Purpose
of
Training
•  This
training
is
designed
to
teach
you
about
one
ac5on
you
can
take
in
case
of
an
overdose
of
opiates.
•  Death
by
opiate
overdose
is
a
tragedy
that
can
be
simply
and
safely
reversed
by
administra5on
of
naloxone.
•  This
training
program
will
not
make
you
a
doctor,
or
capable
of
ac5ng
like
one,
but
you
will
leave
with
an
understanding
of
the
more
common
life‐saving
ac5ons
helpful
to
someone
who
has
overdosed
Your
process
•  Pass
the
post‐test
with
>90%
•  Pass
an
‘in‐the‐field’
test,
being
observed
with
a
par5cipant
•  Get
a
‘naloxone
kit’
–  Medical
history
and
naloxone
checklist
forms
–  Partner
checklists
and
pocket
guides
–  Naloxone
(check
from
5me
to
5me
that
yours
is
all
current)
–  Syringes
with
muscle
needles
•  Submit
all
paperwork
back
to
the
van
Medical
History
&
Checklist
Opiate
Overdose
Deaths
in
Cook
County
198 340
384 428
466
“Mo5vated
more
by
loss
than
by
brilliance”
•  Begin
distribu5ng
naloxone
in
1999
•  2000
begin
ac5vely
expanding
program
•  January
2001
train
all
CRA
opera5ves
to
educate
and
distribute
Progress
to
Date
•  Approximately
25,000
10mg
mul5‐dose
vials
of
naloxone
distributed
• 1300
known
reversals
NDP
begun
1996
2000
2004
2007
Other
Places
•  NY,
NM,
and
CT
have
passed
laws
exemp5ng
the
physician
and
person
administering
from
liability
•  UK
changed
regula5ons
so
SEPs
can
distribute
NLX
without
prescrip5on
•  Bal5more,
San
Francisco
have
ac5ve
programs
connected
with
their
city
public
health
departments.
•  Glasgow,
Scotland
has
a
program
directed
towards
families
of
addicts,
and
trains
parents
and
spouses
to
use
naloxone.
San Francisco
After 6 months follow-up:
• Knowledge of heroin overdose increased
significantly
• Frequency of heroin injections/ month
decreased significantly (p=0.003).
• Participants entering drug treatment
increased from 35% to 60% (p=0.16)
• There was no significant change in the
number of overdoses before or after the
intervention (p=0.83).
“Personally,
it
makes
me
more
aware
…
it
doesn’t
influence
me
to
do
more;
it
actually
influences
me
to
do
less
…
I’ll
use
less
drugs,
knowing
that
if
they
go
out
I
could
help
them,
I’ll
do
it
so
I
can
kinda
watch
‘em.”
Available
Forms
of
Naloxone
• 
• 
• 
• 
Nasal
spray
Pre‐loaded
single‐dose
syringe
One‐dose
glass
ampules
Mul5‐dose
10mg
boele
Risk
Factors
Iden5fied
by
ME
Data
•  Age
>
34
•  Using
in
combina5on
with
other
drugs
– Alcohol
– Cocaine
– Benzos
Risk
Factors
Iden5fied
by
our
Par5pants’
Reports
 Recent
period
of
abs5nence
 Detox
program
(as
liele
as
3d)
 Incarcera5on
(even
a
weekend)
 Using
alone
 Mixing
drugs
How
does
Opiate
Overdose
Kill?
•  cyanosis
.
.
.
(breathing
is
too
slow),
progressing
to
apnea
.
.
.
Breathing
stops
•  cardiac
arrest
.
.
.
the
heart
stops
because
it’s
not
geing
oxygen
•  circulatory
collapse
.
.
.
circula5on
of
blood
to
the
brain
stops
HEROIN >> RESPIRATION
COCAINE >> HEARTBEAT
Preven5ng
Overdose
•  Know
your
dealer,know
your
stuff
•  Inject
with
OD
preven5on
technique
(tourniquet
off
amer
hit,
several
slow
pushes
to
taste...)
“He
got
out
of
jail,
he
was
in
the
joint…
came
back,
thought
he
had
the
same
tolerance…
but
he
didn’t…
that’s
what
happened
to
me.
