1. Naloxone Central MA EMS Corporation EMS Region II www.cmemsc.org Version 2a (2014)

2. Location Logistics Emergency Exits Restrooms Breaks Cell phones Interruptions (You must be present for the entire course to earn OEMS credit.)

3. This Course… Includes the training required for First Responder (police/fire) agencies electing the optional skill of naloxone Meets the required training for EMTs Does not result in certification

4. OEMS CE Credits This course is eligible for 1.5 hours OEMS credit for all EMT levels (use for Local or Individual Category). The OEMS Approval Number is listed on the course completion document you’ll receive at the end of this program.

5. Course Overview Introductions Goal, Purpose, Objectives and History The “Why, What, and How” of Naloxone Course Summary & Questions Written Quiz Skills Practical Assessment (Required) Course Evaluation Roster & Course Completion Document

6. Goal Goal (What are we trying to accomplish?) Reduce death from opioid overdose

7. Purpose Purpose (Why are we here today?) To teach police & fire department First Responders and MA certified EMTs how to administer Naloxone in accordance with MDPH/OEMS AR 2-100 and EMS Prehospital Treatment Protocols

8. Objectives By the end of this course the student will: Recognize the signs and symptoms of an overdose Identify the indications, contraindications and possible adverse reactions of Naloxone Prepare and administer Naloxone (intranasal & auto-injector) Describe how continued support will be provided to the patient

9. History (state data 2000-2009) Poisonings, most of which are ODs, continued to be the leading cause of injury deaths in MA and have increased at 4.9% per year since 2000.

10. Opioids, including but not limited to: Heroin Oxycodone Morphine Codeine, and Methadone continued to be the class of drugs most associated with poisoning deaths (67%)

11. History (Legislation) On March 27, 2014, Governor Deval Patrick declared the state’s opioid addiction epidemic a public health emergency, directing MDPH to allow First Responders the option to carry and administer naloxone. And later that same day…

12. History (Protocols) OEMS changes naloxone administration from an option to a required skill for all EMTs.

13. History (Protocols) Demand for intranasal naloxone causes shortages, leading OEMS to release an emergency protocol change on 10/21/14 allowing naloxone administration by auto-injector as well.

14. Naloxone Naloxone (Narcan) is an opioid (narcotic) antagonist that can reverse Central Nervous System and respiratory depression secondary to an overdose of opioids. Naloxone is not effective against respiratory depression due to non-opioid drugs.

15. Opioids Synthetic or semi-synthetic alkaloid that acts on the Central Nervous System to: decrease the perception of pain decrease the reaction to pain increase pain tolerance May be prescribed for acute pain, debilitating pain, or chronic pain as part of palliative care (e.g., cancer).

16. Opioid vs. Opiates Opiates are an alkaloid derived from the opium poppy plant. (non-synthetic)

17. Opioids may include: Buprenorphine Butorphanol (Stadol) Codeine Fentanyl (Duragesic patch) Hydrocodone (Vicodin) Hydromorphone (Dilaudid) Meperidine (Demerol) Morphine Nalbuphine (Nubain) Oxycodone (Percocet/Percodan) Oxymorphone Pentazocine (Talwin) Paregoric Propoxyphene (Darvon)

18. Opioids Heroin is an illegal Opioid which may be injected, snorted, or smoked. Street names include: Big H Boy Capital H China white Chiva Dead on arrival Diesel Dope Eighth Good HH Hell dust Horse Junk Mexican horse Mud Poppy Smack Thunder Train White junk

19. Opioids Tolerance and/or addiction may occur, requiring increasing doses for the same effect Common side effects include: -Nausea and vomiting -Drowsiness -Constricted or “pin-point” pupils -Itching -Dry mouth -Constipation

20. Treatment Drugs Methadone Opioid which may be used as a pain reliever, but commonly prescribed to minimize the effects of opioid withdrawal Suboxone (tablets & film strips) Opioid (Buprenorhpine) and Naloxone combined to both minimize effects of opioid withdrawal while blocking the effects of euphoria (“high”)

21. Who’s At High Risk? Individuals demonstrating drug-seeking behavior (e.g., frequent ED visits, or accessing care from multiple doctors) High dose users Prescription pain-killer users (often not own prescription) IV drug users

22. Others At Risk Over-medicated elderly patients Patients with pain relieving patches Children with access to prescription pain- killers

23. Target Population The target population for intranasal Naloxone:  those who use opioids as substances of abuse  those whose respiratory drive is at a life- threatening level

24. Why Intranasal? Minimizes risk for blood borne pathogen exposure (no needle) May be administered rapidly and painlessly Onset of action is 3-5 minutes, peak effect is 12-20 minutes Protect Naloxone from light

25. Why Intranasal? Nasal mucosa is highly vascularized and absorbs drugs directly into the blood stream.

26. Why an Atomizer? Briskly compressing the syringe converts the liquid drug to a fine atomized mist. This results in broader mucosal coverage and better chance of absorption into the blood stream than drops that can run straight back into the throat.

