Overdose Prevention Train-the-Trainer for NYPD October 29, 2013 Amu Ptah-Riojas Anne Siegler NYC Department of Health and Mental Hygiene Bureau of Alcohol and Drug Use Prevention, Care and Treatment

Objectives After today’s session, participants will be able to: Discuss the epidemiology and physiology of overdose, including risk factors for overdose Properly identify and respond to an opioid overdose using intranasal naloxone Develop and offer a 30-minute overdose prevention training to other NYPD members

Schedule for our training Why are we talking about overdose? Who is at risk of overdosing? What does an opioid overdose look like? Responding to an opioid overdose Tools for training others to respond to an opioid overdose

Why are we talking about overdose? Epidemiology of drug overdose in NYC Why are we talking about overdose?

Comparison of motor vehicle deaths and OD deaths in the United States, 1999-2010 NOTES: Drug poisoning deaths are a subset of poisoning deaths. Unintentional drug poisoning deaths are a subset of drug poisoning deaths. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm. Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm

Drug poisoning is now the leading cause of injury death In NYC, drug overdose is the third leading cause of premature death, after cancer and heart disease1 Almost 2 people die of a drug overdose in NYC every day2 Main point: overdose is a big problem, both in the U.S and in NYC specifically. In NYC – almost 2 OD deaths every day (677 deaths in 2012) 1 Zimmerman R, et al. Summary of Vital Statistics, 2011: Mortality. New York, NY: New York City Department of Health and Mental Hygiene, 2013. 2 Paone, et al. Unintentional drug poisoning (Overdose) deaths in NYC, 2000-2012. Epi Data Brief. Sept 2013 (No.33).

Drug overdose deaths in NYC 2000-2012

Drugs involved in overdose deaths: United States, 1999-2010 NOTES: Opioid analgesic categories are not mutually exclusive. Deaths involving more than one opioid analgesic category shown in this figure are counted multiple times. Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm

Drugs involved in overdose deaths: NYC, 2000-2012 OA: Prescription opioids involved in 28% of all OD deaths in NYC in 2012. OA rates increased 267% between 2000 and 2011. Heroin: Heroin involved in 52% of all OD deaths in NYC in 2012. Heroin rates increased 71% between 2010 and 2012.

Where in NYC are overdose deaths occurring?

Opioid analgesic deaths are 4 times higher on Staten Island than elsewhere in NYC

Recent headlines from Staten Island “Prescription plague rages: A fatal overdose on Staten Island every 9 days in 2011” Staten Island Advance, May 14, 2013 “On Staten Island, painkiller overdoses deadlier than car crashes, murder” Staten Island Advance, May 11, 2012

What does an opioid overdose look like? Physiology of opioid overdose – Part 2 What does an opioid overdose look like?

Opioid overdose physiology Opioids repress the urge to breath, leading to respiratory depression and death Slow breathing Breathing stops Heart stops Circulation of blood to the brain stops Generally happens over course of 1-3 hours. The stereotype “needle in the arm” death only occurs in about 15% of overdose deaths. The key is that there is time to respond to an overdose

Continuum of Overdose Heavy/ uncontrollable nodding Overdose Still arousable Snoring or loud breathing May have excess drooling Overdose Not responsive Very shallow breathing, gurgling Skin changes, blue lips and nails Fatal overdose

Signs of an opioid overdose Slow breathing or difficulty breathing Loud snoring Blue or grey lips, nail beds Unresponsive

Physiology of opioid overdose – Part 1 Who is at risk?

