Overdose Prevention,Education and

Naloxone Response Training

The Council of Southeast Pennsylvania, Inc.Overdose Prevention and Education Advisory Board

Presented By:

David Fialko, BS, CTTS, Prevention Specialist

This project is made possible by funding through the Bucks County Drug Alcohol Commission, Inc.

What Are Opioids?

Opioids(Derived from the opium

poppy)(Narcotics)

Natural Opioids(Opiates)

OpiumMorphineCodeine

Semi-Synthetic Opioids(Opiates)

HeroinHydrocodone

(Vicodin)Oxycodone

(OxyContin, Percocet)

Fully Synthetic Opioids

Fentanyl (Duragesic)Methadone

Hydromorphone (Dilaudid)

Acetyl Fentanyl (an analog of Fentanyl)

What do Opiates Affect?

Mobilizes the body's nervous system, controls fight-or-flight responses.

Responsible for regulation of internal organs and gland: "rest-and-digest" "feed and breed”.

Frontal LobeHow do opiates and naloxone effect this region

Controls• Decisions-Choice• Self Control• Behaviors

Long term drug use leads to drug use not being a matter of choice. The users actually have a reduced level of biological resources and find it hard to control their use.

Limbic SystemHow do opiates and naloxone effect this region

Controls• Motivation• Fear• Drive• Emotion

• Emotional memory

Euphoric Tolerance• Rapid progression

to attain high tolerance

Lower Brain StemHow do opiates and naloxone effect this region

Controls• Breathing• Heart Rate• Blood PressureRespiratory Tolerance• Slower progression to

build high tolerance.

locus Coeruleus• Pacemaker • Secrets

norepinephrine

Physical Signs of use

• Shortness of breath• Dry mouth• Constricted (small) pupils• Disorientation• Cycles of hyper alertness followed by suddenly nodding off• Droopy appearance, as if extremities are heavy• Weight loss• Runny nose (not explained by other illness or medical condition)• Needle track marks visible on arms• Infections or abscesses at injection site• For women, loss of menstrual cycle (amenorrhea)• Cuts, bruises or scabs from skin picking

Physical signs of withdrawal

• Early symptoms of withdrawal include: (decrease in opiates available)• Agitation• Anxiety• Muscle aches• Increased tearing• Insomnia• Runny nose• Sweating• Yawning

• Late symptoms of withdrawal include: (no opiates available)• Abdominal cramping• Diarrhea• Dilated pupils• Goose bumps• Nausea• Vomiting– Opioid withdrawal reactions are very uncomfortable but are not life-threatening. Symptoms

usually start within 12 hours of last heroin usage and within 30 hours of last methadone exposure.

What is an Opioid “Overdose”?

• Opioid Overdose kills by:– Respiratory Depression

• This involves signaling to the heart.

• Most overdoses occur 1 to 3 hours after the drug us taken

• Most drug overdoses are witnessed

What drugs are we talking about?

• An overdose can occur with most ANY drug!• Narcotics or Opioid analgesics are the reason we

are all here tonight.– Naloxone only works with Opiates / Opioids

• Mixing Drugs increases risk – especially when you mix a “downer” with an “upper”, or a “downer” with another “downer”

• Highest risk with certain drugs: Opioids – extremely high risk of overdose Benzodiazepines Alcohol Stimulants

What is an opioid overdose?

Things to look for:

• An overdose after using an opioid can occur 1-2 hours after use unlike after injecting or snorting

• A person who uses an opioid should be checked on for several hours after use to make sure they are not slipping into an overdose

• Pay close attention to the overdose signs especially:

Slowed/shallow/no breathing

Heavy nod and unresponsive

Bluish lips and nail beds

What is the difference between being “high” and an

overdose?• Relaxed muscles• Slow/slurred speech (CNS / vocal chords)• Drowsy look• Slight head nod (first warning sign)• Response to stimulation

“High”

• Deep snoring sound or gurgling• Infrequent or no breathing• Blue, pale or clammy skin• Slow or no pulse/heartbeat• Throwing up• Passing out

Overdose

Increased risk of overdose for persons involved in theCriminal Justice System

Former inmates, adjudicated youth, probation mandated persons are at the highest risk for death from drug

overdose, especially in the immediate post-release / post probation period.

Other Risk Factors

Loss Of Tolerance

Mixing Drugs

Variation in strength

Serious Illness

Using Drug Alone

Previous Non-Fatal Overdose

Good Samaritan Law

Signed into LAW September 31st, 2014

Good Samaritan' provision of Act 139• How does this change things?

