Using Naloxone to Reverse Opioid Overdose in the Workplace: Information for Employers and Workers

Introduction

Opioid misuse and overdose deaths from opioids are
serious health issues in the United States. Overdose
deaths involving prescription and illicit opioids doubled
from 2010 to 2016, with more than 42,000 deaths in 2016
[CDC 2016a]. Provisional data show that there were more
than 49,000 opioid overdose deaths in 2017 [CDC 2018a].
In October 2017, the President declared the opioid
overdose epidemic to be a public health emergency.

Naloxone is a very effective drug for reversing opioid
overdoses. Police officers, emergency medical services
providers, and non-emergency professional responders
carry the drug for that purpose. The Surgeon General
of the United States is also urging others who may
encounter people at risk for opioid overdose to have
naloxone available and to learn how to use it to save lives
[USSG 2018].

The National Institute for Occupational Safety and Health
(NIOSH), part of the Centers for Disease Control and
Prevention (CDC), developed this information to help
employers and workers understand the risk of opioid
overdose and help them decide if they should establish a
workplace naloxone availability and use program.

Background

What are opioids?

Opioids include three categories of pain-relieving drugs:
(1) natural opioids (also called opiates) which are derived
from the opium poppy, such as morphine and codeine;
(2) semi-synthetic opioids, such as the prescription drugs
hydrocodone and oxycodone and the illicit drug heroin;
(3) synthetic opioids, such as methadone, tramadol, and
fentanyl. Fentanyl is 50 to 100 times more potent than
morphine. Fentanyl analogues, such as carfentanil, can
be 10,000 times more potent than morphine. Overdose
deaths from fentanyl have greatly increased since 2013
with the introduction of illicitly-manufactured fentanyl
entering the drug supply [CDC 2016b; CDC 2018b]. The
National Institute on Drug Abuse [NIDA 2018] has more
information about types of opioids.

What is naloxone?

Naloxone hydrochloride (also known as naloxone,
NARCAN® or EVZIO®) is a drug that can temporarily stop
many of the life-threatening effects of overdoses from
opioids. Naloxone can help restore breathing and reverse
the sedation and unconsciousness that are common
during an opioid overdose.

Side effects

Serious side effects from naloxone use are very rare.
Using naloxone during an overdose far outweighs any
risk of side effects. If the cause of the unconsciousness is
uncertain, giving naloxone is not likely to cause further
harm to the person. Only in rare cases would naloxone
cause acute opioid withdrawal symptoms such as body
aches, increased heart rate, irritability, agitation, vomiting,
diarrhea, or convulsions. Allergic reaction to naloxone is
very uncommon.

Limitations

Naloxone will not reverse overdoses from other
drugs, such as alcohol, benzodiazepines, cocaine, or

amphetamines. More than one dose of naloxone may
be needed to reverse some overdoses. Naloxone alone
may be inadequate if someone has taken large quantities
of opioids, very potent opioids, or long acting opioids.
For this reason, call 911 immediately for every overdose
situation.

Opioids and Work

Opioid overdoses are occurring in workplaces. The Bureau
of Labor Statistics (BLS) reported that overdose deaths at
work from non-medical use of drugs or alcohol increased
by at least 38% annually between 2013 and 2016.
The 217 workplace overdose deaths reported in 2016
accounted for 4.2% of occupational injury deaths that
year, compared with 1.8% in 2013 [BLS 2017]. This large
increase in overdose deaths in the workplace (from all
drugs) parallels a surge in overall overdose deaths from
opioids reported by CDC [2017]. Workplaces that serve
the public (i.e. libraries, restaurants, parks) may also have
visitors who overdose while onsite.

Workplace risk factors for opioid use

Opioids are often initially prescribed to manage pain
arising from a work injury. Risky workplace conditions
that lead to injury, such as slip, trip, and fall hazards or
heavy workloads, can be associated with prescription
opioid use [Kowalski-McGraw et al. 2017]. Other factors,
such as job insecurity, job loss, and high-demand/low-
control jobs may also be associated with prescription
opioid use [Kowalski-McGraw et al. 2017]. Some people
who use prescription opioids may misuse them and/
or develop dependence. Prescription opioid misuse
may also lead to heroin use (Cicero et al. 2017]. Recent
studies show higher opioid overdose death rates among
workers in industries and occupations with high rates
of work-related injuries and illnesses. Rates also were
higher in occupations with lower availability of paid sick
leave and lower job security, suggesting that the need
to return to work soon after an injury may contribute to
high rates of opioid-related overdose death [MDPH 2018,
CDC 2018c]. Lack of paid sick leave and lower job security
may also make workers reluctant to take time off to seek
treatment.

