Overdose Prevention & Response Shoshanna Scholar & Adam Butler LA Community Health Project

US Programs CDC MMWR, 2012: Over 50,000 drug users (and their friends/ family) trained between 1996-2010. Over 10,000 reversals reported. 60 programs distributing or prescribing naloxone, with approximately 240 individual sites, in 18 US states.* *unpublished results of 2013 US naloxone programs survey, completed by the Harm Reduction Coalition

It’s legal & it’s safe In California it’s legal to prescribe naloxone & it’s legal to use naloxone to save someone’s life (see slides at the end of this presentation for details on legal status) Naloxone is very safe and very effective http://www.fda.gov/downloads/Drugs/NewsEvents/UCM300866. pdf

What is an opioid overdose? The brain has many opioid receptors. Too much heroin in too many receptors slows down and sometimes stop breathing. Heroin fits exactly in receptor Opioid receptor on brain

Opioid overdoses Opioid overdoses are rarely instantaneous! Overdoses happen as a process: someone slowly stops breathing They usually happen 1-3 hours after the drug was used Someone “found dead with a needle in their arm” is a rare event that is sensationalized

Examples of opioids Heroin Codeine Demerol Morphine Darvocet Fentanyl Dilaudid Methadone Opium Hydrocodone Oxycodone Vicodin OxyContin Tylenol 3 Tylox Levorphanol Percocet Percodan

Are all opioids equal?

A few words about benzodiazepines Long acting Impair short-term memory Common, cheap, and easily obtained Diverted pills as low as $0.50 Often prescribed for mental health reasons People often use “benzos” to manage withdrawal Enhance the effects of opiates Often used as “cut” They are long acting (at least a day, usually) They impair your short-term memory. So you can actually forget how many benzos or how much heroin you have used in the last 24 hours- this could put someone in danger for an OD!! They are really really common and easy to find on the street They are cheaper than heroin They are frequently necessary for mental health reasons- there is a high comorbidity between substance abuse disorders and mental illness like anxiety, depression, and post-traumatic stress disorder People use benzos to get well- makes people who are in withdrawal feel better People use benzos to get jammed- enhances the effects of heroin (or methadone, etc) Drugs could be cut or enhanced with benzos without the user knowing

A few words about Cocaine & Heroin Slang: Speedballing: Any combination of a stimulant (upper) and a depressant (downer) taken together and injected into the bloodstream Speedballing does not cancel out overdose risk. The more drugs the body has to process, the harder it is to process which increases the chances of overdosing People who speedball often use more frequently than people who use only heroin which increases the chances of overdosing

What puts people at risk? Tolerance Mixing drugs Physical health Variation in strength and content of ‘street’ drugs Using alone

How can you avoid an overdose? Know your tolerance Know your supplier Control your own high Injection techniques Be aware of the risks of mixing drugs Try not to use alone Make a plan Talk with other users

Signs & symptoms of an overdose Blue skin tinge- usually lips and fingertips show first Body very limp Face very pale Pulse (heartbeat) is slow, erratic, or not there at all Throwing up Passing out Choking sounds or a gurgling/snoring noise Breathing is very slow, irregular, or has stopped Awake, but unable to respond

Being really high vs. overdosing OVERDOSE Muscles become relaxed Deep snoring or gurgling (death rattle) Speech is slowed/slurred Very infrequent or no breathing Sleepy looking Pale, clammy skin Nodding Heavy nod, not responsive to stimulation Will respond to stimulation like yelling, sternal rub, pinching, etc. Slow heart beat/pulse

How Naloxone reverses an overdose Heroin Naloxone has a stronger affinity to the opioid receptors than the heroin, so it knocks the heroin off the receptors for a period of time allowing the person breathe again. Naloxone Opioid receptor

How to use Naloxone . Pop off caps from Naloxone and syringe . Insert syringe into Naloxone bottle . Pull back plunger until Naloxone bottle is empty. Make sure at least 1cc is in syringe . Grab a pinch of flesh on the shoulder and insert syringe fully 5. Depress plunger

