Overdose Education & Naloxone Distribution Note

Date/Time: [Date and time of encounter]

Author/Credentials: [Author name and credentials]

Setting: [Emergency department / Primary care / Pain clinic / Addiction medicine / Inpatient discharge / Harm reduction program / Community outreach / Other: specify]

Participant(s) Educated: [Patient / Family/caregiver / Both]

Interpreter Used: [Yes: language and modality / No / Not applicable]

Clinical Context

[Brief narrative describing why OEND was initiated, including visit reason or care transition context] (Use neutral, non-stigmatizing language throughout.)

Relevant Risk Factors: [Include only those explicitly applicable: opioid prescription; suspected or diagnosed opioid use disorder; prior overdose; recent abstinence or reduced tolerance due to detox, incarceration release, or treatment gap; concurrent sedatives including benzodiazepines, alcohol, or gabapentinoids; polysubstance use; uncertain drug supply; patient or caregiver request]

Clinical Indication: [1-2 sentence summary of why OEND was clinically indicated for this patient today]

Overdose Education Provided

[Education content summary] (Document the core topics covered: opioid-induced respiratory depression as the mechanism of overdose; key risk amplifiers including using alone, uncertain potency, reduced tolerance after abstinence, and mixing depressants; safer use principles including avoiding depressant combinations, keeping naloxone accessible, and avoiding using alone when possible.)

[Overdose recognition signs reviewed] (Document that signs were reviewed: unresponsiveness/cannot awaken, slow/shallow/absent breathing, choking or gurgling sounds, and abnormal skin color or cyanosis.)

[Response steps reviewed:]

1. Attempt to rouse the person
2. Administer naloxone
3. Call 911
4. Support breathing and use recovery position
5. Stay with the person until help arrives
6. Repeat naloxone if no response after 2–3 minutes

[Post-reversal counseling] (Document that risk of overdose recurrence after reversal was discussed and that medical evaluation is recommended even if the person wakes.)

[Special considerations, if applicable] (Include only if relevant, such as pediatric accidental ingestion risks if young children are in the home, or need for multiple kits if multiple household members are at risk. Omit if not applicable.)

Fentanyl and Polysubstance Counseling

(Include this section only when relevant—e.g., non-prescribed pills or powders, stimulant use, uncertain drug sources, or patient request for fentanyl education. Omit entire section if not applicable.)

[Fentanyl counseling content] (Document that illicit fentanyl may be present in counterfeit pills and in non-opioid drugs including stimulants; that fentanyl cannot be reliably detected by appearance, smell, or taste; and that naloxone remains indicated for any suspected opioid exposure including fentanyl.)

[Fentanyl test strips] (If discussed: document whether provided or referred, and note that limitations were explained—detects presence only, not potency; may miss some analogs. Omit if not discussed.)

[Polysubstance counseling] (Document counseling to avoid mixing opioids with alcohol, benzodiazepines, or other sedatives.)

Naloxone Action

Outcome: [Provided on-site / Prescribed / Referred to pharmacy or community program / Patient declined / Not provided due to barrier: specify]

(Complete only the corresponding subsection below based on the selected outcome.)

If Provided On-Site:

• Product form: [Intranasal spray / Auto-injector / Injectable kit]
• Quantity: [Number of kits provided]
• Recipient: [Patient / Caregiver / Both]
• Training method: [Verbal instruction / Device trainer demonstration / Return demonstration by recipient] (Include details of return demonstration if performed.)
• Counseling documented: [Naloxone may precipitate withdrawal in opioid-dependent individuals; has no abuse potential; should be stored accessibly and replaced after use or upon expiration]

If Prescribed:

• Prescription sent to: [Pharmacy name/location]
• Training provided: [Yes: method / No: plan for training at pharmacy pickup]
• Access assistance: [Cost assistance or access instructions discussed, if applicable]

If Referred to Pharmacy or Community Program:

• Referral location: [Program name and access instructions]
• Reason for referral: [Cost assistance / Stock availability / Program eligibility / Insurance considerations / Other: specify]
• Training provided today: [Yes: method / No]

If Patient Declined:

• Offer documented: Naloxone was offered and education was provided
• Patient-stated reason: [Reason if shared, using neutral language / Not disclosed]
• Alternatives offered: [Pharmacy access information / Community program referral / Offer to revisit at future visit]

If Not Provided Due to Barrier:

• Barrier: [Cost / Stock unavailable / Patient left before provision / Other: specify]
• Follow-up plan: [Immediate workaround or plan to obtain naloxone]

Understanding Assessment

Method: [Teach-back / Verbal confirmation / Written instructions provided / Caregiver completed assessment / Other: specify] (Preferred method is teach-back. If teach-back was not completed, document why—e.g., time constraints, patient left, altered mental status.)

Assessed with: [Patient / Caregiver / Both]

Outcome: [Correct teach-back demonstrating understanding / Partial understanding with misconceptions corrected / Needs additional training: plan documented] (Include brief details on areas clarified or plan for re-education if applicable.)

Risk Mitigation Plan

Safety steps agreed to:

• [Where naloxone will be kept and who else knows its location]
• [Plan to avoid using alone, or identified safer-use strategy]
• [Plan to avoid mixing opioids with depressants]
• [Additional concrete step(s) the patient agrees to try, if any]

Follow-up and Referrals: [Clinical follow-up plan and any referrals discussed and accepted or pending] (Examples: next appointment, referral to addiction medicine or pain clinic, substance use treatment, harm reduction services, mental health, social needs support. If OUD is suspected or diagnosed, document whether medication treatment was offered and patient preference. Include only referrals actually discussed—omit if none.)

Incomplete Elements

(Include this section only if a core element was not completed. Omit entirely if all elements were addressed.)

[Element not completed and reason] (Explicitly document any core element not completed—e.g., teach-back not performed due to patient leaving, naloxone not provided due to stock outage—and any follow-up plan to address.)