Naloxone

Summary sheet: Naloxone

Naloxone
Chemical Nomenclature
Common names	Naloxone, Narcan, Evzio
Substitutive name	1-N-Allyl-14-hydroxynordihydromorphinone
Systematic name	(4R,4aS,7aR,12bS)-4a,9-Dihydroxy-3-prop-2-enyl-2,4,5,6,7a,13-hexahydro-1H-4,12-methanobenzofuro[3,2-e]isoquinoline-7-one
Class Membership
Psychoactive class	Opioid (Antagonist)
Chemical class	Morphinan
Routes of Administration
WARNING: Always start with lower doses due to differences between individual body weight, tolerance, metabolism, and personal sensitivity. See responsible use section. ⇣ Oral Dosage Threshold 4 mg Light 4 - 8 mg Common 8 - 16 mg Strong 16 - 28 mg Heavy 28 mg + Duration Total 1 - 2 hours Onset 5 - 15 minutes Come up 20 - 40 minutes Peak 1 - 2 hours Offset 30 - 60 minutes After effects 1 - 12 hours ⇣ Insufflated Dosage Common 1 - 4 mg Duration Total 30 - 60 minutes Onset 0 - 10 minutes ⇣ Intramuscular Dosage Common 0.4 - 2 mg Duration Total 30 - 60 minutes Onset 0.25 - 2 minutes ⇣ Intravenous Dosage Common 0.4 - 2 mg Duration Total 30 - 60 minutes Onset 0.25 - 2 minutes DISCLAIMER: PW's dosage information is gathered from users and resources for educational purposes only. It is not a recommendation and should be verified with other sources for accuracy.
Interactions

Naloxone (commonly sold under the brand names Narcan and Evzio) is a synthetic mu-opioid antagonist of the morphinan chemical class that is widely used to reverse the effects of an acute opioid overdose. Naloxone is sold under the brand name Narcan as a nasal spray and Evzio as an auto-injector with voice instructions.

Naloxone has been credited with saving an unprecedented number of opioid overdose victims. This is partially due to naloxone programs in several countries to give naloxone to people who use opioids along with the rapid deployment of naloxone by law enforcement agencies and emergency medical services. Many emergency responders and law enforcement are trained to administer naloxone to reverse the effects of opioid overdoses immediately.

Besides its use in emergency medicine, naloxone has been researched in the treatment of depersonalization disorder with promising results.

Chemistry

Naloxone, also known as N-allylnoroxymorphone or as 17-allyl-4,5α-epoxy-3,14-dihydroxymorphinan-6-one, is a synthetic morphinan derivative and was derived from oxymorphone (14-hydroxydihydromorphinone), an opioid analgesic. Naloxone is a racemic mixture of two enantiomers, (–)-naloxone (levonaloxone) and (+)-naloxone (dextronaloxone), only the former of which is active at opioid receptors. The drug is highly lipophilic, allowing it to rapidly penetrate the brain and to achieve a far greater brain to serum ratio than that of morphine.

The chemical half-life of naloxone is such that injection and nasal forms have been marketed with 24-month and 18-month shelf-lives, respectively. A 2018 study noted that the nasal and injection forms presented as chemically stable to 36- and 28-months, respectively, which prompted an as yet incomplete five year stability study to be initiated. This suggests that expired caches of material in community and healthcare settings may still be efficacious substantially beyond their labeled expiration dates.

Pharmacology

Naloxone acts as a potent μ-opioid receptor inverse agonist. Because of its high affinity for the μ-opioid receptor, it knocks other ligands out of the receptor. If naloxone is administered without previous administration of opioids, it has few biological effects, notably a lower pain threshold.

Naloxone has two isomers, (+)naloxone and (-)naloxone, with the latter being active. The liver metabolizes naloxone. It has very low oral bioavailability, which is why it is administered intravenously, intramuscularly or intranasally. Small amounts of naloxone are often added to opioids like buprenorphine and pentazocine to prevent abuse. This is because of the bioavailability difference; injecting the isolated ingredients from the pill will also inject naloxone.

