Opioid overdoses are on the rise among older adults, with a 300% increase in opioid overdose deaths among adults 65 years of age and older since the year 2000. Narcan (Naloxone) is a life-saving agent for treating opioid overdose that has no contraindications for use in emergencies.

Federal regulators have made Narcan widely available for emergency use as an over-the-counter medication, encouraging everyday citizens and non-clinicians to administer Narcan to those showing signs and symptoms of opioid overdose.

Yet older adults who reside in community residences and nursing homes may have limited access to Narcan due to restrictive institutional policies. Despite the fact that one in six community-dwelling older adults reports heavy or chronic opioid use, nursing homes and assisted living facilities do not allow access to Narcan for all patients and residents, limiting their ability to intervene effectively during life-threatening emergencies. 

It is a common misconception that people diagnosed with opioid use disorder — a diagnosis used to identify persons with problematic opioid use — are the only individuals who may experience opioid overdose and require Narcan administration. Increasingly, fentanyl mixing, a process in which illicit fentanyl is covertly mixed into non-opioid recreational substances, can lead to overdose in persons who do not intend to use opioids or who are not prescribed opioids. The covert nature of fentanyl use makes it difficult for long-term care staff to predict ahead of time which residents might one day be at risk of opioid overdose and in need of Narcan.

The Centers for Medicare & Medicaid Services recently put out a memo calling to improve guidance for administering Narcan in long-term care settings, noting that institutional practices should not conflict with residents’ rights to quality care. However, assisted living communities and skilled nursing facilities have no uniform policy governing Narcan administration.

Too often, Narcan is reserved only for residents who are diagnosed with opioid use disorder or who have a Narcan prescription, when in reality many more residents may require Narcan access. This threshold for receiving Narcan is unnecessarily restrictive and is misaligned with current trends in substance use during the fentanyl epidemic. 

If a resident who lacks a prescription for Narcan shows signs of overdose, Narcan is sometimes withheld by the facility, and emergency services are called to administer it instead. This is an outdated and misinformed practice that could cost lives. The time it takes for emergency services to arrive and assess the resident is much longer than the time it could take for staff to administer Narcan and start the reversal of an opioid overdose while help is on the way.

Long-term care administrators need to revise Narcan policies and protocols, and educate staff about the signs of opioid overdose, the method for administering Narcan, and the risks of withholding Narcan to patients experiencing symptoms of overdose. CMS’ Narcan toolkit for long-term care is a valuable resource for developing these policies and protocols.

Non-traditional community residences, including permanent supportive housing sites and homeless shelters, can serve as a model for a successful Narcan administration policy. Due to the complex histories of the residents served in such settings, including substance use and overdose-related health events, non-traditional residences have implemented policies that ensure resident safety. This includes training non-clinical staff to assess opioid overdose and administer Narcan to any resident. 

Given the substance use trends in today’s aging population, traditional community residences like assisted living communities and skilled nursing facilities could benefit from adopting the philosophy that overdose could strike anyone at any time. Best practice for Narcan administration should be likened to that of CPR: all staff must be trained and prepared to administer at any time and should not discriminate against patients who do not have a documented substance use history.

Kelseanne Breder, PhD, PMHNP, RN, GERO-BC, is a clinical assistant professor at NYU Rory Meyers College of Nursing and assistant director for behavioral health at the Hartford Institute for Geriatric Nursing. She is also a psychiatric nurse practitioner with the Center for Urban Community Services where she serves community-dwelling older adults with lived experience of homelessness in New York City.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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