4. 3. Create and maintain naloxone use report form and log (see Appendix 2 for template) 7. It has few known adverse effects, no potential for abuse, and can be rapidly administered through intramuscular injection or nasal spray. The median naloxone t max after intranasal administration of Narcan Nasal Spray (one nasal spray in one nostril (2 mg or 4 mg) or two nasal sprays as one spray in each nostril (4 mg or 8 mg) was not significantly different compared to the 0.4 mg dose of naloxone hydrochloride intramuscular injection (Table 1).. Talking to patients about naloxone (PDF): tips to get started ; Information to share with pharmacies (PDF) Complete Naloxone Prescribing Guidance (PDF): Guidance for prescribing naloxone for overdose prevention in clinical settings. Naloxone is currently a prescription drug, but is not a controlled substance. Pharmacist will document via prescription record each person who receives a naloxone prescription under this protocol. The NDP aims to address the opioid crisis by reducing opioid overdose deaths through the provision of free naloxone, in its nasal spray formulation. The Naloxone Distribution Project (NDP) is funded by SAMHSA and administe red by DHCS to combat opioid overdose-related deaths throughout California. NARCAN ® (naloxone hydrochloride) Nasal Spray is an opioid antagonist indicated for the emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression. Q: Whenthe pharmacist initiates patient consultation to the recipient of the naloxone, is the recipient allowed to waive the patient consultation? • Naloxone Recipient Form (Appendix B) • NYSDOH Opioid Overdose Prevention Initiative Community Naloxone Usage Form (Appendix C) • Clinical Resources For Shelters – Routine Care (DHS-14h) • Naloxone Order Form (DHS-14i) • DHS Monthly Site Report (DHS-14j) SIGNAGE and IV.E.) Ensure that authorized staff are adequately trained in overdose recognition, naloxone use, and storage (see subsections IV.D. In addition to standard information required in the prescription record, documentation will include name and title of pharmacist providing education to recipient of naloxone. (4) The dispensing shall be documented and labelled as a prescription dispensed per this protocol. A life-saving law took effect on April 1, 2006, making it legal in New York State for non-medical persons to administer Naloxone to another individual to prevent an opioid/heroin overdose from becoming fatal. (C) The pharmacist or intern shall answer any questions the recipient may have regarding naloxone hydrochloride. All registered opioid overdose programs are furnished Naloxone … Naloxone Supplies Order Form COMPLETE AND EMAIL THIS SIGNED FORM, OR ANY QUESTIONS, TO [email protected] OR FAX TO 347-396-8974 Clinical Director Name Program Director Name Agency/Site Name Delivery address State City ZIP Phone number Email address I certify that the information provided in this verification is true and accurate. A: No, the recipient is not allowed to waive the patient consultationfor naloxone. Responses to any questions the recipient may have about naloxone. A. Baltimore Police Naloxone Deployment Reporting Form (“Narcan Report”) Form 18-15 ASSOCIATED POLICIES Policy 1115, Use of Force Policy 1401, Control of Property and Evidence Policy 1402, Management of Evidentiary Controlled Dangerous Substances COMMUNICATION OF POLICY This policy is effective on the date listed herein. 6. See More INDICATION AND USAGE. NARCAN ® Nasal Spray is intended for immediate administration as emergency therapy in settings where opioids may be present. (3) Product Selection: A pharmacist or intern may supply naloxone hydrochloride in any FDA- approved product form. If you are a pharmacist, visit our Naloxone Dispensing Information for Pharmacies page for pharmacist resources. Ensure that naloxone kits are current and not past expiration date 5.