SCIENCE AND PRACTICE

Journal of the American Pharmacists Association xxx (2019) 1e4

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RESEARCH NOTES
A novel naloxone training compared with current recommended
training in an overdose simulation
Thomas S. Franko II*, Danielle Distefano, Lauren Lewis

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: The aim of this study was to determine if a novel naloxone training program with a
Received 25 August 2018 focus on situational stress management yields better results than the currently recommended
Accepted 26 December 2018 state training in a simulated overdose response.
Methods: Students were randomized to receive either the state training or a novel training
developed by the Wilkes University Nesbitt School of Pharmacy. After their respective training,
each student individually completed a live simulated overdose response with an added
stressor of a panicked bystander. A checklist was used to evaluate students during the simu-
lation, and the results were compared.
Results: The average grade for the novel training students was 89% compared with 64% for the
state training students (P < 0.001). There was no statistically significant difference in time to
complete the simulation.
Conclusion: Students who underwent the novel training received the state training. The novel
training appears to be effective in preparing students to manage a live opioid overdose.
© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Overdose is now the leading cause of death in Americans
under the age of 50 years.1 In 2017 there were over 72,000
deaths nationally due to drug overdose, over 49,000 of which
were associated with opioids.2 In Pennsylvania alone there
were 5456 overdose-related deaths in 2017.3 From 2014 to
2017, Luzerne County saw over a 700% increase in overdose
deaths.4
Naloxone has been used to reverse opioid overdose since its
approval in 1971.5 As of 2017, naloxone is available in 3 delivery
devices for outpatient use in Pennsylvania: nasal atomizer,
nasal spray, and autoinjector. Each of these products requires
certain provider and patient education to ensure proper use.
Pennsylvania Act 139 (2014) provides that all first
responders (e.g., police, fire and rescue, EMS) are allowed to
administer naloxone if an opioid overdose is suspected. The law
also permits family and friends to obtain and administer
naloxone if necessary. In addition, anyone who administers
naloxone in good faith, remains with the patient until help
Disclosure: All of the authors declare no potential conflicts of interest.
Previous presentation: American Association of Colleges of Pharmacy
Annual Meeting, Boston, MA, July 2018.
* Correspondence: Thomas S. Franko II, Department of Pharmacy Practice,
Nesbitt School of Pharmacy, Wilkes University, 84 West South Street, Wilkes-
Barre, PA 18766.
E-mail address: thomas.franko@wilkes.edu (T.S. Franko).
arrives, and receives approved training is immune from pros-
ecution under the Act.6 As a result of this law, as of August 2016
more than 430 police departments and 1200 state police units
carried naloxone, and more than 1300 overdoses were
reversed.7
In October 2015, Pennsylvania Physician General Rachel
Levine signed a standing order for naloxone. Under the new
standing order, anyone who wishes to obtain naloxone may do
so at any pharmacy.8 Through this order, pharmacists are
permitted to provide the naloxone atomizer, nasal spray, or
autoinjector to any person requesting it.
The standing order does not require any formal training for
the pharmacist.8 However, the statutory immunity from
prosecution provided under Act 139 requires proof that the
person administering the naloxone completes a state-
approved training program. Currently, Pennsylvania has
approved an online program for the general public, which is
available at: www.getnaloxonenow.org/online_training.html.6
This program takes about 20 minutes to complete, and a
suggested donation of $10 is now required to receive a cer-
tificate of completion.
The American Society of Addiction Medicine (ASAM) rec-
ommends that all clinicians who provide services to patients
with substance use disorders have naloxone readily available.
ASAM goes on to recommend that all persons who have
naloxone supplies be provided training on how to

