Naloxone (Narcan) Distribution and Training Policy
Policy Statement
To comply with California Behavioral Health Information Notice (BHIN) 22-025, Morro Bay Recovery is committed to ensuring all staff members are trained in naloxone administration and
that an adequate supply of naloxone is maintained on-site for emergency use to address opioid overdoses.
Purpose
This policy establishes guidelines for:
1. Staff training on naloxone administration.
2. The procurement, storage, and distribution of naloxone in accordance with state and federal guidelines.
3. Compliance with California BHIN 22-025 to enhance client safety and reduce opioid-related harm.
Procedure
1. Training Requirements
Who Requires Training:
All clinical and non-clinical staff who may encounter clients or situations requiring naloxone administration are required to complete training.
Training Curriculum:
Training must include the following topics:
Recognition of opioid overdose symptoms.
Proper administration techniques for Narcan (nasal spray) and other naloxone products.
Legal protections under California’s Good Samaritan laws.
Protocols for calling emergency services (911) during an overdose incident.
Post-administration steps, including monitoring the individual and documentation requirements.
Compliance with CCR, Title 9, Section 10564(k): Training will include an overview of the regulation and its relevance to naloxone use in the facility.
Training Resources: Staff training will include online resources and materials from the National Harm Reduction Coalition's Opioid Overdose Basics website, available at:
https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/.
Staff Availability:
At least one staff member, at all times, on the premises must:
Know the specific location of the naloxone.
Be trained in its administration.
Frequency of Training:
All new employees must complete naloxone training within 30 days of hire.
Refresher training will be conducted annually.
Training Documentation:
Proof of training, including completion of modules and resources such as the National Harm Reduction Coalition's materials, will be maintained in the individual staff member’s personnel file.
Documentation will include the date of training, content covered, and the trainer’s credentials.
2. Naloxone Supply
Minimum Inventory Requirement:
A minimum of four (4) unexpired doses of naloxone must be maintained at all times on-site.
If the inventory falls below this threshold, an immediate order must be placed to replenish the supply.
Procurement:
Naloxone (Narcan) will be procured in sufficient quantity to meet the needs of the facility, maintaining the minimum required inventory. Orders will be placed promptly through Morro Bay Recovery Management Personnel,
Reordering Protocol:
If the number of naloxone doses in inventory drops below four (4), the Program Director or designee must immediately initiate a reorder process. Expired or damaged naloxone must be
replaced promptly to ensure the facility complies with the minimum inventory requirement.
Storage:
Naloxone will be stored in a secure, easily accessible location. Storage conditions must adhere to
manufacturer recommendations (e.g., room temperature).
Inventory Management:
Monthly inventory checks will ensure an adequate supply of unexpired naloxone. The inventory log will record the quantity, expiration dates, and any reordering actions.
Distribution:
Naloxone kits will be made available to clients or their families upon discharge, as appropriate, and documented in client records.
3. Use of Naloxone
Response to Overdose:
In the event of a suspected opioid overdose, trained staff will:
Administer naloxone immediately.
Call emergency services (911).
Remain with the individual until emergency responders arrive.
Post-Event Documentation:
An incident report will be completed, including details of naloxone administration and client outcome.
4. Compliance Monitoring
The Program Director will:
Review training records monthly to ensure compliance with annual training requirements.
Monitor naloxone inventory monthly to verify compliance with the minimum threshold of four (4) unexpired doses.
Address non-compliance with corrective actions immediately.
Related Policies
Emergency Response Protocols
Client Discharge Planning
Medication Inventory Management
References
California Behavioral Health Information Notice (BHIN) 22-025
California Code of Regulations (CCR), Title 9, Section 10564(k)
Naloxone Standing Orders under California law
California Good Samaritan Law (AB 635)
National Harm Reduction Coalition Opioid Overdose Basics
(https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/)
Feel free to contact us for any reason and if you have any questions, concerns, or requests.
Contact Information
Morro Bay Recovery
2460 Main Street,
Morro Bay, California, 93442
+1 (805) 772-2212