– Removes restrictions to accessing Naloxone.• Allows any Physician / • Allows anyone to administer Naloxone

– Training is recommended in most situations» Auto-Injectors are the exception

Good Samaritan Law

Signed into LAW September 31st, 2014

• How does ACT 139 change things?– Removes restrictions to accessing

Naloxone.• Allows any Physician to prescribe Naloxone

– Family and Friends

• Allows anyone to administer Naloxone– Training is recommended in most situations

» Auto-Injectors are the exception» GiveNaloxone.org

Naloxone  

• Naloxone is an opioid antagonist

• Approved by the FDA and utilized by emergency medical professionals for 40 years.

• Effective in the human body for 30 to 90 minutes.

How Naloxone Works

Physiology of Naloxone

• Admission of Naloxone may result in any of the following:– Agitation– Tachycardia– Pulmonary Edema– Seizures– Nausea– Vomiting

Naloxone• Temperature sensitive

– Avoid extreme highs– Avoid extreme lows

• Recommended to store in protective impact resistant case

• Recommended items found useful to keep in kit– Latex gloves– Mouth barrier shield– Extra dose of naloxone

Naloxone• How do you get it?

– See Handout: Guidance Document & Letter• ACT 139 allows anyone who thinks they can help

someone else during an overdose to get a prescription.

• Provide your prescribing doctor with the DDAP letter.

– Take online training and print certificate• http://www.getnaloxonenow.org/index.aspx

Other Resources• Pharmacies that carry or will carry:

– Upper Bucks: Sellersville Pharmacy at Penn Foundation 267-354-1833• Currently have it in stock

– Lower Bucks: Shoprite Pharmacy 9910 Frankford Ave.  Phila., Pa. 19114    215-824-1830

– All CVS’s:• They are currently phasing it in

• Other Resources:– Getnaloxonenow.org– Naloxone-hydrochloride.com

Naloxone Kits

NaloxoneInformation & common questions

• Prescribers have immunity from civil liability for prescribing, dispensing or distributing naloxone to a layperson.

• Prescription by a standing order is authorized.• Laypersons are immune from criminal and civil

liability when administering naloxone.

http://www.getnaloxonenow.org/mission.aspx

Good Samaritan LawSigned into LAW September 31st, 2014

• Limitations regarding protection when calling 911– Caller Must:

• Be Cooperative and provide personal information including name and / or identifying info.

• Call 911 with “good intent”– Drug dealers trying to cover tracks is not “good intent”

• Must stay with person until emergency responders arrive.

Good Samaritan Law

Signed into LAW September 31st, 2014• Limitations regarding protection when

calling 911– Exceptions

• When providing name, if there is a warrant out for the caller, they can be arrested.

• Caller can be charged if it is determined that they provided the drugs resulting in the overdose.

How to Respond To

An Overdose

What to Do

An Overdose is scary so remember:

S - Stimulate/Sternal Rub

C - Call 911

A - Airway

R - Check Breathing and Respond (NALOXONE)– If the person is not breathing, the responder should start by giving a few rescue breaths and

then administer naloxone. – If the person is breathing but unresponsive, then the responder should administer naloxone

first.

E - Evaluate

D - Don’t leave/Rescue Position

Knowing these steps in advance will

leave you feeling less scared!

Stimulation

• Yell the user’s name.• Sternal rub

– The sternal rub is a very good technique to awaken someone from a heavy nod. To do a sternal rub, make a fist and then rub the sternum (also known as the breastbone) with your knuckles in center of the person’s chest, and apply pressure while rubbing. If the person does not respond after 15-30 seconds of doing a sternal rub, it is likely that the person is overdosing and requires immediate attention.

New York State Department of HealthOpioid Overdose PreventionGuidelines for Training Responders

Call for Help • Call for Emergency Medical Services

(frequently, though not necessarily, 911)– If leaving the person alone, place them in the

Recovery Position:

• Put the person on his/her side. This will help to keep the airway clear and prevent the person from choking on vomit.

New York State Department of HealthOpioid Overdose PreventionGuidelines for Training Responders

AirwayHead-tilt/chin-lift maneuver • Head tilt: One hand is placed over person's

forehead and firm, backward pressure is applied with palm to tilt the head back

• Chin lift: Fingers of other hand are placed under bony portion of the lower jaw near the chin to bring the chin forward and helps tilt the head back; the fingers must not press deeply in the soft tissues under the chin, as this might obstruct the airway.