What to do in the event of an overdose Call 911 Perform rescue breathing Administer Naloxone

Rescue Breathing chin-lift method to open the airway hand under chin bone and lift 2 slow breaths Blow enough air into their lungs to make chest rise Turn head after each breath to ensure the chest is rising and falling If it doesn’t work, tilt the head back more

Rescue Breathing Breathe again. Count one-one thousand, two- one thousand, three-one thousand, four-one thousand… Breathe every 5 seconds Continue until: The person starts to breathe on their own An ambulance comes Someone else can take over for you You are too exhausted to continue

Barriers to calling 911 from user’s perspective Fear of legal risk (outstanding warrants, DCFS involvement, loss of public housing) Fear of judgment from family/community Personal embarrassment/shame Other punitive measures (students lose federal financial aid) Urban legends (homicide charge, deportation…)

Recovery position

Street methods: debunking the myths 1. Don’t leave the person alone—they could stop breathing! 2. Don’t put them in a bath—they could drown! 3. Don’t induce vomiting—they could choke! 4. Don’t give them something to drink—they could throw up!

Street methods: debunking the myths 5. Don’t try to stimulate them in a way that could cause harm! 6. Don’t put ice down their pants- it’ll make their pants wet! 7. Don’t inject them with anything (saltwater, cocaine, milk)! 5. harm- slapping too hard, kicking in the testicles, burning the bottom of the feet, etc. can cause long-term damage 6. Cooling down the core body temperature of someone who is ODing is dangerous because it will slow down their body function even more than just the OD 7. it won’t work any more than physical stimulation and can waste time or make things worse depending on what you inject; a salt injection, for instance, could cause someone to go into cardiac arrest if they already have high sodium levels in their system. Also, every injection brings a risk of bacterial infection, abscesses, endocarditis, cellulitis, etc.

It’s legal to save a life! Good Samaritan Law AB472 CA’s 911 Good Samaritan Law provides limited protection from arrest, charge, and prosecution for people who seek emergency medical assistance at the scene of a suspected drug overdose Does not affect laws that prohibit selling, giving, or exchanging drugs AB472 seeks to encourage people to QUICKLY seek medical care for a person who is overdosing According to CDPH, more Californians die from accidental overdose death than motor vehicle accidents

California Law:   AB635, Jan 2014 Designed to encourage CA healthcare providers and community programs to widely distribute naloxone Expands previous naloxone legislation in CA: Allows for prescription & distribution throughout the state. Protects licensed health care professionals from civil & criminal liability when they prescribe, dispense, or oversee distribution via a standing order of naloxone via an overdose prevention program or standard medical practice. Permits individuals to possess and administer naloxone in an emergency and protects these individuals from civil or criminal prosecution for practicing medicine without a license. Clarifies that licensed prescribers are encouraged to prescribe naloxone to individual patients on chronic opioid pain medications to address prescription drug overdose.

Resources Videos about naloxone, opioid safety/overdose, and how to respond in emergencies: http://harmreduction.org/issues/overdose-prevention/tools- best- practices/overdose-videos/ www.prescribetoprevent.org/video How to find a community-based naloxone distribution program (for parents and drug users who do not have access through the health care system): http://www.overdosepreventionalliance.org/p/od- prevention-program- locator.html

Resources for Families Learn to Cope: online discussion forum for parents of drug users: http://www.learn2cope.org/ Grief Recovery from a Substance Passing (GRASP), for people who have lost a loved one to overdose: http://grasphelp.org/ Broken No More, a support group and advocacy organization for parents interested in advocating for drug policy reform: http://broken-no-more.org/ Al-anon and Nar-anon, 12 step recovery groups for families and friends affected by another person’s drinking or drug use.

Questions? Shoshanna S. Scholar Executive Director LA Community Health Project scholar@lachop.org 213.483.5846 Adam Butler Training & Healthcare Access LA Community Health Project adam@chpla.org 617.459.5542