https://doi.org/10.1016/j.japh.2018.12.022
1544-3191/© 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.
SCIENCE AND PRACTICE
T.S. Franko II et al. / Journal of the American Pharmacists Association xxx (2019) 1e4
appropriately respond to an overdose.9 The state training
program does not cover all aspects of responding to an opioid
overdose, such as use of the nasal atomizer or management of
stress and/or anxiety, that may be encountered.
Objective
The aim of the present study was to determine if a novel
naloxone training with focus on stress management yields
better results than the state training in a simulated overdose
response. The hypothesis was that students who completed
the novel training would more appropriately manage an
overdose, and do so more quickly, than those receiving the
state training.
Methods
All students in the third professional year (P3) participate
in a substance use disorder series as part of a 1-credit clinical
laboratory series. The class is evenly spread across 3 course
sections. This study ran for 2 academic years, 2016-2017 and
2017-2018. Each section was randomized into 2 groups
through an online program. One group received a link to the
Pennsylvania state training, and the other received a link to the
novel training. The state training covers signs and symptoms
of overdose, use of the naloxone intranasal spray and auto-
injector, and management of an overdose. The novel program,
a voiceover of Powerpoint slides, discussed the same issues as
the state training plus an overview of the opioid crisis in
Pennsylvania, use of the naloxone atomizer, naloxone avail-
ability in Pennsylvania and corresponding laws, stress man-
agement techniques used during emergencies, and strategies
that providers can use to reduce opioid misuse. In addition, the
novel training contained a brief video, made in house, of the
management of a live overdose with the naloxone atomizer.
The novel training takes about an hour to complete. Each
section was provided their respective training via e-mail 2
days before their scheduled section to complete the assigned
training before the laboratory section began. To assure that the
students completed the training, those receiving the state
training submitted a certificate of completion, and those
completing the novel program submitted a signed attestation.
After a brief overview of the course work for the day, the
groups were taken separately to complete a live overdose
simulation. The simulation was staged in a mock living room
where the student acted as a first responder. Each student
completed the simulation individually and was met at the door
by a standardized bystander and taken to the patient. The
standardized patient was a volunteer from the School of
Nursing who was instructed to lie on his or her back and “come
to” after the student successfully administered naloxone. The
patient was different for each section. The bystander acted in a
panicked manner throughout the simulation to produce added
stress to the exercise. A different person played the bystander
during each academic year. The bystanders were trained by
several people who had witnessed overdoses and used
naloxone in practice. Students were evaluated with the use of a
checklist as well as for time to complete the simulation. The
checklist was adapted from the steps listed in the state-based
training. All items on the checklist were included from the
state training except the items related to remaining calm and
2
composed during an emergency and use of the atomizer de-
vice. Student names were not included on the evaluation
forms. All checklist items were weighted equally. Students
waiting to complete the simulation were sequestered in a
separate room from those already finished. The group was able
to return to the laboratory after every student had completed
the simulation. After the simulation, each group received the
other group’s training. At the end of the laboratory section, a
general debriefing session was held allowing students to share
their own experiences and thoughts on both trainings.
Data gathered from the simulation checklist for each section
were combined and entered into a spreadsheet in Microsoft
Excel 2010. Data from the simulation checklist were analyzed
by means of Fisher exact test. The time to complete the simu-
lation was assessed by means of Mann-Whitney U test, and the
simulation checklist grades were analyzed by means of an
unpaired t test. An alpha level of < 0.05 was considered to be
significant.
This study was approved by the Wilkes University Institu-
tional Review Board. Students could decline to participate in
the study but still had to complete the simulation per course
requirements. Students were informed in advance that the
simulation itself was participatory only, and the score received
did not count toward the course grade. Students were
informed that they could stop the simulation for any reason. If
this happened, their results were excluded.
Results
One hundred percent of eligible students (139) agreed to
participate in the study, and 135 (97%) completed the simu-
lation. Two students failed to complete the simulation on the
first attempt owing to anxiety, and 2 failed owing to prema-
turely stopping the exercise out of confusion. Two additional
students were not eligible and did not participate because they
were coinvestigators on the study.
The median time to complete the simulation for the novel
training group was 2:00 minutes versus 2:10 minutes for the
state training group (P ¼ 0.31). The average grade from the
checklist for the state training group was 64% (SD 15.4) versus
89% (SD 11) for the novel training group (P < 0.001).
Table 1 summarizes the results from the simulation check-
list. Significant differences were seen in 5 checklist items:
determining if the patient had a pulse, determining if the pa-
tient was breathing, assembling the naloxone atomizer, tilting
the patient’s head, and properly administering naloxone.
Discussion
The aim of any training program is to prepare the trainee to
complete a task in a real-life situation. The Pennsylvania state
training is limited in its ability to do this. Furthermore, the
training does not implement a minimal time restriction on
each slide, meaning that one could easily click through the
entire presentation in a matter of minutes without actually
reading the content. These limitations led to our development
of a more robust program that filled the gaps of the state
training.
The novel training provided the same foundational knowl-
edge as the state training but then expanded on key points
relative to what a trainee would actually encounter. There was
 SCIENCE AND PRACTICE
A novel naloxone training

