LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 352.01 Intranasal Opioid Antagonist Prescribing Requirements and Administration in Clinical Settings (306.08)
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Review and Approved by:  Pharmacy and Therapeutics

Approved by Curley L. Bonds, MD, Chief Medical Officer
Reviewed and Approved by Pharmacy and Therapeutics Committee on January 31, 2024
I. PURPOSE
 
To establish a policy and procedures for the administration of intranasal opioid antagonists (e.g. naloxone) by Los Angeles County Department of Mental Health (DMH) in emergency situations when suspected opioid overdose may be present and/or to prescribe and dispense intranasal opioid antagonists to a client who is at high risk of an opioid overdose.
 
II. DEFINITIONS
 
Opioid: Substances include opiate and related synthetic and semi-synthetic compounds that act on opioid receptors to produce morphine-like effects.

Opioid Antagonists: Life-saving medications that can temporarily reverse opioid overdose, allowing the individual to breathe and providing enough time for emergency personnel to arrive. Example includes intranasal naloxone.

Authorized Personnel: Physician, PA, NP, Pharm.D., RN, LVN, psychiatric technician

Specially Trained Staff: Any DMH staff member who has completed approved Administration Training for corresponding opioid antagonist
 
III. POLICY
 
All DMH programs shall have the capacity to properly administer intranasal opioid antagonists in instances where opioid overdose is probable.

Intranasal opioid antagonists shall be administered by Authorized Personnel or any specially trained staff.

All DMH programs shall have the capacity to prescribe and dispense intranasal opioid antagonists to clients who are at high risk of an opioid overdose.

Intranasal opioid antagonists shall be prescribed and dispensed by physicians, nurse practitioners, physician assistants, or pharmacists.

Directly operated clinics shall receive intranasal opioid antagonists from the DMH pharmacy warehouse for clinic stock in accordance with DMH Pharmacy Warehouse Policy 352.17.

All storage of intranasal opioid antagonists shall conform to County, State, and Federal regulatory requirements.
 
IV. PROCEDURES
 
Procedures - Intranasal Opioid Antagonist Prescribing Requirements and Administration in Clinical Settings - Naloxone
 
V. AUTHORITIES
 
VI. ATTACHMENTS