Rural Community In 2019, a reported 1.6 million Americans were diagnosed with opioid use disorder, and 48,006 individuals overdosed on synthetic opioids (Assistant Secretary of Public Affairs, n.d.). The national opioid epidemic has continued to reach unprecedented levels, with an estimated 81,000 drug-related fatalities reported in the United States in 2020. Fentanyl was the primary driving force behind a 98% increase in synthetic opioid-related deaths documented within 10 Western States from June 2019 to May 2020 (Center for Disease Control and Prevention [CDC], 2020). Naloxone Utah (n.d.) statistics list opioid overdose as the leading cause of injury-type deaths. An estimated 10 individuals die weekly, a rate even higher than a motor vehicle or firearm accident. In addition, rural communities have less access to resources to treat and prevent drug addiction, which places individuals living within the community at an even higher risk of experiencing or witnessing an overdose fatality (Rodgers, 2019). As the rise in opioid-related deaths continues an upward trend, emergent intervention and prevention will be necessary to decrease overall fatality rates (CDC, 2020). In a rural community’s mental health facility that treats addiction, staff must stay up-to-date and implement evidence-based practices that reduce opioid-related fatalities. Narcan (naloxone) is a proven, safe, and effective medication if used promptly to reverse the devastating effects of an opioid-related overdose (Fairview Health Services, 2019). Education is the key to preventing and protecting community members. Therefore, every employee must be educated and trained to recognize and confidently respond by administering Narcan to an individual in the event of an opioid-related overdose (Kottler & Reising, 2021). NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 6 Background and Problem Statement The lack of a standardized Narcan protocol in a mental health office that treats opioid addiction creates barriers to receiving adequate treatment and care. An opportunity for change was identified at Northeastern Counseling Center (NCC) when 216 boxes of Narcan were found in a closet, and only six kits had been handed out in a five-month timespan. An imbalance between Narcan inventory, needs, and distribution was identified. Narcan kits can be accessed for free at the facility through state grant funding to treat addiction, and there are roughly 80 individuals currently seeking treatment for addiction through NCC services (R. Hall, personal communication, July 7, 2021). Without a standardized Narcan protocol in place, a knowledge-deficit barrier exists among staff members, inhibiting community members from learning about and receiving access to the life-saving drug. Without access to Narcan and the confidence to intervene, fatality rates due to opioid-related overdoses will continue to climb within the community. Diversity of Population and Project Site The direct population involved in the project includes every staff member employed at NCC in Vernal, Utah. The medical staff includes one registered nurse, two licensed practical nurses, one medical doctor, and one psychiatric mental health nurse practitioner. In addition, 94% of NCC staff are non-medical personnel (R. Hall, personal communication, July 7, 2021). Non-medical personnel include secretaries, case managers, certified and licensed therapists, administrative staff, and technical support. The indirect population for the project includes every community member in the Uintah Basin, either at risk of experiencing an opioid-related overdose or witnessing an opioid overdose. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 7 Patients with opioid use or abuse diagnoses also qualify for Narcan training and Narcan kit distribution. Significance for Practice Reflective of Role-Specific Leadership The DNP-prepared student is professionally qualified to research evidence-based information and effectively transition evidence into practice (Chien, 2019). Active leadership opportunities allow a nurse practitioner (NP) to engage in a higher level of responsibility by shaping and designing new policies and procedures (Institute of Medicine, 2011). Furthermore, an NP leader’s responsibility is to guide other nurses and staff members and ensure that practices comply with safe, effective, quality care for every patient (The University of New Mexico, 2018). A Narcan protocol will reduce opioid-related fatalities, improve staff communication and understanding, and strengthen community members’ participation in a care plan. Search Methods Search terms used in this project include “opioids”, “opioid-related overdose”, “Narcan”, “Narcan prevention”, “addiction”, “opioid use disorder”, “opioid addiction treatment”, “Narcan protocol”, and “Kotter’s Change Theory”. The Centers for Disease Control, the American Psychiatric Association, the American Addiction Centers, the Substance Abuse and Mental Healthcare Services Administration, and the National Institute on Drug Abuse supported evidence-based knowledge and practices. Literature Review This literature review explores evidence-based research on opioid addiction and its associated factors. Themes throughout this literature review will also center on the benefits of developing a successful Narcan protocol based on a) an understanding of the weight of the opioid epidemic, b) recognizing the signs of an overdose, c) the value of treating an individual NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 8 who has overdosed with Narcan, and d) the ability to implement a risk-reduction strategy including dispensing Narcan to high-risk individuals (Kottler & Reising, 2021). The overarching goal of the proposed intervention is to reduce the rate of opioid-related overdoses throughout the community. Opioid Use Disorder The CDC (2021) and Dydyk et al. (2020) define an opioid as a chemical within a drug that acts on the mu, kappa, and delta-opioid receptors in the brain. The effects of an opioid result in the feeling of euphoria and a reduction in the perception of pain. Common opioid prescriptions are oxycodone, hydrocodone, morphine, and methadone. Tramadol and Fentanyl are synthetic opioids used to treat patients in severe pain. The diagnosis of opioid use disorder (OUD) must first meet the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) criteria before being given and is based on a patient’s history and physical. As OUD is likely to be a chronic, lifetime diagnosis, concerns include tolerance, dependence, addiction, and withdrawal (American Psychiatric Association [APA], 2018). According to the American Medical Association, 3-19% of individuals prescribed pain medications become addicted, and 45% of individuals with a heroin addiction start with opioid addiction (APA, 2018). Risk Factors Chronic pain is defined as pain lasting longer than three months or existing longer than the average expected healing time and places an individual at a higher risk of receiving an OUD diagnosis. In the United States, 11.2% of the adult population experience chronic pain (Dowell et al., 2016). Other factors that may place an individual at a higher risk for an OUD diagnosis include those younger or living in environments that support misuse (Webster, 2017). NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 