Table 1
Results from the simulation checklista

Item Total items completed on simulation, n (%) P value

State training (n ¼ 64) Novel training (n ¼ 69)

Assesses that the scene is safe 59 (92) 65 (94) 0.74
Assesses patient’s state of consciousness (sternum rub) 49 (77) 59 (86) 0.27
Determines if the patient has a pulse (checks pulse) 16 (25) 62 (90) < 0.0001
Determines if the patient is breathing (e.g., chest rise/fall, put ear to nose) 22 (34) 58 (68) < 0.0001
Contacts emergency personnel (call 911) 62 (97) 62 (90) 0.17
Correctly assembles naloxone device 42 (66) 58 (84) 0.02
Slightly tilts patient’s head to expose nasal passage better 7 (11) 47 (68) < 0.0001
Properly administers naloxone 30 (47) 67 (97) < 0.0001
Places patient in the recovery position 47 (73) 59 (86) 0.09
Remains calm and composed during the process 62 (97) 66 (96) > 0.99
Stays with person until help arrives 63 (98) 65 (94) 0.37
a
Survey instrument adapted from current state training available at: https://www.getnaloxonenow.org/signup.aspx.

greater emphasis on assembly and use of the nasal atomizer in
addition to a thorough review of the intranasal spray and the
autoinjector. Results clearly showed that the training on the
atomizer was beneficial during the simulation. Students were
provided details on stress management, such as focused
breathing and how to manage panicked bystanders. In addi-
tion, providing a live video of a simulated opioid overdose and
response, with each step fully described, allowed students to
better understand the overdose management process. The
training also discussed the current state of opioid misuse and
overdose in Pennsylvania, which could provide more incentive
for trainees to improve awareness of the benefits of naloxone in
their communities. Compared with the state training, the novel
training better prepared pharmacy students for a live overdose
simulation.
Even though the state training did not include stress
management techniques, both groups scored high on this item
on the checklist. Evaluator feedback did show that students in
the novel training group provided reassurance and compas-
sion toward the bystander whereas the state training group
did not.
The results from the simulation checklist show that both
groups were similar for various areas, such as determining if
the patient is alert, placing the patient into the recovery po-
sition, and staying with the patient until help arrives. It is
concerning that the state training group greatly missed
checking for a pulse and breathing. Missing either of these
issues in a real-life situation could result in patient death.
There was no statistically significant difference in time to
complete the simulation.
There were several limitations to this study. Even though
there were methods to verify that students completed their
respective trainings, there is no way to fully guarantee that
each student watched the full extent of each training. The state
training does not have a required time limit per slide, and one
can easily skip through the entire program. Furthermore, the
final quiz permits unlimited attempts until the student gets at
least 80% correct. For the novel training, students could easily
have been untruthful when claiming that they had watched
the webinar. The second limitation was that the assessment
tools were modified from other programs and not validated as
written. This may have led to a lack of reliability or sensitivity
of the data. A third limitation was that the evaluator and
panicked bystander were not consistent across each section
during the 2 years of the study. The bystander was the same for
all sections within the same year, but the evaluator was
different in all sections. This was due to logistical issues in
ensuring that the same individuals participated in the simu-
lation for all sections. A fourth limitation is that several stu-
dents in the second year of the study may have received the
novel training before the laboratory. The novel training itself
was offered as a live program at a recent meeting of the
Pennsylvania Pharmacists Association, where several students
were in attendance. Because the groups were randomized,
there was no chance to ensure that students with no previous
training were in the state group. Finally, the simulation was for
a participation grade rather than the grade obtained through
the checklist. Knowing that the simulation checklist did not
count for an actual grade may have resulted in students not
putting forth their best effort during the exercise.
Anecdotal student feedback was positive, and students
commented that although the situation was stressful, they
appreciated that it emulated real life. To enhance this experi-
ence moving forward, efforts will be taken to ensure that the
bystander and evaluator are consistent through each section.
The training can be adapted to practicing pharmacists through
live and online-based educational sessions provided through
professional organizations and employers. Though currently
focused on Pennsylvania law and figures, the training can
easily be adapted to other states. The information provided on
naloxone use and prevention of opioid misuse is widely
applicable, so only the statistics and naloxone laws relative to
each state would need to be changed. Furthermore, there is no
associated cost with the novel training, whereas the state
training recently added a $10 suggested donation to receive a
certificate of completion. This cost should be weighed against
the time commitment needed to complete the novel training if
broadened to other institutions.
Simulated overdose responses are used to better train
health care students.10 The use of stressors as part of simulated
learning is also documented as a possible method to enhance
the fidelity of simulations and to better prepare learners for
actual practice.11 Although pharmacy students are provided
training on naloxone, simulations focus more on patient
counseling and dispensing.12,13 Little evidence exists regarding
the ability of pharmacists to actually play the role of a first
responder by administering naloxone to a patient experi-
encing an overdose. Some data exist to demonstrate that after