(http://medical-dictionary.thefreedictionary.com)

Check Breathing

• If the person is not breathing, the responder should start by giving a few rescue breaths (see following slide) and then administer naloxone.

• If the person is breathing but unresponsive, then the responder should administer naloxone first.

New York State Department of HealthOpioid Overdose PreventionGuidelines for Training Responders

Rescue Breaths• Open Airway:

– Tilt the head back and lift the chin up

• Take 2 deep breaths• Pinch the nose shut• Seal your lips around person’s mouth and

gives 2 full breaths –1 to 1.5 seconds/breath

• Watch for good chest expansion• Note: If chest does not rise with rescue breaths, re-tilt the head

and give another rescue breath.

• Give rescue breaths, one after the other. Source: American Red Cross

HandoutAdminister Naloxone Source – Harm Reduction Coalition –harmreduction.org

Overdose Response

Nasal Naloxone:

1. Do rescue breathing for a few quick breaths if the person is not breathing. 2. Affix the nasal atomizer (applicator) to the needleless syringe and then assemble the glass

cartridge of naloxone (see diagram). 3. Tilt the head back and spray half of the naloxone up one side of the nose (1cc) and half

up the other side of the nose (1cc). 4. If there is no breathing or breathing continues to be shallow, continue to perform rescue

breathing for them while waiting for the naloxone to take effect.

5. If there is no change in 3-5 minutes, administer another dose of naloxone and continue to breathe for them. If the second dose of naloxone does not revive them, something else is wrong—either it has been too long and the heart has already stopped, there are no opioids in their system, or the opioids are unusually strong and require more naloxone (can happen with Fentanyl, for example).

Administering Naloxone

(Intra-muscular) • Wipe area to be injected with alcohol pad.• Inject 1cc of naloxone into a large muscle such

as the upper arm or thigh. • If no response in 3-5 minutes, inject an

additional 1cc of naloxone with a new needle.• If EMS has not yet been called, it is urgent to do

so now!!

Administering Naloxone

(Intra-muscular) • Intramuscular injections are slower to enter the

bloodstream.• Inject into a muscle – thighs, upper, outer quadrant of

the butt, or shoulder are best.– Injections to the buttocks are known to reach the bloodstream

quickly due to the large amount of muscular tissue and corresponding blood supply.**

• Inject straight in to make sure to hit the muscle.• In general for IM (intramuscular) injections you would

use a 21 to 23 gauge needle 1” to 1.5” in length.– Obese patients 1.5 to 2 inch needles may be

necessary.**

** Recent studies at the Adelaide and Meath Hospital in Dublin show that obesity and the size of the buttocks may be affecting the successful injection of IM medications. Longer needles may be needed to ensure proper absorption of medications.

Administering Naloxone

MAD (Mucosal Atomization Device)

Source: Harm Reduction Coalition Place cone in or near the nasal opening. DO NOT force the cone into the nasal passage.

Epistaxis: Hemorrhage from the nose, usually due to rupture of small vessels overlying the anterior part of the cartilaginous nasal septum.

Administering Naloxone

MAD (Mucosal Atomization Device)• Do rescue breathing for a few quick breaths if the person is not breathing.• Affix the nasal atomizer (applicator) to the needleless syringe and then

assemble the glass cartridge of naloxone (see diagram).• Tilt the head back and spray half of the naloxone up one side of the nose

(1cc) and half up the other side of the nose (1cc).• If there is no breathing or breathing continues to be shallow, continue to

perform rescue breathing for them while waiting for the naloxone to take effect.

• If there is no change in 3-5 minutes, administer another dose of naloxone and continue to breathe for them. If the second dose of naloxone does not revive them, something else is wrong—either it has been too long and the heart has already stopped, there are no opioids in their system, or the opioids are unusually strong and require more naloxone (can happen with Fentanyl, for example).

Rescue Position

What NOT to do

• Leave them alone• Amphetamine or salt water shots • Showers and/or baths• Inducing vomiting or giving them

something to drink• Ice or painful stimulation

NATIONAL TAKE-BACK INITIATIVEhttp://www.deadiversion.usdoj.gov/drug_disposal/takeback/

This project is made possible by funding through the Bucks County Drug Alcohol Commission, Inc.

CouncilSupport and Resources

• Information / Advocacy Hotline

1-800-221-6333

www.councilsepa.org

• Pro-Act – Family Program

www.councilsepa.org/programs/pro-act/contact-pro-act/