9 According to the National Institute on Drug Abuse (2021b), substance abuse and mental illness comorbidities share common risk factors. Mental illness alone may contribute to substance abuse. Individuals with mental illness are at a higher risk for opioid use due to past trauma and increased life stressors. Chemical changes in the brain that occur in drug abuse may enhance pleasurable effects, reduce mental illness awareness, alleviate mental illness symptoms, and decrease the medication side effects used to treat mental illness (National Institute on Drug Abuse, 2021b). Addiction Opioid addiction has many potential consequences. An individual who is addicted may experience mental and physical decline, disrupted interpersonal relationships, and decreased participation in social events (APA, 2018). Addictive behaviors may result in an inability to meet obligations at school or work. Extra time may be needed to acquire the drug or recover from the effects of the drug. Tolerance and withdrawal symptoms may lead an individual to drug seek despite safety concerns (APA, 2018). Opioid-related overdoses are a frequent occurrence among individuals addicted to opioids. As opioids produce a positive reinforcement such as euphoria, the odds that an individual will continue to use despite negative consequences are increased (APA, 2018). An individual who overdoses and survives is at an even greater risk of experiencing additional overdoses and an eventual fatal overdose (Coffin et al., 2017). Cost The CDC reports the economic burden of opioid misuse to be $78.5 billion in the United States. The economic burden includes the price of addiction treatment, criminal justice, and healthcare costs (National Institute on Drug Abuse, 2021a). From an insurance perspective alone, the effects of opioid abuse are astounding. Results of a study conducted by Kirson et al. (2017) NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 10 indicate that individuals suffering from opioid use disorder have an estimated excess of $10,000 to $20,000 in annual insurance medical costs per patient, with an average of $14,810 of the cost occurring in the first six months before and after the initial opioid-abuse event. This study’s data will likely underestimate the total opioid abuse cost as the incremental cost may continue well after a six-month timeframe (Kirson et al., 2017). In a cost-effective analysis conducted by Fairley et al. (2021), data indicate that expanded access to medication-assisted treatment (MAT) and Narcan education, when used in combination, are associated with a cost-saving reduction in mortality and morbidity. When compared with no treatment for opioid abuse, medication-assisted treatment was associated with savings of $25,000 to $105,000 in lifetime costs per person. The lack of such programs limits access to life-saving medical intervention, and providers are encouraged to be familiar with alternative treatments used in medication-assisted treatment to treat opioid use disorder effectively. Treatment Early identification and treatment of opioid misuse can help halt the progression to an opioid use disorder diagnosis in the future (APA, 2018). The Substance Abuse and Mental Health Services Administration (SAMHSA) (2016) cautions that early intervention is the most effective way to treat an individual with an opioid addiction before the addiction can progress. While mild substance abuse can be quickly identified and treated in a general practice setting, patients with severe substance abuse may need to be referred to a specialist. A shift in the mainstream delivery of care in recognition, prevention, and treatment must occur to effectively treat opioid use disorder and prevent opioid-related overdoses (SAMHSA, 2016). NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 11 Treatment options should include a cognitive-behavioral, motivational, educational, and supportive approach. Finding appropriate treatment is critical as 90% of patients experiencing opioid withdrawal relapse within a month (Dydyk et al., 2020). A rehabilitation approach can help the individual acknowledge the addiction, take accountability for the consequences, and correct the addictive behavior. Rehabilitation centers are advantageous as they provide a safe, controlled environment to detox and help individuals focus on changing addictive behaviors (Schuckit, 2016). The U.S. Food and Drug Administration has approved methadone, buprenorphine, and naltrexone for use in MAT for opioid use disorder (SAMHSA, 2016). MAT improves patient adherence to treatment and decreases opioid use compared to a non-medication treatment approach (The Pew Charitable Trusts, 2021). Suboxone and methadone are two types of opioid replacement therapies. Suboxone works by replacing the abused opioid with the long-acting, less addictive opioid buprenorphine. When combined with naloxone, a reduction in cravings and withdrawal symptoms without the euphoric effects of the opioid can be appreciated. Suboxone requires close monitoring with a plan to taper. Frequent follow-up visits, drug urinalysis screenings, and reviewing the controlled medication database will be necessary to ensure compliance. Buprenorphine initiation and stabilization during the induction period are critical to the successful outcome of treatment for opioid use disorder (SAMHSA, 2016). Methadone is an opioid used to treat substance abuse and blocks the euphoric opioid effects, reducing the cravings for narcotics. Methadone is closely monitored and dispensed in a clinic. Finding a location certified to dispense methadone is often tricky, and patients may have to travel to receive treatment. Disadvantages of methadone treatment include possible lifetime adherence and daily dispensing requirements (Dydyk et al., 2020). NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 12 Vivitrol, extended-release naltrexone, is a long-acting opioid blocking injection. Vivitrol works by blocking opioid receptor sites, thus preventing the euphoric and sedating effects in the central nervous system. Vivitrol is a monthly injection, and the individual must abstain from opioids at least seven days before starting the medication, or immediate withdrawal effects can make the patient feel like they have the flu. A disadvantage to this treatment is that it is invasive and requires monthly doses to maintain therapeutic effects (American Addiction Centers, 2020). Although a combination of medication and behavioral therapies are keys to success in treating opioid use disorder, the risk of relapse continues to be a challenge. In 100 substance abuse treatment sites across the United States, 1,100 individuals suffering from opioid addiction were followed for checkups at the three, six, and 12-month mark post-discharge. Results showed that about half of the participants, 55.1% women and 51.5% men, were reported to have used an opioid within one year (Miller, 2021). The results suggest that even with treatment, individuals may still be at risk for an overdose. Intervening and preventing opioid-related fatality are the overall goals of distributing Narcan (Miller, 2021). As Narcan is a proven life-saving intervention, establishing a Narcan protocol within the NCC organization will be a robust implementation to reduce overall