3
SCIENCE AND PRACTICE
T.S. Franko II et al. / Journal of the American Pharmacists Association xxx (2019) 1e4
simulation-based trainings, students feel more knowledgeable
about the process of responding to an overdose, but the long-
term retention and application of these skills have not been
demonstrated.14,15
The majority of states require that pharmacists undergo a
required training before participating in a naloxone program, but
little is mentioned about the need for pharmacists to potentially
administer naloxone.16 Instituting training for students will
ensure that every graduate is able to administer naloxone
appropriately, provided he or she is permitted to under state law.
Both the Academy of Student Pharmacists through the American
Pharmacists Association and the American Association of Col-
leges of Pharmacy recommend that students and pharmacists be
trained to properly administer life-saving medication.17,18
The training and simulation required minimal time and
cost to develop. Because the training was delivered online, it
would be widely accessible. Colleges of pharmacy and other
health care institutions looking to expand their naloxone
training programs with a live overdose simulation would be
encouraged to begin planning at least 3 months ahead of time.
Volunteers to act as standardized patients should be solicited
ahead of the simulation. The highest expense is associated
with obtaining an adequate supply of naloxone training de-
vices. Several were broken or severely damaged during the
simulation by students who were unaware of their proper use.
Based on this experience, having enough training devices so
that each trainee could have his or her own would be prudent.
Conclusion
Students who underwent the novel training completed the
simulation in a more appropriate manner than those that
received the state training. All institutions should consider
adding more robust education on all delivery devices as well as
videos on appropriate responses to an overdose to their
naloxone training programs. Such training appears to be effec-
tive in preparing students to manage a live opioid overdose.
Acknowledgments
The authors thank the Wilkes University Passan School of
Nursing for providing the space and standardized patients to
complete the live simulation.
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Thomas S. Franko II, PharmD, BCACP, Department of Pharmacy Practice, Nes-
bitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA
Danielle Distefano, Student, Nesbitt School of Pharmacy, Wilkes University,
Wilkes-Barre, PA
Lauren Lewis, Student, Nesbitt School of Pharmacy, Wilkes University, Wilkes-
Barre, PA