Considering a Workplace Naloxone Use Program

Anyone at a workplace, including workers, clients,
customers, and visitors, is at risk of overdose if they use
opioids. Call 911 immediately for any suspected overdose.
Overdose without immediate intervention can quickly
lead to death. Consider implementing a program to make
naloxone available in the workplace in the event of an
overdose. The following considerations can help you
decide whether such a program is needed or feasible:

• Does the state where your workplace is located
  allow the administration of naloxone by non-
  licensed providers in the event of an overdose
  emergency?
• What liability and legal considerations should be
  addressed? Does your state’s Good Samaritan law
  cover emergency naloxone administration?
• Do you have staff willing to be trained and willing
  to provide naloxone?
• Has your workplace experienced an opioid
  overdose or has there been evidence of opioid
  drug use onsite (such as finding drugs, needles or
  other paraphernalia)?
• How quickly can professional emergency
  response personnel access your workplace to
  provide assistance?
• Does your workplace offer other first aid or
  emergency response interventions (first aid kits,
  AEDs, trained first aid providers)? Can naloxone
  be added?
• Are the risks for opioid overdose greater in your
  geographic location? The National Center for
  Health Statistics provides data on drug overdose
  deaths in an online state dashboard. [CDC 2018a.]

Photo: Hands holding piece of paper labeled “Safety procedures” in a blue binder

• Are the risks for opioid overdose greater in
  your industry or among occupations at your
  workplace? [See MDPH 2018 and CDC 2018c.]
• Does your workplace have frequent visitors,
  clients, patients, or other members of the public
  that may be at increased risk of opioid overdose?

Review the above questions periodically even if
a program is not established right away. Ideally, a
naloxone program is but a part of a more comprehensive
workplace program on opioid awareness and misuse
prevention.

Establishing a Program

You will need policies and procedures for the program.
These should be developed in consultation with
safety and health professionals. Involve the workplace
safety committee (if present) and include worker
representatives. You also will need a plan to purchase,
store, and administer naloxone in case of overdose.
Additional considerations for establishing a program are
described below.

Risk assessment

Conduct a risk assessment before implementing the
naloxone program.

• Decide whether workers, visiting clients,
  customers, or patients are at risk of overdose.
• Assess availability of staff willing to take training
  and provide naloxone.
• Consult with professional emergency responders
  and professionals who treat opioid use disorders
  in your area.

Liability

Consider liability and other legal issues related to such a
program.

Records management

Include formal procedures for documenting incidents
and managing those records, to include safeguarding the
privacy of affected individuals. Maintain records related
to staff roles and training.

Staff roles

Define clear roles and responsibilities for all persons
designated to respond to a suspected overdose. Include
these roles and responsibilities in existing first aid or
emergency response policies and procedures (first aid
kits, AEDs, training for lay first-aid providers, and/or onsite
health professionals).

Training

Train staff to lower their risks when providing naloxone.
Staff must be able to:

• Recognize the symptoms of possible opioid
  overdose.
• Call 911 to seek immediate professional
  emergency medical assistance.
• Know the dangers of exposure to drug powders
  or residue.
• Assess the incident scene for safety concerns
  before entering.
• Know when NOT to enter a scene where drug
  powders or residues are visible and exposure to
  staff could occur.
• Know to wait for professional emergency
  responders when drug powders, residues, or
  other unsafe conditions are seen.
• Use personal protective equipment (PPE; nitrile
  gloves) during all responses to protect against
  chemical or biological exposures including opioid
  residues, blood, or other body fluids.
• Administer naloxone and recognize when
  additional doses are needed.
• Address any symptoms that may arise during the
  response, including agitation or combativeness
  from the person recovering from an overdose.
• Use additional first aid, CPR/basic life support
  measures. Opioid overdose can cause respiratory
  and cardiac arrest.

Prepare for possible exposure to blood. Needles or other
sharps are often present at the scene of an overdose.
Provide bloodborne pathogen training to responding
staff members and consider additional protection, such
as hepatitis B vaccination.

Purchasing naloxone

Naloxone is widely available in pharmacies. Most states
allow purchase without a prescription. Choose nasal
sprays or injectable forms that can be delivered with an
auto-injector, a pre-filled syringe, or a standard syringe/
needle. Customize training to fit the formulation stocked
at your workplace.

Consider the nasal spray formulation for its safety to lay
providers and its ease of administration. Research shows
that people trained on intranasal spray reported higher
confidence both before and after training compared
with people trained on injectable forms [Ashrafioun et al.
2016].

Stock a minimum of two doses of naloxone. Some
workplaces may choose to stock more. In some cases, one
dose of naloxone is inadequate to reverse an overdose.
The size, layout, and accessibility of the workplace
may require placement of doses in multiple locations.
Consider the time needed to replace supplies when
determining the number of doses to stock.

Naloxone storage

Follow manufacturer instructions for storing naloxone.
Keep in the box or storage container until ready for use.
Protect from light and store at room temperature (59-
77°F or 15-25°C). Naloxone can expire and its potency
can wane over time. Note the expiration date for timely
replacement.