Where there are more opioids available, more people overdose

When tolerance decreases, risk of overdose increases Tolerance goes down if an individual stops using opioids for a period of time. Incarceration Drug treatment/ Detox Hospitalization

Risk of overdose increases when more than one drug is used at the same time Alcohol Benzodiazepines, i.e. Xanax, Klonopin Antidepressants Cocaine

Overdose deaths in New York City involve multiple drugs (2008) Nearly all unintentional drug overdose deaths in NYC (98%) involve more than one substance, including alcohol. Opioids were the most commonly noted drug type(74%). Types of opioids included heroin, methadone, and prescription pain relievers. Other drugs commonly found were: cocaine (53%), benzodiazepines (35%), antidepressants (26%),and alcohol (43%). NYC Vital Signs, Volume 9, No. 1, NYC DOHMH

Context of opioid overdose The majority of overdoses are witnessed (gives an opportunity for intervention) Fear of police may prevent calling 911 Witnesses instead may try ineffectual things Myths and lack of proper training Abandonment is the worst response Since most overdoses that look like they may be fatal are not (it is estimated that 1-2/10 are fatal) people have reason to believe that interventions like salt shots are effective

Strategies to address overdose Prescription monitoring programs Prescription drug take-back events Safe opioid prescribing education for MDs Expansion of drug treatment Use of naloxone by non-medically trained personnel Good Samaritan 911 laws

Responding to an opioid overdose using naloxone So what do we do? Responding to an opioid overdose using naloxone

An antidote exists Naloxone (Narcan®) opioid antagonist injectable or intranasal reverse the effects of opioids preventing an overdose from becoming fatal regulated substance (by prescription only) but not a controlled substance

Naloxone’s effects Usually acts within 2-5 minutes If the person was opioid dependent, naloxone will put them into withdrawal Naloxone blocks the effects of all opioids Naloxone lasts for 30-90 minutes Harmless/no effects if the person had no opioids in their system Will not reverse overdoses caused by substances that are not opioids (cocaine, alcohol, benzodiazepines, methamphetamine)

Intramuscular (IM) naloxone A face mask for rescue breathing 2 safety syringes 2 pre-filled vials of naloxone 2 alcohol swabs 2 latex gloves 1 brochure reviewing OD and rescue steps

Intranasal (IN) naloxone A face mask for rescue breathing 2 needle-less syringes 2 pre-filled vials of naloxone 2 nasal atomizers 2 latex gloves 1 brochure reviewing OD and rescue steps

Legal Status - Overdose Law in New York State (Effective April 1, 2006) Protects the non-medical person who administers naloxone in setting of overdose from liability “shall be considered first aid or emergency treatment” “shall not constitute the unlawful practice of a profession” Allows the medical provider to provide naloxone for secondary administration Naloxone must be prescribed by MD, DO, PA, or NP Naloxone is just like most any prescription medicine. The prescriber must see the recipient, one cannot just sign the script. There must be an order or prescription for the RN or pharmacist to dispense. Also the recipient must use their own naloxone- there cannot be a centrally located kit for non-medical personnel to use.

Steps to responding to an overdose

Step 1. Stimulate Shake, call to the person loudly Sternal rub: rub knuckles hard up and down breast bone (It hurts them, but won’t cause damage)

Step 2. Check for breathing Chest rising and falling Nostrils moving in and out Mirror or glass by nose or mouth will fog up Touch moistened finger next to nostrils, feel for cool draft of inward breathing

Administer rescue breathing or CPR Rescue breathing alone can sustain someone until EMS arrives Mouth-to-mouth Chest compressions not included (unless Responder is trained in CPR) In some cases rescue breathing may blow off enough CO2 to raise level of consciousness

How to perform rescue breathing Tilt back head to open airway with hand under neck or chin lift Pinch nose shut Make a seal over the mouth with your mouth Start by giving 2 quick breaths. Then give one breath about every 5 seconds until EMS arrives or person breathes on their own.

More on rescue breathing American Heart Association recommends hands-only resuscitation for sudden cardiac arrest In opioid overdose (and drowning), oxygen is depleted. Breaths are vital for survival! Few overdose victims survive if the heart stops ADVICE: Rescue breathing should always be included in a suspected overdose. harmreduction.org/article.php?id=1186

Step 3. Administer naloxone Assemble your naloxone dose. Tilt victim’s head back. Spray half of the vial up nostril. Spray the remainder of the vial up the other nostril. Spray until all of the liquid has been expelled. If no response in 2-5 minutes, administer the 2nd naloxone vial. Continue rescue breathing until response.