opioid-related fatalities. Barriers to Treatment In 2016, 21 million individuals needed treatment for substance abuse, yet only 3.8 million received treatment (American Addiction Centers, 2021b). The four main barriers to receiving treatment include stigma, inadequate provider education, medication regulations and restrictions, and fragmented payment policies. In a 2016 national survey, more than three-quarters of the individuals surveyed viewed individuals diagnosed with OUD as lacking self-discipline (The National Academy of Sciences, 2019). Time and associated cost of care may also prevent NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 13 individuals from seeking help. Rural areas often lack resources for prevention and treatment and place community members at a higher risk for an overdose (American Addiction Centers, 2021b). Opioid Overdose The CDC defines an opioid overdose as an “injury to the body (poisoning) that happens when a drug is taken in excessive amounts. An overdose can be fatal or nonfatal” (Macano et al., 2018, p. 2). An opioid overdose may occur when the number of opioids, either alone or mixed with other opioids, causes the individual to become unresponsive and exhibit inadequate breathing (National Harm Reduction Coalition, 2020). An opioid overdose involves a reduced level of consciousness (Glasgow Coma Score of <13; score range: 3-15, with the highest score indicating normal responses), increased respiratory depression (<10 breaths per minute), and inadequate oxygenation (saturation <95%; Dietze et al., 2019). Populations at Risk/Risk Factors Five populations at a greater risk for an opioid-related overdose include a) justice-involved populations, b) individuals living within a rural community, c) veterans, d) adolescents and young adults, and e) individuals who participate in injection drug use (Blanco et al., 2020). The justice-involved population includes individuals experiencing an economic decline who are more likely to spend time in jails, detention, and prisons. Individuals living in rural communities are less likely to access advanced medical care and resources. Veterans are more likely to suffer from chronic pain, mental illness, and depression. In adolescents and young adults, the brain is undeveloped until 25, which places individuals younger than this age at a greater risk for experiencing more harmful effects of opioids. Finally, injection-drug users are more likely to suffer from other health-related illnesses such as viral hepatitis and human immunodeficiency NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 14 virus (HIV) (Blanco et al., 2020). Individuals with HIV are often treated with opioids, and some continue to engage in illicit opioid use, placing them at an even greater risk for an opioid-related overdose (Green et al., 2012). In a systematic review by Richards et al. (2020), the factors related to the patients prescribed high-dose opioids were explored. In a total of 4,248,119 participants, 3.64% of the participants were found to be taking high doses. In addition, depression, co-prescriptions of diazepines, and frequent emergency visits are common factors associated with a greater risk for harm in patients taking high doses of opioids. Consequences Peers, bystanders, and family members who witness opioid overdoses may be hesitant to intervene (National Harm Reduction Coalition, 2020). Bystanders may choose not to intervene due to stigma, fear of repercussions, and an inability to recognize an overdose (Bennett et al., 2020). An overdose is likely fatal without immediate action to reverse respiratory distress. Family members and friends who witness another individual suffering from addiction and overdose are also more likely to experience emotional, financial, legal, and medical consequences (American Addiction Centers, 2021a). Solutions Key actions to fight the opioid epidemic and reduce opioid-related overdoses include mandating prescriber education, implementing opioid prescribing guidelines, treating opioid overdose, and increasing the availability of OUD treatments (National Safety Council, 2021). These key actions will require changing the culture of prescribing by every provider. In 2018, the U.S. Surgeon General recognized the severity of the opioid epidemic and called for a heightened awareness of and availability of the life-saving drug Narcan. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 15 (“Naloxone: The Opioid Reversal Drug”, n.d). Evidence-based protocols and prevention strategies will need to be implemented into clinical practice to provide Narcan education and access to at-risk individuals. Changing the Culture. There is a call for changing the culture of opioid-prescribing practices. The CDC guidelines highlight safer prescribing practices for providers treating patients with chronic pain. The 12-guideline recommendations aim to improve communication between healthcare providers and patients regarding the risks and benefits of long-term opioid therapy, improve safety and efficacy in pain treatment, and reduce the overall risk of opioid addiction and opioid-related deaths (Dowell et al., 2016). In addition to these recommendations, the CDC, the Substance Abuse and Mental Health Services Administration, and the American Medical Association encourage providers to co-prescribe naloxone when prescribing opioids to patients who are at high risk (Leonard Davis Institute of Health Economics [LDI], 2019). Narcan. According to the National Harm Reduction Coalition (2020), Narcan is an opioid antagonist and the drug of choice to reverse the effects of opioids in an opioid-related overdose. Narcan can be administered intravenously, intranasally, or intramuscularly, and the effects can last for 30 to 90 minutes. In addition, Narcan works to reverse respiratory depression in the central nervous system and is short-acting, non-addicting, and a non-controlled substance. Therefore, family members can minimize the risk of an opioid-related fatality by having access to Narcan and knowing how to use it (“Naloxone: The Opioid Reversal Drug”, n.d). Legislature has provided specific statutory protection for individuals who are not medical professionals to have the ability to administer naloxone. The Good Samaritan Law protects the person administering the naloxone from arrest, charge, or prosecution for drug possession and paraphernalia. The Good Samaritan Law requires the caller to reasonably believe that an NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 16 individual needs medical attention due to an overdose and is reporting the event in good faith (Widgery, 2021). Expanding Access to Narcan. Currently, there are several ways individuals may gain access to Narcan. Narcan can be purchased without a prescription at the pharmacy. As most community members treated at NCC have Medicaid, naloxone will likely cost little or nothing. Without insurance, the cost of two naloxone intramuscular injections ranges from $200-400. Two intranasal naloxone injections may be purchased for $49.14 (GoodRx, 2021). Another way to obtain access to Narcan is through overdose education and naloxone distribution programs. These programs are beneficial as they provide free education and access to Narcan (LDI, 2019). In a randomized control trial conducted by Dietze et al. (2019), 