Naloxone has been noted to block a placebo based analgesic effect. For example, if an individual has been administered something that they were told was morphine and had an analgesic response to it, naloxone will block that response.

Naloxone also has a lower affinity as an antagonist at the κ-opioid and δ-opioid receptors.

If naloxone is administered in the absence of concomitant opioid use, no functional pharmacological activity occurs, except the inability for the body to combat pain naturally. In contrast to direct opiate agonists, which elicit opiate withdrawal symptoms when discontinued in opiate-tolerant people, no evidence indicates the development of tolerance or dependence on naloxone. The mechanism of action is not completely understood, but studies suggest it functions to produce withdrawal symptoms by competing for opiate receptor sites within the CNS (a competitive antagonist, not a direct agonist), thereby preventing the action of both endogenous and xenobiotic opiates on these receptors without directly producing any effects itself.

Subjective effects

When taken by itself and outside the context of an opioid overdose, naloxone causes relatively comfortable sedation and general suppression of emotions.

Disclaimer: The effects listed below cite the Subjective Effect Index (SEI), an open research literature based on anecdotal user reports and the personal analyses of PsychonautWiki contributors. As a result, they should be viewed with a healthy degree of skepticism.

It is also worth noting that these effects will not necessarily occur in a predictable or reliable manner, although higher doses are more liable to induce the full spectrum of effects. Likewise, adverse effects become increasingly likely with higher doses and may include addiction, severe injury, or death ☠.

Physical effects

• • Sedation - Naloxone is considerably sedating. It can result in the user feeling sleepy and having difficulty keeping their eyes open.
  • Dehydration
  • Nausea - This is a relatively uncommon effect that may occur randomly.

Cognitive effects

• • Emotion suppression - The emotion suppression found on naloxone is noticeably similar to the same experience found within antipsychotics although without the accompanying analysis suppression and thought deceleration.
  • Identity alteration - Naloxone has been demonstrated by a pilot study to significantly reduce the symptoms of chronic long-term depersonalization. Within this study, 11 patients received single doses (1.6 or 4 mg i.v.) and three others received multiple infusions, with the maximal dosage being 10 mg, and the effect of naloxone on symptom severity was then measured and determined.

  In most cases, the first signs of improvement were recorded soon after the naloxone infusions (within 20–40 min), and greater brightness marked the patients' perception of the world. A full reduction or disappearance of depersonalization occurred within the interval of 1–4 hours and, in some patients, continued for as long as 12–24 h. This was followed by some deterioration, although the depersonalization never recurred to the initial level. Five patients showed evidence of a stable improvement.

Experience reports

There are currently no anecdotal reports which describe the effects of this compound within our experience index. Additional experience reports can be found here:

• Erowid Experience Vaults: Naloxone

Administration

When administering naloxone, it is important to understand which formulation it is coming in and what that means. In the United States, naloxone primarily comes in four formulations. Narcan is a prescription nasal spray that is inserted and administered into the nose. Evzio is an autoinjector with voice instruction capabilities similar to many epinephrine autoinjectors. Naloxone may come in a pink or orange box that reads "Naloxone Hydrochloride, INJ., USP" or a green box that reads the same thing. The main difference between these two is that the green ones come with a needle built in and is meant for intramuscular injection specifically.

The three most common types of naloxone. Narcan, Evzio and generic orange/pink box naloxone respectively.

Common Brands (United States)

Narcan is one of the most common brands containing naloxone. To use it, these steps are followed:

1) Peel the device out of the packaging

2) Hold the device with the thumb on the bottom of the plunger and 2 fingers on the nozzle

3) Place and hold the tip of the nozzle in either nostril until one's fingers touch the bottom of the patient’s nose

4) Press the plunger down, which will release the medication.

Narcan is not a substitute for professional medical care. On brand Narcan will deliver 4mg of naloxone. Narcan does not last as long as many opioids, so before or after administering Narcan, one should call for emergency services.

