BOP Program Statement 1610.02 § 4

Each time naloxone is administered to an inmate, whether by medical or non-medical staff, the

attending physician or on-call provider will be notified. In most instances the inmate will need to

be evaluated by an outside hospital, unless the institution has the staff and equipment to monitor

the inmate after an opioid overdose (e.g. MRC) according to criteria listed in the Opioid Use

Disorder Clinical Guidance. The Clinical Director, attending physician, or on-call provider will

determine the best course of treatment.

After the emergency is resolved, the staff involved will provide details of naloxone use to the

HSA and Clinical Director. Use of naloxone on inmates, either by health services and/or other

staff, will be documented as a medication order in the Electronic Health Record (EHR) by an

appropriate clinical staff member. If naloxone was administered after-hours, documentation will

be completed the next day by an appropriate clinical staff member.

In addition to the medication order, documentation in the EHR will also include the following:

 Symptoms observed during the emergency response

 Number of doses administered

 Response to naloxone administration

 If the inmate was sent to the outside hospital

 Other pertinent details should be included in the encounter if known, such as relevant urine

drug screening, drug paraphernalia found/tested, if there has been a suspected illicit use in the

previous 24 months, and if the inmate will be referred for substance use disorder evaluation.

1610.02 3/19/2026 PROPERTY OF US GOVERNMENT 3

Each time naloxone is administered to staff, the following information must be reported to

National Occupational Safety & Health Branch and the local Occupational Safety Department

for inclusion in the Occupational Safety and Health Administration (OSHA)’s Form 300, Log of

Work-Related Injuries and Illnesses:

 date of incident

 facility

 last name, first name of staff member affected

 job title

 location of exposure

 staff member’s actions at the time of incident

 presumed source the individual came into contact with

 substance (if identified)

 symptoms experienced

 number of times naloxone was administered

 if personal protective equipment (PPE) was worn, and what type

 respiratory fit testing status

 referral to outside medical facility

The Institution Safety Administrator or HSA will report naloxone use to the Regional Health

Services Administrator (RHSA) as soon as practical after such use, but not later than five days.

The RHSA may establish the preferred reporting method.

A report on naloxone maintenance and usage will be included in the biannual institution

Pharmacy and Therapeutics (P&T) agenda and minutes. Reports will include at a minimum, the

date used or replaced and the individual who was treated, if applicable.