197 individuals received either intranasal or intramuscular naloxone to use in an opioid-related overdose event. Results suggest that individuals given intramuscular naloxone were only 8.6% likely to require a second dose of intramuscular naloxone administration compared to a 23% likelihood by the internasal route. Although intranasal Narcan is considered less efficient than intramuscular naloxone, consideration must be given to cost, access, risk, and education. Rural areas are three times less likely to dispense Narcan due to cost (CDC, 2019). Co-partnering with larger companies will expand resources within smaller communities. For example, Utah Naloxone is an organization that uses donations from the public to provide free injectable Narcan kits to the community (Utah Naloxone, n.d.). “While naloxone alone cannot address the magnitude of the opioid crisis, it is one part of a multi-pronged strategy to prevent immediate deaths and link people with opioid use disorders to effective treatments” (LDI, 2019, p. 5). NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 17 Narcan Prevention Protocol. In a quasi-experimental study by Espelt et al. (2017), the effects of an opioid prevention program were evaluated in 1,447 patients at risk for an opioid-related overdose. Researchers noted a 40.4% increase in Narcan administration in response to an overdose event among participants who received clinical instruction. Evidence suggests that training and education on administering Narcan improves the likelihood that Narcan will be administered in a real-world scenario. A descriptive study by Janssen et al. (2020) evaluated the effectiveness of a program implemented within a sheriff’s office to train non-medical individuals in administering Narcan in an opioid-related drug overdose situation. In 184 opioid-related overdoses throughout the community, a 94.6% successful administration rate was reported. Therefore, the administration of Narcan increased when employees were adequately trained to administer the life-saving drug. Narcan training and education result in a higher knowledge base in an individual placed in an opioid overdose situation (Lott & Rhodes, 2016). The National Harm Reduction Coalition (2020) reports that between 1996 and 2010, 53,032 individuals were educated, trained, and given Narcan. Reports from 48 take-home naloxone programs throughout the United States identified 10,071 cases of opioid reversals. Discussion Evidence supports expanding education and access to Narcan as an effective intervention that reduces fatality rates in opioid-related events (National Harm Reduction Coalition, 2020). Naloxone distribution programs support harm-reduction strategies to reduce the rates of opioid-related fatalities. In a systematic review conducted by Chimbar and Moleta (2018), the effects of take-home Narcan kits were examined with the reduction in opioid-related mortality rates. Seventy-three articles were reviewed concerning Narcan distribution. The results strongly NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 18 support take-home Narcan kits’ effectiveness in reducing opioid-related fatalities. Furthermore, the authors encourage a practice change for Narcan to be made available to reduce opioid overdoses throughout the community. They recommended further research to examine the cost-effectiveness of Narcan programs. Although Narcan programs have proven effective, studies often do not consider cost, which is necessary for program expansion. Acharya et al. (2020) developed a Markov model with an attached tree for the pharmacy distribution of Narcan to high-risk opioid users by using a one-time and biannual follow-up distribution schedule. Fourteen overdose deaths were prevented from a one-time distribution per 100,000 people with a cost-effective ratio of $56,669 Quality Adjusted Life Year (QALY). Biannual distribution resulted in 107 lives saved with a cost-effective ratio of $84,799 (QALY) when compared to the one-time distribution. Not every state allows pharmacy distribution, and there is a concern about the effectiveness when a bystander administers the intramuscular form. A pharmacy-based Narcan distribution program is a cost-effective strategy to prevent fatal opioid-related overdoses. Implementing a Narcan protocol within NCC can help identify individuals at high risk and provide education and access to the life-saving drug. Barriers that may prevent a successful Narcan protocol implementation include lack of preparation and initiation to the proposed change emphasized in the beginning steps in Kotter’s change model and staff resistance to making the change. Careful planning, preparation, and persistence will be critical components in transitioning evidence into practice (Najjar & Ascione, 2020). Implications for Practice DNP Essential II highlights the DNP’s invaluable role and commitment to engage in a leadership opportunity and improve the quality of health and the safety of the populations with NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 19 whom they work. In addition, the DNP has a unique opportunity to design, implement, and evaluate guidelines and practices that reduce undesired health outcomes within the community (American Association of Colleges of Nursing, 2006). Mitchell & Higgins (2016) acknowledge the critical role of the advanced practice registered nurse (APRN) and their involvement in implementing Narcan distribution laws and regulations. As the APRN professional diagnoses and treats patients with chronic pain, their role in educating, managing, and evaluating individuals using Narcan is fundamental. The APRN is considered a valuable patient advocate capable of lobbying for state and federal legislative changes. The APRN is qualified to develop screening tools to help identify at-risk patients and implement safer guidelines and practices for Narcan education and distribution. In the 2016 General Session, Utah State Legislature passed the Opioid Overdose Response Act, including the House Bill (HB) 192 Opiate Overdose Outreach Pilot Program. The Utah Department of Health authorized grants to be available to persons qualified to assist an individual at high risk for an opioid-related drug overdose. HB 238 authorizes an overdose outreach provider to furnish an opioid antagonist, including instruction on how to correctly identify and intervene in the event of an opioid-related overdose (Utah Department of Health, 2020). NCC has had the opportunity to participate in the pilot program and is prepared to implement a Narcan protocol to supply intranasal naloxone and education to at-risk patients. Narcan distribution programs reduce overdose deaths, increase response confidence, and decrease disparities within the community compared to communities that do not have programs (Wyoming Prevention Depot, 2021). Individuals, friends, and family members of individuals suffering from opioid use disorder and addiction can find hope and healing through treatment and prevention. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 20 Framework John Kotter’s 8-step change model will be used to implement a Narcan protocol at NCC. Najjar and Ascione (2020) highlight the eight steps in the change theory process. Step one involves creating buy-in and urgency, which can be accomplished by sharing data and statistics on opioid-related overdoses. Data will be compiled to compare the number of Narcan kits distributed with the number of individuals treated for opioid addiction at NCC. Personal stories will be shared to put a human connection behind the data and numbers. Creating a coalition to help lead the change is a critical component of step two. Individuals with a wide range of skills and education should be chosen to support and guide the change process. For this project to be successful, the site supervisor, nurses, and providers at NCC will be included to help advance the protocol into practice. The team chosen to help lead the change process will be positive influences to help guide staff members at NCC in making the change. Developing the change, coordinating actions, and motivating staff members to make the change is included in step three. Each designated team lead will report successes and failures throughout the protocol implementation process. Revisions can be made according to staff input and recommendations. Communicating the vision is a crucial component of step four. Frequent emails, meetings, and presentations with staff members to keep the momentum for the new protocol going are critical. Making appropriate adjustments to make the Narcan protocol as efficient and easy as possible for staff members and patients will be a significant factor in achieving successful outcomes. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 21 Empowering a broad-based action will be accomplished in step five. This step requires changing structures, systems, and behaviors that undermine the vision for change. Change can often be met with resistance from staff members. Step six involves generating short-term wins and celebrating the things that are going right to ensure successful overall changes. Sharing success stories in Narcan distribution and education can help enforce compliance. Step seven emphasizes the importance of never giving up, even if the protocol is met with resistance. The consequences of letting up can be dangerous, and the Narcan protocol must be driven deeper into a routine until it becomes the standard practice within the NCC organization. Step eight involves incorporating the changes into the culture. The new Narcan protocol must be anchored and embedded and should reflect the core values established within the company (Najjar & Ascione, 2020). Project Plan This project describes implementation of a Narcan protocol for staff members employed in a healthcare office in a rural community. The project encourages staff members to a) receive Narcan education training, b) follow protocol to dispense Narcan distribution and provide training to at-risk community members, and c) track the Narcan kits dispensed over six months after staff training has taken place. Project Design This quality improvement project aims to standardize a Narcan protocol within a mental healthcare setting by advancing the staff knowledge and training on the life-saving drug. All NCC employees will be given a short PowerPoint presentation (See Appendix A). The training is designed to expand the employee’s knowledge of how and when to administer Narcan, improve NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 22 patient training, and increase Narcan distribution. Once the staff has been trained, a short Narcan video administration presentation will be uploaded to the NCC website for staff and community members to review (See Appendix B). In addition, a handout on Narcan (Appendix C) will be given to each employee to review the signs and symptoms of an overdose and provide instruction on the administration of intranasal Narcan. The Narcan handout will also be distributed to each patient given a Narcan kit. Increasing Narcan kit education and distribution to at-risk individuals have been shown to reduce opioid-related overdoses within the community (Espelt, 2017). Needs Assessment of Project Site and Population Implementing the Narcan protocol impacts the 48 members employed at NCC and the at-risk individuals throughout the community. The main participants are administration, secretaries, case managers, therapists, nurses, providers, and patients. Two site supervisors oversee the case managers and therapists employed at NCC, and a Clinical Director oversees the two nurses and three providers employed at NCC. All stakeholders share the project’s vision to offer hope, help, and healing throughout the community. Individual, interpersonal, community, and societal factors can influence an individual’s substance use, and interventions that address multiple factors are more likely to promote successful outcomes (Minnesota Department of Health, n.d.). The standardized Narcan protocol will provide opioid identification and overdose prevention education in addition to Narcan kits and training. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 23 Cost Analysis and Sustainability of Project The Narcan Protocol can be implemented at a minimal cost, and the administration board has approved the funds required to implement the protocol. Narcan kits are purchased by NCC through Federal grant money and are provided to the community members free of charge. The grant money is evaluated every six months and is continued based on the availability of the grant money allotted for overdose prevention. NCC will provide printing and paper for the Narcan handouts. Cost includes: • 10 cents per Narcan handout • 10 cents per pre/post Narcan test • 10 cents per printed Narcan tracking sheet The Narcan handout and the Narcan pre/post-test will be updated to stay current with best practice guidelines. Sustainability efforts will be directed at providing Narcan kits or naloxone injectables at the lowest cost to every patient. The out-of-pocket price for patients without insurance through a pharmacy such as GoodRx is listed. This plan will be necessary if Federal grant money is no longer available to NCC. Below is the projected cost. • Narcan injectable- one vial of 0.4 mg/1ML at Walgreens for $ 9.17 for those patients without insurance once grant money has been expended (GoodRx, 2021) Project Outcomes Project outcomes will be evaluated through the measurement of the following goals: • NCC will adopt the new Narcan protocol as standardized practice. • Narcan education and training will increase throughout the company and community. • Staff members and community members will express their confidence in when and how to administer Narcan in an emergency. