Opioid Overdose Reversal & Naloxone Training Iowa Harm Reduction Coalition

Background on Opioids in the US/Iowa Prescription opioid sales have increased 300% since 1999 Increases in opioid/heroin-related hospitalizations and overdose deaths Not only in large cities, but also in rural areas like Iowa Source: https://dhs.iowa.gov/sites/default/files/MHDS-Heroin-and-Opioid-Use-in-Iowa.pdf

What Are Opioids? Any drug which acts on opioid-receptors Pain medications with high addiction risk Addiction can affect anyone Examples of opioids: heroin, morphine, hydrocodone, oxycodone, fentanyl, percocet

Risk Factors for Overdose Using alone New users with unknown tolerance Unknown content/strength ‘street’ drugs Mixing drugs with opioids or using different drugs in a night (benzodiazepines like xanax; alcohol) Switching administration method (snorting, injecting, pills) Tolerance changes (getting out of jail, leaving treatment, relapsing) Physical health (dehydration, weight loss, asthma, immune conditions, malnutrition, liver function, etc.)

Overdose Physiology Opioids overwhelm the available receptors (respiratory, nervous system) This causes analgesia, euphoria, respiratory depression and sedation Highest cause of morbidity and mortality is due to respiratory compromise

Overdose Physiology NALOXONE REVERSING AN OVERDOSE OPIOID OVERDOSE Opoiod overdose: The brain has many receptors for opioids. An overdose occurs when too much of an opioid, such as heroin or Oxycodone, fits in too many receptors, slowing and then stopping breathing. Naloxone reversing an overdose: Naloxone has a stronger affinity to the opioid receptors, so it knocks the opioids off the receptors for a short time. This allows the person to breathe again and reverses the overdose. Image: https://www.practicalrecovery.com/prec/wp-content/uploads/2016/02/naloxone-and-opioids_edited-1.png

Some signs to look for in an overdose HIGH OVERDOSE Muscles become relaxed Deep snoring or gurgling (death rattle) or wheezing Speech is slowed/slurred Blue skin tinge- usually lips and fingertips show first Sleepy looking Pale, clammy skin Will respond to stimulation like yelling, sternum rub, pinching, etc. Heavy nod, will not respond to stimulation Nodding out Breathing is very slow, irregular, or has stopped/faint pulse

Overdose Myths - Don’t do these! Ice/Cool down Cooling core temperature slows down body functions further Salt water injection Can cause heart attack Undue painful stimulation Responsiveness can easily be determined with sternal rub Other stimulation can cause further, long-term damage “Balancing out” with stimulants Makes body work harder External stimulation, sternal rub, works well to try to alert person

What is Naloxone? Used in emergency overdose situations Drug that blocks/reverses effects of opioid overdose Nasal spray or injection Administered by medical professional, nurses, or trained family/friends Wide distribution decreases opioid related deaths

Naloxone Misconceptions “Naloxone has NO potential for abuse” - Iowa Department of Public Health Naloxone distribution does NOT encourage substance abusers to continue to use, since they have this rescue agent. Naloxone is not given ONLY to heroin drug users since a large percentage of opioid overdose comes from prescription drugs. Naloxone usage does NOT mean that the person who overdosed is now safe. He/she must immediately seek medical attention at a nearby hospital.

Naloxone Laws/Protection As of 2016, Iowa Pharmacies are allowed to dispense an opioid antagonist (naloxone) to “a person in a position to assist someone at risk of an opioid-related overdose” without a prescription. Can also be prescribed to family members, law enforcement, firefighters and EMS. Under a standing order, Iowa Harm Reduction Coalition provides free vials of naloxone and syringes to individuals, organizations, and communities across Iowa.

Naloxone Administration Methods Auto-Injector (EvzioTM) Comes with training device Can be injected through pants Maximal Effect in 15 min Nasal Spray (NarcanTM) 1 dose per device No priming! Maximal Effect in 30 min

Naloxone Administration Methods Naloxone Kits Contents: syringes, naloxone vials 1 dose (2 mg) per vial Maximal Effect in 30 min

Overdose Response Follow I-CARE Procedure: I-dentify overdose C-all 911 A-dminister naloxone R-escue breathing and CPR E-nsure safety while awaiting EMS arrival Image: http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/responding-to-opioid-overdose/administer-naloxone/

Identification Identify overdose with: “Hey buddy” Sternal rub Identify Call Administer Rescue Ensure Identification Identify overdose with: “Hey buddy” Sternal rub Signs of OD slow/absent breathing gasping for breath, snoring, gurgling sound pinpoint pupils blue/gray/purplish lips and nails Explain why you are offering naloxone. Use clear, simple words.