Recovery Position If you must leave the victim even for a few minutes, put them into the recovery position so they won’t choke on vomit

Results: Awake and breathing Narcan wears off in 30-90 minutes Don’t leave the victim alone as sedation may return Reassure the victim if s/he is in withdrawal that the naloxone will wear off and the effects of the opioids will return. (And if s/he uses more drugs they won’t have any effect.) Dispose of used naloxone into trash receptacle

Reporting requirements Report use of naloxone to Desk Officer Aided Report Worksheet (PD 304-152b) in non-arrest situations or Medical Treatment of Prisoner Form (PD 244-150) in arrest situations NYSDOH Opioid Overdose Reporting Form NOTE: location, type of substances used if known, condition of aided, if CPR was administered, if victim survived Submit reports to Desk Officer within xx hours/days Two doses are not for 2 overdoses but in case the first one is not enough

Replace your naloxone Get a refill of naloxone Even if just one dose was used If kit is lost If naloxone is nearing expiration date (ever 2 years) Store naloxone at room temperature and away from direct light Two doses are not for 2 overdoses but in case the first one is not enough

Stay up on your skills Receive a Refresher Training every year. Every so often, take out your kit, review instructions, and practice assembling your naloxone dose quickly. Two doses are not for 2 overdoses but in case the first one is not enough

Naloxone around new york What else you need to know Naloxone around new york

State-certified “Opioid Overdose Prevention Programs” Over 80 sites registered in New York including: Hospitals Drug treatment programs HIV programs Homeless shelters Syringe exchange programs Not all are currently up and running

Progress to date: 2006 - 2012 Over 10,000 overdose rescue kits (IN and IM) have been dispensed to NYC residents at risk of overdose, as well as their friends and loved ones Nearly 750 reports of overdose reversals

Encouraging people to call 911: NY’s Good Samaritan law This law protects the overdose victim and those who call 911: From arrest in the presence of misdemeanor possession and/or underage drinking From prosecution in felony possession Went into effect in September, 2011 NY is one of several states to pass such laws It was meant to protect all but the District Attorney’s objected so it is complicated. But the upshot is that it sends a message that saving a life is more important than an arrest.

Training others to respond to an overdose Pass it on! Training others to respond to an overdose

30-minute training for NYPD members Goals: Instruct : How to identify an overdose (when should I use naloxone?) How to respond, including administering naloxone Protocol: Reporting use of naloxone, safe storage, when and where you must carry it with you, refresher trainings, replacing used or expired naloxone Dispense: Overdose prevention kit with 2 doses of IN naloxone (prescribed by NYPD surgeon)

Materials you need to do the training An Overdose Rescue Kit for demonstration (can be vial filled with water, or expired naloxone) Overdose Rescue Kits for each member attending training (to be dispensed by surgeon), which includes: 2 doses of naloxone 2 nose pieces Face mask Instruction sheet Blue New York State certification cards PowerPoint presentation, laptop, projector Other informational materials: e.g. fact sheets, brochures, Operations Order Optional: dummy to demonstrate rescue breathing

Agenda for 30-minute training of NYPD members Recognizing an overdose: what does an OD look like? Risk factors for an opioid overdose Responding to an overdose Sternum rub Rescue breathing/CPR Naloxone NYS law on naloxone administration and 911 Good Samaritan law Expectations of NYPD trained in overdose prevention Reporting Storage Refresher trainings Dispense naloxone and prescription, blue state certification card

By the end of the 30-minute training, each trained responder should: Have hands-on practice with naloxone device (intranasal assembly) Receive blue Certificate of Completion card Meet with medical provider for short medical history, receive Overdose Rescue Kit with naloxone Receive prescription to keep in Kit Understand new Operations Orders, and expectations for use of naloxone

Resources for the Trainer Sample PowerPoint presentation Online audio slideshow Instructional materials Infographic assembly instructions Sample videos Wallet cards http://www.nyc.gov/html/doh/html/mental/drug-provider-od.shtml

Contact us for more assistance Amu Ptah-Riojas (347) 396-7909 aptahriojas@health.nyc.gov Anne Siegler (347) 396-7008 asiegler@health.nyc.gov And thank you for helping save lives!