27. Indications Respiratory arrest or hypoventilation Unresponsive or depressed mental status Constricted or “pinpoint” pupils Evidence of opiate use (opioid Rx bottles, drug paraphernalia, “track marks”) Yarmouth police officers work to save the life of a 25-year-old man following an apparent heroin overdose. (Yarmouth Police Dept. photo)

28. Contraindications Recent seizure (by report or signs) Head/facial trauma Nasal trauma (obstruction and/or bloody nose) Cardiopulmonary arrest

29. On Scene Scene Safety/BSI is a top priority EMTs: Are police responding? Be non-judgmental and non- confrontational Ask bystanders what and when the patient injected, ingested, or inhaled (or if a transdermal patch has been used) Was more than one substance used?

30. On Scene Multiple bottles of the same prescription medication Multiple bottles of the same prescription medication that don’t belong to the patient or anyone else at that residence Some prescription bottles may be used to “hide” narcotics (i.e., pills inside don’t match what’s on the label) Drug use clues

31. On Scene Drug Kit “Packaged” Drugs (An “8-ball” of heroin) Drug use clues

32. On Scene Drug use clues “Track Marks”

33. Signs & Symptoms Unresponsive/minimally responsive with pulse Respiratory arrest (not breathing) Depressed respiratory rate (<12 per min) Paramedics work on a 20-year-old man who collapsed from a drug overdose after coming out of a bar. Source: Herald Sun

34. Signs & Symptoms

35. Decreased mental status or confusion Slurred speech and/or difficulty walking Bluish skin/mucous membranes Nausea/vomiting Constricted pupils

36. Intranasal Preparation Steps The following slides are intended only as a visual preparation for hands-on practice. Each student must satisfactorily demonstrate atomizer assembly and administration on a manikin before being released into the field to perform this skill on an actual patient.

37. Preparation Step 1 You will need: One Luer-Jet needle-free syringe One ampule of Naloxone 2.0 mg One atomizer Do not assemble medication on atomizer until ready to use. Dosage indicator

38. Preparation Step 2 Remove the caps from each end of the Luer-Jet needle-free syringe.

39. Preparation Step 3 Remove the red cap from the Naloxone glass vial. Insert and gently twist the Naloxone glass vial into the syringe/adapter.

40. Preparation Step 4 Attach the nasal atomizer to the opposite end.

41. Dispose in sharps container as soon as possible after administration.

42. Protocol 2.14

43. Routine Care Scene safety/Body Substance Isolation FRs: ensure ambulance response EMTs: activate ALS Determine unresponsiveness (call out to victim/noxious stimulus) Check for reduced respirations Start rescue breathing (use BVM and nasal airway /oxygen)

44. PMDD …Or the “Four Rights” for Medication Administration: Right Patient (drug overdose) Right Medication (Naloxone/check for clarity) Right Date (check expiration) Right Dose (refer to protocol)

45. Administration: Intranasal Ensure nasal cavity is free of blood or mucous (EMTs: suction if needed) Control patient’s head with one hand Place atomizer within one nostril, occlude opposite nostril

46. Administration: Intranasal Aim slightly upwards and toward ear on same side as nostril Briskly compress syringe to administer up to 1.0 mg of atomized naloxone Repeat in other nostril (using both nostrils doubles the surface area available for absorption) Give second dose if no response after 3-5 minutes

47. Administration: Auto-Injector Pull auto-injector from outer case Pull off safety guard: Don’t touch the black base where the needle comes out!

48. Administration: Auto-Injector Place end of auto-injector firmly into the outer thigh (through clothing if needed) Press firmly (listen for click & hiss) and hold in place for 5 seconds

49. Administration: Auto-Injector Needle should retract fully into its housing after administration Do not replace safety guard; put auto- injector back into outer case and place in sharps container

50. Continued Patient Care Return to rescue breathing until spontaneous respirations are restored If respirations return to normal, roll victim on their side to prevent patient from choking on own vomit

51. The effects of Naloxone may not last as long as the effects of the opioid; be prepared for a return of overdose signs & symptoms! First Responders: Note time of administration to report to EMTs and monitor patient until ambulance arrives, ensuring transfer of care (provide detailed verbal report)

52. EMTs: Initiate transport as soon as possible (don’t wait on scene for ALS) Consider contacting poison control if poly-substance use is suspected: (800) 222-1222 Confirmed or suspected hypoglycemia: do not administer oral glucose if patient is not sufficiently conscious with a normal gag reflex

53. Key Points EMTs: Contact CMED for early entry notification to the nearest emergency department

54. Critical Reminder Do NOT get distracted by drug administration Be sure to ventilate properly as needed

55. Avoid “Tunnel Vision” If level of consciousness does not improve after five minutes, what could be going on?

56. Other Possibilities The patient has taken an amount of opioids that is more than the Naloxone is able to counter. Maybe it’s not an overdose! What other conditions may have similar signs & symptoms? Discuss how each changes the treatment plan.