Identify Call Administer Rescue Ensure If more than 1 person capable of assisting is present, 1 person can call 911 while the other moves to the next step. It is essential to call 911 because naloxone might not work, and even if the person responds to naloxone, it may wear off in as little as 30 minutes.

Administer Naloxone (NarcanTM nasal spray) Identify Call Administer Rescue Ensure Administer Naloxone (NarcanTM nasal spray) Deliver one spray into one nostril. (Do not “prime” or test the spray device before spraying it into the nostril, as this will waste the medicine.) Repeat with the second nasal spray device in the opposite nostril if there is no response after 2-3 minutes, or if the victim relapses back into respiratory depression or unresponsiveness before emergency assistance arrives. From:http://www.chaindrugreview.com/wp-content/uploads/2016/07/Narcan-Nasal-Spray_Adapt-Pharma.jpg

Administer Naloxone (syringe nasal spray) Identify Call Administer Rescue Ensure Administer Naloxone (syringe nasal spray)

Administer Naloxone (auto-injector) Identify Call Administer Rescue Ensure Administer Naloxone (auto-injector) Pull auto-injector from outer case. Pull off red safety guard. Place the black end of the auto-injector against the outer thigh, through clothing if needed, press firmly and hold in place for 5 seconds. Repeat with the second auto-injector if No response after 3 minutes Victim relapses back into respiratory depression Unresponsiveness before emergency assistance arrives.

Administer Naloxone (manual syringe injection) Identify Call Administer Rescue Ensure Administer Naloxone (manual syringe injection) Place a needle on the 3 mL syringe. Insert the needle through the gray rubber plug with the vial upside down. Pull back on the syringe plunger and draw up 1 mL of naloxone. Insert the needle into the muscle of the upper arm or thigh, through clothing if needed, and push on the plunger to inject the naloxone. Repeat injection with second vial if... No response in 3 minutes Victim relapses back into respiratory depression Unresponsive before emergency assistance arrives

Rescue airway/breathing Identify Call Administer Rescue Ensure Rescue airway/breathing Make sure airway is clear! Place one hand on chin. Tilt head back to open airway. Pinch nose closed. Give 2 slow rescue breaths into mouth. Make sure chest rises with each breath.

Ensure Safety Identify Call Administer Rescue Ensure Don’t give the person overdosing more opioids. Place in rescue position to prevent vomit from getting in the airway. Reversal in 2-3 minutes after dose Ensure safety while awaiting EMS arrival Monitor person for signs of reversal and withdrawal. Vomiting, diarrhea, pain, fast heart rate, increased blood pressure, runny nose, sneezing, irritability, agitation, shivering or trembling, sweating

Ensure Safety (Rescue Position) Identify Call Administer Rescue Ensure Ensure Safety (Rescue Position)

Recovery/Waking Up Remember - Naloxone only lasts 30-90 minutes but the effects of opioids may last much longer! Just because someone wakes up does not mean they are safe from recurrent episode of overdose. Ensure that 911 has been called and that EMS is en route. People can wake up from an overdose differently (i.e. confused, tired, upset, violent, etc.). Some might not realize that they overdosed at all.

Recovery/Waking Up If it has been 30 minutes since administering the first dose of naloxone and you have chosen not to call 911 or EMS has not arrived… Administer a second dose of naloxone! Heroin and pain medications have a longer half life than naloxone, meaning that the naloxone dose will wear off, the opioid can still be active in the body, and the person can re-experience the overdose and go back into respiratory distress.

After-care/Support Withdrawal If person uses opioids for pain - may begin experiencing pain upon administration of naloxone May feel sick and want to use again Until naloxone wears off, further use of opioids/heroin will be ineffective Once awake, stay with the person to make sure they do not overdose again once naloxone wears off -> further administration of naloxone may be necessary

Naloxone storage/care Check expiration date (typically lasts 1-2 years) Keep out of light if not stored in a box Store somewhere where medication is secure but also readily available Store at room temperature (between 60 and 70 degrees)

Free Naloxone Kits for Iowans www.iowaharmreductioncoalition.org (319) 214-0540 hello@iowaharmreductioncoalition.org