I
put
myself
in
detox
and
I
got
out,
shot
up
a
bag,
it
didn’t
really
do
the
same
thing,
you
know,
that
I
was
expec5ng.
I
was
expec5ng
a
more
intensive
high
so
instantly
I
went
to
two
and
he
was
with
me,
thank
god,
because
I
went
out.”
All
opiates
are
similar
in
that
they
.
.
.
•  come
from
the
opium
poppy
or
are
chemically
created
to
be
like
a
drug
which
comes
from
the
opium
poppy
•  have
their
effect
on
the
same
part
of
the
brain;
&
•  cause
overdose
in
the
same
ways
if
too
much
is
used
–
death
from
overdose
occurs
when
breathing
stops.
Opiates
differ
in
that
they
.
.
.
•  have
different
concentra5ons
or
strengths
•  have
varying
dura5ons
of
ac5on
Comparison
of
Some
Opiates
Drug
Duration
potency
Methadone
24 hr
++++
Heroin
6 – 8 hr
+++++
Oxycontin
3 – 6 hr
+++++
Codeine
3 – 4 hr
+
Demerol
2 – 4 hr
++
Morphine
3 – 6 hr
+++
Fentanyl
2 – 4 hr
+++++++++++
+++++++++++
Recognizing
Overdose
•  Somnolence
.
.
.
Can’t
waken
(doesn’t
respond
to
painful
s5muli)
•  Respiratory
depression
.
.
.
very
slow
and
ul5mately
no
breathing
(apnea)
•  Cyanosis
.
.
.
Turning
blue,
around
lips
and
fingers
first
•  Pinpoint
pupils
•  Cold
or
clammy
skin
•  Bradycardia
.
.
.
slow
heartbeat
(<50)
The
Recovery
Posi5on
• Mouth down, head turned so vomit cannot
block airway
• Brain at same level of (or lower than) heart
911
• Lots of good reasons not to call
ambulance
• EMTs called in only ~20% of OD’s
• About the same number with NLX
• Naloxone defers the emergency
• Bring him around
• Put him in the car and drive him to ER
• Keep NLX with you in the car in case he
starts going out again
A
+
B
of
Life
• Airway
–
make
sure
there
is
nothing
in
the
throat,
and
the
airway
is
protected
from
blockage
(pillow,
vomit,
chewing
gum)
Don’t
let
them
choke!
• Breathing
–
if
they
are
not
breathing,
you
must
breathe
for
them
Beginning
Rescue
Breathing
•  Roll
onto
their
back
•  Tip
chin
up
to
open
the
airway
(be
ready
to
turn
the
head
to
protect
the
airway
if
they
vomit)
•  Pinch
off
the
nose
•  Seal
your
mouth
over
theirs
and
give
three
quick
breaths
Beginning
Rescue
Breathing
•  Roll
onto
their
back
•  Hand
under
neck,
5p
chin
up
to
open
the
airway
(be
ready
to
turn
the
head
to
protect
the
airway
if
they
vomit)
•  Pinch
off
the
nose
•  Seal
your
mouth
over
theirs
and
give
three
quick
breaths
Con5nuing
Rescue
Breathing
•  Check
–
has
spontaneous
breathing
started
yet?
•  If
no,
–  Administer
naloxone!
–  Breathe
at
6
breaths
per
minute
un5l
spontaneous
breathing
starts
•  If
yes,
administer
naloxone
and
watch
them
carefully
Administering
Naloxone
•  1
ml
–
2
ml
or
cc
(equals
100units)
•  Repeat
the
dose
every
2‐3
minutes
un5l
they’re
waking
up •  If
not
responding
a?er
3
doses,
it’s
probably
not
an
opiate
overdose
–
CALL
FOR
HELP
and
conInue
CPR
unIl
help
arrives.
Administering
Naloxone
•  Into
the
muscle…
might
take
3‐5
minutes
to
work—you
must
con5nue
to
breathe
for
them.
Use
a
1
‐
1
1/2
inch
needle
to
reach
muscle
•  Under
the
skin.
.
.
this
is
about
as
far
as
an
insulin
syringe
needle
will
go.