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 24 • Narcan distribution rates will increase at NCC. • This project’s long-term goal is that opioid-related deaths in the community will decline. This goal will not be measured in this project. Consent Procedures and Ethical Considerations Approval for this quality improvement project was obtained through the Weber State University Institutional Review Board (IRB). Since it does not require human testing, an NCC IRB is not required. Paper copies of the employee’s original pre/post-test will be shredded once the results have been uploaded into the employee’s file to maintain employee privacy. All employee pre/post-test results will be protected through encryption in the NCC database and can be accessed to confirm Narcan training. When a Narcan kit is given to a patient, the staff member will fill out the information on the distribution tracking sheet in the nursing office. Once the information is recorded, the sheet will be stored in the nurse’s office in a filing cabinet behind locked doors. The information on the Narcan sheet will remain confidential and used for tracking purposes only. Once the Narcan sheet has been completed and the number of kits distributed has been recorded, the sheet will be shredded to ensure patient confidentiality. Instruments to Measure the Effectiveness of Intervention Two instruments will be used to measure the effectiveness of the Narcan protocol. A pre/post-test (Appendix D) will be given to each employee to test knowledge of Narcan before and after the PowerPoint presentation. After the post-test, an answer key will be shared with the employees (Appendix E). The second instrument used to measure effectiveness is the Narcan tracking sheet (Appendix F). This sheet will be used for the employees to write down the patient’s name and how many Narcan kits the patient received. The Narcan tracking sheet will be NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 25 used to track how many Narcan kits were distributed in the six months following employee training compared to the six months before Narcan training was given. Project Implementation The Narcan Protocol will be implemented at the staff meeting in May 2022. The 48 staff members employed at NCC will be educated and trained on Narcan administration. The sustainability of the Narcan Protocol will largely depend on the attitude and commitment to making a change to prevent opioid-related overdoses throughout the community. Therefore, Narcan education received before the project implementation is vital as it will help create a buy-in for the new protocol to be set into practice. Education will help prepare every employee to recognize the value of the life-saving drug, thus increasing the distribution rate of Narcan throughout the Vernal community. Interventions Prior to Narcan Protocol implementation, interventions involved a collaborative approach from NCC’s administration and IT division. With the unanimous goal to increase the distribution of Narcan throughout the community, interventions were primarily focused on increasing Narcan awareness within the NCC organization. Next, extensive research on Narcan was conducted and involved using evidence-based articles and tools to help prepare the educational information that would be presented to the staff. Northeastern Counseling Center administration expressed the desire to test the staff members’ knowledge based on four areas of interest. The areas include a) recognizing the signs of an opioid-related overdose, b) understanding what the medication Narcan is used for, c) knowing how Narcan should be administered, and d) knowing what to do after Narcan has been administered. Based on the feedback from the administration, the pre/post-test was created using NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 26 evidence-based information from reliable journal articles and Narcan websites, including NaloxoneUtah.org. Upon completion, the Narcan pre/post-test with corresponding answers was presented to the administration and approved by the Clinical Director of NCC. A PowerPoint presentation was created to enhance the staff member’s knowledge of Narcan based on the previously identified areas of interest discussed with the NCC administration. In addition to the PowerPoint presentation, a Narcan handout was created using evidence-based information and up-to-date guidelines. The NCC administration approved, and the PowerPoint and Narcan handouts were incorporated as part of the mandatory educational training for every staff member. The Narcan administration video clip was created based on the simple principles of administering Narcan founded by NaloxoneUtah.org. Staff and community members can access the information as a reference to safely, quickly, and easily administer Narcan. Northeastern Counseling administration viewed the video clip and approved the information to be uploaded to the NCC website. Northeastern Counseling IT created a place in the system profile to upload mandatory Narcan pretest/post-test results from every employee, thus confirming that Narcan education had been completed. The Narcan tracking sheet that had previously been created was also used to track the number of Narcan kits that were handed out once staff education and training had been completed. The NCC administration approved the tracking sheet as an instrument to compare Narcan kit distribution before and after Narcan training. Interventions Align with Long and Short-term Outcomes The overarching goals and outcomes included increasing Narcan awareness through educational training, increasing Narcan distribution, and decreasing the overall opioid-related overdose rates throughout the community. Short-term goals were achieved by providing NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 27 education to every staff member employed at NCC. Long-term goals involved identifying patients at risk for an opioid-related overdose and providing the at-risk patients with Narcan education and distribution. Community incidences of opioid-related overdoses that were reversed with Narcan administration cannot be accurately identified and tracked. Successful project outcomes were based on increasing NCC employee and community members’ Narcan awareness and increasing the number of Narcan kits that NCC employees distributed throughout the community. Project Timeline The project timeline encompasses the initial research of evidence-based practice and guidelines through implementing the Narcan protocol at NCC. The timeline progressed through appropriate communication and approval from the NCC administration and IT involvement. The project guideline was used as a project management tool to track interventions as they were completed from June 2021 to March 2022. The timeline can be viewed in Appendix G. Project Evaluation A Narcan PowerPoint was presented to all NCC employees. Forty-eight employees attended the presentation and completed a pre- and post-educational survey. Survey items reflected six knowledge-based questions inquiring of the nature of the medication Narcan, and how and when it should be administered. The final question on the survey assessed the participant’s comfort level of administering the life-saving medication in the event of an opioid-related overdose. Data Maintenance and Security Project data were secured on a password protected computer. Survey results were uploaded to the employee file via the Credible behavioral healthcare (CredibleBH) software. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 28 Survey results were secured through a password-protected website requiring a two-step verification. Data Collection and Analysis Before the Narcan presentation, the pre-and post- surveys were distributed to every NCC employee. Individual employee results were uploaded into CredibleBH by the DNP student. Participant characteristics were located via CredibleBH under the employee’s file. Participants were primarily female (75%), with 25% mal; ages ranged from 20 to 70. (See Table 1.) Table 1 NCC Staff Demographics N % Gender - Female 36 0.75 - Male 12 0.25 Age - 20-30 years 8 0.17 - 31-40 years 16 0.33 - 41-50 years 9 0.19 - 51-60 years 12 0.25 - 61-70 years 3 0.06 Note: N = 48. The number of NCC employee participants The effectiveness of Narcan teaching was assessed using the pre-and post-test survey responses. The NCC employees were asked how comfortable they were in administering Narcan in the event of an opioid-related overdose in the survey’s final question (see Appendix D). Data shows that participants felt more comfortable administering Narcan after education and training had been given. (See Table 2.) NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 29 Table 2 Means and Standard Deviation of Scores on Pre/Post Measures Variable Pre-Assessment Post-Assessment M SD M SD Comfort in administering intranasal Narcan 2.64 1.12 3.60 0.64 Note: To view complete survey see Appendix D Narcan Pretest/Posttest. The number of Narcan kits distributed six months before the Narcan education was tallied and added to Table 3. Narcan education was then provided for every NCC employee in April 2022. Narcan kits distribution tallied monthly post Narcan education and as available (See Table 3). Table 3 Narcan kit distribution Oct 2022 Nov 2021 Dec 2021 Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sept 2022 Oct 2022 Kits 2 3 1 2 4 4 6 8 8 8 7 8 3 Note: Data was taken 6 months prior to the April 2022 Narcan education date. Narcan distribution will continue through October 2022. Findings The results show that Narcan education increased the employee’s knowledge base and improved the comfort level in administering intranasal Narcan in an opioid-related overdose event. Data also shows an increase in the overall amount of Narcan kits dispensed post Narcan education (7 kits/month) when compared with the overall distribution rates when there was no Narcan education and training provided (2.67 kits/month). Therefore, Narcan education and training improved overall distribution rates among NCC employees. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 30 Strengths The DNP student evaluated the overall comfortability of Narcan administration from various age groups and genders amongst staff members employed at NCC. One educator, the DNP-FNP student, consistently taught the education and training. The educator was available at the facility to answer any questions that arose. Educational materials were transparent and made accessible for every staff member to review. Weaknesses The smaller sampling size (N=48) may have affected the reliability of the survey resulting in higher variability. Narcan can be dispensed intranasally, intramuscularly, and intravenously. Education and distribution focused only on this study’s intranasal route of Narcan. Incorporating education for intramuscular administration to non-medical personnel may have expanded the NCC employee knowledge base by increasing the options to intervene in an opioid-related event. Quality Improvement Discussion Quality improvement is a systematic approach guided by data to improve quality and safety in healthcare (Gagnon, 2022). The framework of quality improvement used for this project is based on the primary goals recommended by the Institute of Medicine. The goals encompass safety, effectiveness, timeliness, efficiency, equity, and patient-centeredness (Gagnon, 2022). The project aimed to promote Narcan awareness among staff members, thereby improving Narcan distribution rates to at-risk community members, with a long-term goal of reducing overall overdose rates. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 31 Translation of Evidence into Practice Approximately every 8 minutes, an individual dies from an opioid-related overdose (CDC, 2022). The complexities of opioid-use disorder and opioid overdose can complicate overdose prevention strategies, often making intervention challenging. A fatal opioid overdose is a preventable event through the timely administration of Narcan (CDC, 2022). Narcan education and training improve the comfort level in the administration and increase the Narcan distribution rate among staff members (Janssen et al., 2020). A targeted Narcan education and distribution protocol aims to train and equip individuals most likely to witness or experience an opioid overdose. Take-home naloxone programs are a proven intervention to reduce overdose mortality among community members (CDC, 2022). Following standardized Narcan protocol education and training, an improvement was noted in the comfort level of NCC staff in Narcan administration. In addition, Narcan distribution rates increased. Based on the successful outcomes of the project, the standardized Narcan protocol was adopted by NCC. The protocol requires mandatory Narcan education and training for every staff employed at NCC. Knowledge gained from this project included an awareness of high-stress levels and burnout among therapists in the psychiatric outpatient setting. This project was initiated during the Covid pandemic, and many NCC therapists reported feeling overwhelmed due to a higher patient load. The staff turnover rate was high at the time of the project implementation. Adding another mandatory requirement could have been met with resistance, but creating a simple, effective Narcan protocol remained a priority. The project also reinforced the value of providing various methods of teaching and instruction for staff employees. For example, the PowerPoint presentation was the favored NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 32 instruction method for many NCC staff members, while other staff members preferred the hands-on demonstration of how to administer Narcan. Incorporating both written and hands-on demonstration was vital to accommodating individual preferences, ensuring that education and instruction were well-received and understood. Implications for Practice and Future Scholarship The project findings demonstrate that a standardized Narcan protocol increases an employee’s knowledge base and improves the comfort level in Narcan administration, thereby increasing Narcan kit distribution rates among at-risk community members. Implications for future practice considerations include extending naloxone training and education beyond the intranasal route. Intranasal, intramuscular, and subdermal naloxone training will expand options for treating an overdose event. Sustainability The costs for sustaining the project are minimal. The administration may update the PowerPoint presentation, patient handout, and website video presentation according to company policy and evidence-based practice changes. If funding for Narcan kits becomes unavailable, Narcan kits can be purchased free of charge from online resources such as Utah Naloxone. Most insurances cover the cost of naloxone, and discounts can be given through online discount providers. Dissemination Project outcomes have been shared and will continue to be shared with the NCC administration and employees through October 2022. Publishing the Narcan protocol may also be a consideration to emphasize positive changes and provide structure for future practices. The project’s purpose, framework, design, Narcan protocol, evidence synthesis, data analysis, NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 33 dissemination, and sustainability plan, will be shared with DNP peers and Weber State Nursing faculty in a poster presentation. Conclusion The DNP-prepared nurse is qualified to implement evidence-based guidelines and practices. The DNP can empower other healthcare professionals to improve patient outcomes through evidence-based practice change. At NCC, a lack of knowledge among staff members and low Narcan distribution rates to at-risk individuals for opioid overdose led to the development of a standardized Narcan protocol. By implementing the project, comfort levels in Narcan administration improved notably among staff members, and Narcan distribution rates increased. As Narcan is a proven safe and effective way to reverse opioid overdose, increased efforts to expand access to at-risk individuals are imperative. 