Intravenous Use of Intranasal Naloxone: A Case of Overdose Reversal

Background: Opioid overdose is a growing concern in the United States and internationally. Prehospital or pre–medical personnel (layperson) administration of naloxone, an opioid antagonist, to reverse overdose, is an expanding mode of harm reduction. Recently, community clinics, methadone clinics, needle exchanges, some pharmacies, and other health care facilities have made naloxone available to the community. Case: This case describes heroin overdose reversal of a 28-year-old male who had been using about a gram of heroin intravenously for 3 years but recently reduced frequency of use in an attempt to stop. He was seen initially 1 week prior to a buprenorphine induction in our clinic. After the initial intake, he used intravenous heroin, a larger amount than over the past several weeks in anticipation of abstinence, lost consciousness, and was difficult to arouse. A friend with him noted the patient's respirations to become shallow and administered naloxone nasal spray that the patient had obtained from a needle exchange, but did so intravenously by attaching an unused drug needle to the syringe barrel in place of the nasal atomizer. The patient's overdose was reversed and he recovered. Discussion: This is the first known published case of a community-distributed naloxone nasal spray being used intravenously by a layperson (bystander). The case emphasizes the efficacy of naloxone in overdose reversal and also the need for education or instructions on naloxone use by others (not just the user). Finally, it highlights the risk of overdose in those entering treatment, seeking intoxication one last time.