57. Adverse Reactions Use caution when administering Naloxone to narcotic dependent patients! Rapid opiate withdrawal may cause nausea & vomiting. EMTs: Keep airway clear and be prepared to suction!

58. Adverse Reactions Rapid opiate withdrawal may also cause: Agitation, irritability, and violent behavior Restlessness and nervousness Be prepared to deal with agitated patient Maintain the safety of yourself, your partner and patient when using physical restraint

59. Adverse Reactions Rapid opiate withdrawal may also cause: Runny nose, watery eyes Excessive sweating Shaking, trembling, quivering Sneezing, yawning, muscle aches Rapid heart rate High or low blood pressure

60. Pediatrics When opioid overdose is suspected in a pediatric patient (<15): Administer naloxone if needed Activate ALS EMS response Maintain open airway and assist ventilations Initiate transport as soon as possible

61. Pediatrics, continued For infants less than 1 year old, pinch the middle of the outer thigh before and during auto-injector administration

62. Documentation Carefully document as required by agency/service & medical director: Patient presentation (neurological, respiratory, cardiac) Signs and symptoms (before & after treatment) Vital signs (before & after treatment) Naloxone administration by bystanders, First Responders, EMS

63. Documentation Clinical response Any use of physical restraint Record time drug was administrated, amount, and route, for example:  “19:20, Naloxone 2.0 mg nasal via atomizer” or;  “19:20, Naloxone 0.4 mg auto-injector”

64. Patient Refusals Do not “treat & release” A refusal must be signed by a patient who can reasonably be determined to be competent to make an informed decision to refuse care An overdose patient is unlikely to fall into this category EMTs should request police assistance if needed

65. MDPH Lay Rescuer Program As part of a MA Department of Public Health initiative, lay rescuers are administering intranasal naloxone in cities across the state. “How to Assemble a Nasal Naloxone (Narcan) Rescue Kit” http://www.youtube.com/watch?v=Uq6AxrEY3Vk (You must have internet access to view this 4 minute optional video.)

66. Summary What we learned: Why Naloxone is an option for First Responders & required for EMTs How to identify an opioid overdose Indications and contraindications Adverse reactions and management How an atomizer is prepared Intranasal administration Auto-Injector administration

67. Questions What are the signs and symptoms of an opioid overdose? What are the indications for Naloxone administration? What are the contraindications to administering Naloxone? What adverse reactions are possible with Naloxone? How would you manage these reactions?

68. Skills Practical Assessment Given a scenario by your instructor, demonstrate: Preparation of a naloxone atomizer using required equipment Administration of intranasal naloxone on an adult intubation manikin or skills trainer Administration of naloxone via auto-injector using a auto-injector trainer Continued patient care & support

69. Final Details Written Quiz Course Evaluation Roster Course Completion Document

70. References Centers for Disease Control Drugs.com Federal Drug Administration MacQuarrie, Brian (March 27, 2014) Governor Declares an Emergency on Opiate Abuse The Boston Globe Governor Declares an Emergency on Opiate Abuse MDPH/Division of Research and Epidemiology, Bureau of Health Information, Statistics, Research, and Evaluation (2012) A Decade of MortalityA Decade of Mortality Massachusetts: 2000-2009

71. References MDPH Bureau of Substance Abuse Services MDPH/OEMS, AR 2-100 Minimum Standards for First Responder Training in First Aid, Epinephrine Auto-Injector and Naloxone Use (2014) MDPH/OEMS EMS Pre-hospital Treatment Protocols, 2014 MDPH/OEMS, Treat & Release; Patient Refusals Advisory (2002) N.O.M.A.D. (Not One More Anonymous Death Overdose Prevention Project)

72. Credits Special thanks to the following services and individuals who shared their training materials with the Region to help develop Version 1 of this program: Boston EMS Fallon Ambulance Missy Fasshauer, Woods Ambulance Jerry Flanagan, Bound Tree Medical Joshua McCrillis, East Brookfield Fire Ken Ward, Vital EMS