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Utah Department of Health. (2020). Opiate overdose program. https://health.utah.gov/wp-content/uploads/OpiateOverdoseProgram2020.pdf#:~:text=The%20Opiate%20Overdose%20Pilot%20Program%20was%20implemented%20by,Program%20Report%20at%20the%20end%20of%20the%20report. Utah Naloxone. (n.d.). Donate. http://www.utahnaloxone.org/donate-to-join-us-in-these-efforts/. Webster, L.R. (2017). Risk factors for opioid-use disorder and overdose. Anesthesia & Analgesia, 125(5), 1741-1748. doi: 10.1213/ANE.0000000000002496 Widgery, A. (2021). Drug overdose immunity and good samaritan laws. https://www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx. Wyoming Prevention Depot. (2021). Naloxone education and distribution programs. Environmental Strategies Tool. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 41 https://www.wyomingpreventiondepot.org/strategies/strategies/naloxone-education-and-distribution-programs/. NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 42 Appendix A (Staff Narcan Presentation) NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 43 Utah overdose rates up 20 since Covid pandemic (St. George News, 2021) 81,000 drug related fatalities reported in 2020 (Center for Disease Control and Prevention, 2020) 10 individuals die daily in Utah from an opioid related death. (Utah Naloxone, n.d.) Rural communities have less access to resources. (Rodgers, 201 ) NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 44 NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 45 Narcan education training and access will increase the confidence to intervene, and fatality rates due to opioid related overdoses will decrease throughout the communityNARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 46 NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 47 NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 48 NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 49 Appendix B (Intranasal Narcan Administration Video) WIN_20220123_18_ 32_41_Pro.mp4 NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 50 Appendix C (Narcan Handout) Narcan is a safe, effective medication used to reverse the often-fatal effects of an opioid overdose. Narcan can be easily administered by anyone, even those individuals who are not medically trained. You do not need an order to purchase Narcan. Examples of opioids: • morphine (MS Contin®) codeine hydrocodone (Vicodin®, Norco®) hydromorphone (Dilaudid®) oxycodone (Percocet®, OxyContin®) oxymorphone (Opana®) fentanyl (Duragesic) Heroin, Methadone What are the signs of a possible opioid overdose? • Person is unresponsive and/or struggling to breathe • Small (pinpoint) pupils • Pale/Blue/Greyish color skin • Shallow breathing STEPS TO ADMINISTER NARCAN STEP 1: Recognize the signs of an opioid overdose. STEP 2: Call 911 STEP 3: Administer Narcan U G L “ ” U Department of Health, 2016). What is Narcan (Naloxone)? AA NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 51 • PEEL- back the package to remove the device. Hold the device with your thumb on the bottom of the red plunger and two fingers on the nozzle. • PLACE- and hold the tip of the nozzle in either nostril until your fingers touch the bottom of the patient’s nose. • PRESS- The entire contents of the device into the nostril. If the victim is not responding in 3-5 minutes, give a second dose of naloxone and continue CPR/rescue breathing until help arrives. Where can I get free training and access to Narcan? • Local pharmacy • Northeastern Counseling Center in Vernal, Utah website http://www.nccutah.org/ • Utah Naloxone http://www.utahnaloxone.org/ • Only take medication prescribed to you, and take it as directed. • ’ . • Store your medication in a safe and secure place and dispose of any unused medication. • Not taking opioids for a while changes tolerance levels, which means if you restart you need to start at a lower dose. • Teach your family and friends how to respond to an overdose. For assistance with finding addiction treatment, support groups, or recovery support services in your community please call Northeastern Counseling Center at 1-435-6300. References Rhode Island Department of Health. (n.d.) Steps of naloxone administration – Rhode Island. https://health.ri.gov/materialbyothers/NaloxoneAdministrationSteps.pdf. Utah Naloxone. (n.d). Utah naloxone – home. http://www.utahnaloxone.org Help Prevent an Opioid Overdose NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 52 Appendix D (Narcan Pretest/Posttest) 1. Narcan (Naloxone) is used to: a. Reverse an opioid overdose b. Cause an opioid overdose c. Cause sedation and unconsciousness d. Relieve a person’s pain. 2. Signs of a possible opioid overdose include: a. The individual is yelling and screaming and appears to have a high respiratory rate b. The patient is excited, happy, and does not have any physical complaints c. The patient has a rash, has a high pulse rate, and is complaining of stomach pain d. The patient is unconscious, has pinpoint pupils, and is showing signs of respiratory depression 3. Once administered, Narcan begins to work in: a. 2-3 minutes b. 1 hour c. 30 minutes d. 70 minutes 4. What is the proper order to successfully administer intranasal Narcan? a. Pull, Peel, Place b. Place, Pull, Peel c. Peel, Place, Press d. Press, Pull, Place 5. What should you do if you think someone is showing signs of an opioid-related overdose? a. Try to wake the person up and check to see if the person is breathing, call 911, administer Narcan immediately. Stay with the person until help arrives. b. Administer Narcan, leave the scene immediately, check to see if the person is breathing c. Place the Narcan in the unconscious person’s hand and leave the scene immediately. d. Check to see if the person is breathing. If not, wait for 30 minutes to see if the person starts to breathe on their own and then administer Narcan. 6. I feel comfortable administering intranasal Narcan in an opioid-related overdose situation. a. Not comfortable at all b. Slightly comfortable c. Somewhat comfortable d. Very comfortable References https://www.gachd.org/programs-services/opioids/signs-of-an-overdose/ https://study.com/academy/practice/quiz-worksheet-naloxone-uses.html NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 53 Appendix E (Narcan Post-Test Answer Key) Narcan Post-Test Answer Key 1. A 2. D 3. A 4. C 5. A NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 54 Appendix F (Narcan Tracking Sheet) NARCAN PROTOCOL IN A MENTAL HEALTHCARE CENTER 55 Appendix G (Project Timeline)