It
may
take
much
longer
to
be
absorbed
this
way!
TIMING:
Typical
Heroin
OD
OD threshold
naloxone
1 hr
heroin
2 hrs
3 hrs
Comparison
of
Some
Opiates
Drug
Duration
potency
Methadone
24 hr
++++
Heroin
6 – 8 hr
+++++
Oxycontin
3 – 6 hr
+++++
Codeine
3 – 4 hr
+
Demerol
2 – 4 hr
++
Morphine
3 – 6 hr
+++
Fentanyl
2 – 4 hr
+++++++++++
+++++++++++
OD
with
longer‐ac5ng
opiate
OD threshold
Longeracting
naloxone
1 hr
2nd
dose
2 hrs
heroin
3 hrs
Extra-potent
TIMING:
OD
with
super‐potent
opiate
2nd
dose
OD threshold
naloxone
heroin
1 hr
2 hrs
3 hrs
TIMING:
OD
with
extra
heroin
dose
Second hit
OD threshold
naloxone
2nd
dose
heroin
1 hr
2 hrs
3 hrs
Just Right
OD
Naloxone
Blocks Receptors
Naloxone wears off—
Heroin goes back into receptors
Worse OD!!
Coming
out
of
Naloxone
•  Usual
dose
in
ER
is
2mg
IV
–
SEVERE
withdrawals!
•  We’re
recommending
0.4
–0.8mg
IM
–  much
gentler
–
only
a
couple
of
people
reported
vomi5ng
–  Naloxone
wears
off
in
30‐40
minutes
SUPPORT
THE
PERSON
•  While
the
naloxone
may
have
started
them
breathing
again
it
may
also
start
withdrawal
symptoms.
•  Using
again
will
make
the
OD
worse
when
the
naloxone
wears
off
in
an
hour
or
so.
•  If
you
can
support
the
person
in
dealing
with
any
discomfort,
the
naloxone
will
wear
off
and
the
withdrawal
will
fade.
Trea5ng
Overdose
•  Can
you
wake
him?
–  YES
–
keep
an
eye
on
him
for
at
least
2
hrs
–  NO.
.
.
.
.
•  Is
he
turning
blue?
Has
his
breathing
stopped?
–  NO
–
administer
naloxone
–  YES
–
give
3
quick
breaths
&
administer
naloxone
•  Is
he
breathing
spontaneously?
–  YES
–
wait
5
minutes
–  NO
–
do
rescue
breathing
for
five
minutes
amer
5
minutes.
.
.
.
•  Is
he
coming
around?
–  YES
–
support
him,
stay
with
him,
don’t
let
him
use!
–  NO
–
readminister
naloxone.
If
he
hasn’t
come
around
amer
3
doses,
CALL
FOR
HELP!!!
•  One
hour
later
–
is
he
geing
sleepy
again?
–  NO
–
watch
closely
for
at
least
another
hour
–  YES
–
may
need
another
dose
of
naloxone
Methadone OD may last 6-8 hours –
Find out what they took!!
Talkin’
Talkin’
Talkin’
 ‐
When
do
you
want
someone
to
take
ac5on?
(Breathing
rate?
Pulse
rate?
Turning
blue
–
lips?
fingers?)  ‐
What
do
you
prefer
regarding
CPR
and
how
to
use
naloxone
–
 where/how
injected
 mul5ple
doses
–
how
many
before
911?
 What
do
you
want
done
about
calling
911
or
going
to
the
ER?
Partner
Agreement
Checklist
 Knows
OD
preven5on
techniques
 Knows
if
and
when
you
want
them
to
call
for
help
/
go
to
the
ER
 Knows
if,
when,
and
how
you
want
naloxone
 Has
agreed
to
stay
with
you
for
support
 Notes
your
commitment
to
not
use
again
while
you
wait
for
the
naloxone
to
wear
off
“It
used
to
be,
overdose,
you
always
talk
about
it
in
past
tense:
‘I
HAD
a
friend
who
OD’d’.
Now,
overdose
is
in
the
present
tense:
‘I
HAVE
a
friend
who
OD’d
last
week,
but
it’s
OK,
he’s
all
right.”