Naloxone intranasal or auto-injector; which is better?

Researchers investigate the capability of bystanders to treat a simulated opioid overdose with intranasal naloxone versus auto-injector naloxone


Naloxone is the antidote for opioid overdose. Naloxone can be administered through intravenous, intranasal, subcutaneous, intramuscular, nebulizer and endotracheal routes. The administration route depends on the scope, training and authorization of the person administering naloxone. Laypeople generally have two choices for naloxone administration; intranasal or intramuscular.

A group of investigators, funded by the makers of a naloxone auto-injector, compared the time of administration of naloxone intranasal versus naloxone auto-injector, as well as completion of critical tasks related to administration. In phase 1 the 42 study participants needed to administer naloxone to a simulated patient with no instruction. In phase 2 the same participants received training on intranasal and auto-injector naloxone administration before administering to a simulated patient. In phase 3 the participants completed another naloxone administration simulation with no additional training.

Read the article, published in the open-access journal Pain and Therapy.

Memorable quotes on opioid overdose and naloxone administration

"There were more than four times as many opioid-related fatalities in 2010 as there were in 1999 and opioid-related fatalities have remained at these levels through 2013."

"Nasal atomization kits and their accompanying instructions-for-use have not been subject to rigorous Human Factors Engineering development and testing to evaluate the usability of these kits by the general population."

"Although both products resulted in a statistically significant reduction in time to administer a dose following one-on-one training by a healthcare professional, this study found that less than 60% of participants were able to use the NXN as compared to 100% with the NAI."

Key takeaways for EMS leaders and educators

It is clear that we are in the midst of an opioid overdose epidemic. EMS, public health and hospital officials continue to report increasing responses to, as well as deaths from, opioid overdoses. Many communities have made naloxone available to all-levels of health care workers, police officers, and firefighters, as well as laypeople such as teachers, friends, adult relatives and even children of opioid addicts. CVS is selling naloxone over the counter in more than a dozen states.

After reviewing the results of this study comparing administration of intranasal to auto-injector naloxone by laypersons these are my key takeaways:

1. EMS has an important role as a trusted resource and patient care advocate

Laypersons, elected officials, emergency response partners and other health care providers look to EMS for advice on implementation of lifesaving products and devices. From AEDs to tourniquets to naloxone, EMS officials need to proactively advise their community on how and where devices should be placed, who should be authorized to use them and what training and support will be available. The product recommendations, administration methods and training design are driven by local needs, demographics and geography.

2. Replicable methodology for medication administration instruction

The study investigators have outlined a curriculum for medication administration instruction that EMS educators can easily replicate for initial EMT and medic training, as well as refresher training. Instead of lecturing and demonstrating administration of intranasal naloxone, try this method of making the materials available to EMT students. Watch for the difficulties they encounter and resources they use to complete those tasks. Use those observations to tailor the instruction and demonstration before they try again on a simulator. Return to the same medication two weeks later and two months later to assess knowledge retention and reinforce critical tasks.

3. Valuable initial contribution to research on naloxone administration

This study is a helpful contribution to what we know about naloxone administration, but it is not definitive proof that the auto-injector is preferable to other routes. The population size studied was small and potential shortcomings of an auto-injector (needle deployment failure) or secondary injuries or risks of an accidental needlestick were not discussed.

Finally, though the authors are employees of the auto-injector maker, they have completed a literature review and outlined a potential study methodology for other research on naloxone administration routes. We can learn from their efforts without discounting their intentions.

What are your key takeaways? 

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