Evzio is one of the most common brands containing naloxone. To use it one can follow these steps: 1) Pull the device out of the case 2) Pull off the red safety guard 3) Place the black end of the device against one's outer thigh 4) Ensure there are no solid objects between the black end and their skin -- the needle can go through clothes if necessary 5) Press firmly down on the device until distinct click is heard and hold it there for 5 seconds to ensure all the naloxone is released from the device.

Evzio is not a substitute for professional medical care. Evzio does not last as long as many opioids, so before or after administering Evzio, one should call for emergency services.

To use orange/pink box naloxone, one can follow these steps: 1) Take the device out of the box 2) If the device is not assembled, assemble it 3) Remove the yellow caps off the cylinder 4) On the narrow end, put the cylindrical cap 5) Take the vial of the medication and put it into the chamber, with the colored end pointing towards the patient 6) The dosage for adults is 2 mg of naloxone and the device comes with 2 mg 7) Put the device in either nostril and press down on the vial of medication until half of it is dispersed into that nostril 8) Then, take the device and put it in the other nostril and administer the rest of the medication.

If the patient is under 5 years of age, only administer 1 mg total, or a quarter of the total medication in each nostril. Each naloxone should be administered with the goal of restoring ventilation (breathing) but not necessarily consciousness. Naloxone should not be administered in the field to patients under 28 days of age.

Boxed naloxone is not a substitute for professional medical care. Naloxone does not last as long as many opioids. So before or after administering naloxone, one should call for emergency services.

Naloxone is often combined with otherwise frequently abused Opioids like "Tilidin" (Synthetic Opioid which is 5 times weaker than Morphine; almost only used in European Countries) which is produced in composition of 50mg (Tilidin) / 4mg (Naloxone), 100/8 and 200/16 and given out in extended-elease Tablets.

It should be noted that this doesn't prevent abuse since Naloxone's Oral Bioavailability is around 1%, which therefore requires dosages of around 400mg of Naloxone alone (Oral) for it to show its antagonistic effects.

Toxicity and harm potential

Naloxone in the form it is used by emergency medical services and law enforcement.

Naloxone is considered not habit-forming. When naloxone is administered in an opioid overdose, the individual will go through immediate withdrawal. Sudden opioid withdrawal may be life-threatening in extreme cases. Symptoms of opioid withdrawal may include, but are not limited to agitation, nausea, psychosis, temperature regulation suppression, anxiety, physical fatigue, excessive yawning, sweating, dehydration, and pupil dilation.

It has been noted that naloxone may be needed in higher dosages depending on the opioid that was consumed. It is not uncommon for several doses of naloxone to be administered in overdose cases involving fentanyl or one of its many analogs. If an individual does not have opioids in their system when naloxone is administered, it may cause dehydration and nausea.

It is strongly recommended that one use harm reduction practices when using this substance.

Legal status

Throughout the world, naloxone is not considered a controlled substance. It is a prescription drug in most countries.

• Australia: In Australia, naloxone is considered an over the counter drug and is available at most pharmacies
• Canada: In Canada, naloxone kits are distributed at many emergency rooms, clinics, and some pharmacies.
• Germany: Naloxone is a prescription medicine, according to Anlage 1 AMVV.
• Switzerland: Preparations containing only naloxone are listed as "Abgabekategorie B" pharmaceuticals, which require a prescription to obtain.
• Turkey: Naloxone is only sold as an addictive to buprenorphine to deter abuse, which is prescription only.
• United States: At a federal level, naloxone is a prescription drug. Many states have programs that make naloxone over the counter and available at request at most pharmacies. In the United States, most jurisdictions have programs to deploy naloxone to law enforcement and fire and rescue services.
• United Kingdom: In the United Kingdom, naloxone is considered a prescription drug, but drug services can supply it without a prescription. And anyone can use it to save a life in an emergency.

See also

• Responsible use
• Safer injection guide
• Opioids
• Heroin
• Fentanyl
• Codeine
• Morphine

External links

• Naloxone (Wikipedia)
• Naloxone (Erowid Vault)
• Naloxone (TiHKAL / Isomer Design)
• Combatting America's Opioid Crisis: Heroin's Antidote (Vice)