PPE and other equipment storage

Store personal protective equipment, such as disposable
nitrile gloves, and other first aid equipment, such as a
responder rescue mask, face shield, or bag valve mask
(for use in rescue breathing or CPR) close to the naloxone
for quick response. Include sharps disposal containers if
injectable naloxone is used.

Follow-up care planning

Develop a plan for immediate care
by professional healthcare providers,
referral for follow-up care, and
ongoing support for any worker who
has overdosed. Include emergency
assistance and support (i.e. Employee
Assistance Program, mental health
services) for lay staff responders and
bystanders if necessary.

Maintaining a program

Re-evaluate your program periodically. Assess for new
risks. Plan for maintaining equipment and restocking of
naloxone (including replacement of expired naloxone),
other first aid supplies, and PPE.

Check for updates to procedures and guidance

Incorporate new medical and emergency response
guidance regarding naloxone purchase, storage, and
administration.

Training review and update

Schedule refresher training annually. Training on opioid
overdose and naloxone use can be combined with other
first aid/CPR training and certifications.

References

Ashrafioun L, Gamble S Herrmann M, Baciewicz G [2016]. Evaluation of knowledge and confidence following opioid
overdose prevention training: A comparison of types of training participants and naloxone administration methods.
Subst Abus 37(1):76-81. doi: 10.1080/08897077.2015.1110550

BC [2017]. Naloxone risk assessment tool – for non-public sector organizations. Prepared for the Joint Task Force on
Overdose Response. Vancouver, BC: Canada. https://www2.gov.bc.ca/assets/gov/overdose-awareness/naloxone_risk_
assessment_-_non-governmental_sectors.pdf

BLS (Bureau of Labor Statistics) [2017]. Economic News Release: Census of Fatal Occupational Injuries Summary, 2016.
Washington, DC: Bureau of Labor Statistics, December 19, https://www.bls.gov/news.release/cfoi.nr0.htm

CDC (Centers for Disease Control and Prevention) [2016a]. CDC guideline for prescribing opioids for chronic pain —
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CDC [2016b]. Fentanyl Law Enforcement Submissions and Increases in Synthetic Opioid–Involved Overdose Deaths —
27 States, 2013–2014. MMWR 65(33):837-843

CDC [2017]. Provisional counts of drug overdose deaths, as of 8/16/2017. Atlanta, GA: U.S. Department of Health
and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital
Statistics System. https://www.cdc.gov/nchs/data/health_policy/monthly-drug-overdose-death-estimates.pdf

CDC [2018a]. NVSS Vital Statistics Rapid Release: 12 Month-ending Provisional Number of Drug Overdose Deaths by
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CDC [2018b]. Health alert network: rising numbers of deaths involving fentanyl and fentanyl analogs, including
carfentanil, and increased usage and mixing with non-opioids. Atlanta, GA: U.S. Department of Health and Human
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CDC [2018c]. Occupational Patterns in Unintentional and Undetermined Drug-Involved and Opioid-Involved Overdose
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Resources

Burden of opioid use

edworkforce.house.gov/news/documentsingle.aspx?DocumentID=402497

Commonly abused drugs

drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts

Confidentiality

hhs.gov/hipaa

Emergency response resources

cdc.gov/niosh/topics/emres/responders

hhs.gov/about/news/2018/04/05/surgeon-general-releases-advisory-on-naloxone-an-opioid-overdose-reversing-drug

cdc.gov/niosh/docs/wp-solutions/2010-139

Fentanyl

cdc.gov/niosh/topics/fentanyl/risk

cdc.gov/niosh/ershdb/emergencyresponsecard_29750022

cdc.gov/drugoverdose/opioids/fentanyl

Liability Issues

drugpolicy.org/sites/default/files/Fact%20Sheet_State%20based%20Overdose%20Prevention%20Legislation%20%28January%202016%29

shrm.org/resourcesandtools/legal-and-compliance/employment-law/pages/employers-naloxone

networkforphl.org/_asset/qz5pvn/legal-interventions-to-reduce-overdose

Naloxone

samhsa.gov/medication-assisted-treatment/treatment/naloxone

drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio

tn.gov/health/health-program-areas/health-professional-boards/csmd-board/csmd-board/naloxone-training-information

ccohs.ca/oshanswers/hsprograms/firstaid_naloxone

Naloxone access

drugabuse.gov/publications/medications-to-treat-opioid-addiction/naloxone-accessible

narcan.com/availability

getnaloxonenow.org

NIOSH resources on opioids

cdc.gov/niosh/topics/opioids

cdc.gov/niosh/topics/fentanyl

Overdose prevention

surgeongeneral.gov/priorities/opioid-overdose-prevention

surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory

cdc.gov/drugoverdose/prevention

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DOI: https://doi.org/10.26616/NIOSHPUB2019101

HHS (NIOSH) Publication No. 2019–101
October 2018