1. NALOXONE (NARCAN) ADMINISTRATION

2.  What are opioids?  Who abuses them?  What will an overdose look like?  What is the treatment for opioid overdose?  Basic care  Naloxone (Narcan) administration  Are there any other considerations to be aware of? OVERVIEW

3.  Chemical substances designed to relieve pain  They bind to receptor sites on cells of the central nervous system and the brain  These substances can be naturally derived forms from the opium plant  There are also a number of synthetic forms available WHAT ARE OPIOIDS?

4.  Management of a patient’s pain is an important goal of therapy  Pain management is used in  Cancer  Back injuries PAIN MANAGEMENT

5.  Oxycodone  Oxycontin  Roxicodone  Percocet  Acetaminophen/Oxycod one  Endocet  Tylox  Vicodin  Tylenol with Codeine  Morphine  Fentanyl  Hydromorphone  Dilaudid OPIOIDS TO MANAGE PAIN

6.  15000 deaths per year of overdoses involving prescription pain medications  1 in 20 people (that’s 12 million people!) reported using prescription medications for non-medical reasons ABUSE OF PRESCRIPTION MEDICATIONS Source: CDC Vital Signs – November 2011

7.  Middle age adults have highest overdose rate  People in rural counties are twice as likely to overdose on prescription medications that people who live in urban areas OVERDOSE OF PRESCRIPTION PAIN MEDICATIONS Source: CDC Vital Signs – November 2011

8.  There are 7.3-8.4 kilograms of prescription pain killers prescribed per 10,000 people IN DELAWARE Source: CDC Vital Signs – November 2011

9.  Tracking systems have helped decrease the amounts of pain killers available to patients  Helps prevent patients from getting multiple prescriptions from multiple physicians CONTROL OF MEDICATIONS

10.  Because it is increasingly difficult for people to obtain prescription pain meds they now turn to non-prescription (illegal) sources  Heroin  Heroin is also cheaper and more potent THE RISE OF HEROIN

11.  Often heroin is cut with other substances  These substances can increase the potency and make the drug much more deadly  A common example of this is the fentanyl-laced heroin that has become increasingly available LACED HEROIN

12.  Intravenous  Direct injection into vein  Skin popping  injection beneath the skin  Both present the risk of needle stick to the officer! HOW DO PEOPLE USE?

13.  Ingestion  Pills  Snorting/Sniffing  Transdermal  Patches  Chewed up HOW DO PEOPLE USE?

14.  Accidental – took too much medication  Common in elderly  Intentional overdose  Suicidal gesture  Higher potency drugs  Build up a tolerance and require more HOW DO OVERDOSES OCCUR?

15.  Combinations of multiple medications  Pain killers with alcohol  Pain killers with sedatives  Decreased tolerance after a period of non-use  Subject incarcerated  Subject goes to rehab  After getting clean, they return to previous drug culture  Using a dose that they used when they were addicted could result in fatal overdose HOW DO OVERDOSES OCCUR?

16. SIGNS AND SYMPTOMS OF OVERDOSE

17.  Pinpoint pupils  Respiratory depression  Stop breathing or slow breathing  Nervous system depression  Unconscious or slow to respond  Unable to maintain an open airway THREE CLASSIC SYMPTOMS

18.  Respiratory depression may lead to respiratory arrest  Death will soon follow if untreated OVERDOSES CAN BE FATAL

19.  Temporarily reverses the effects of opioids  Binds to the same sites on the cells as the opioids are trying to bind to  Blocks the opioids from having their depressive effects NALOXONE (NARCAN)

20.  Opioid overdose that is unconscious with inadequate breathing or is not breathing  Actual or suspected overdose  Bystander history  Prior knowledge of patient  Paraphernalia nearby WHEN TO USE NALOXONE

21.  Opioid overdose that is unconscious and breathing adequately  Known hypersensitivity (rare) WHEN NOT TO USE NALOXONE

22.  Give naloxone:  Suspect opioid OD  Unconscious  Not breathing, or  Difficult breathing  Shallow  Slow (less than 8 breaths per minute)  Noisy (snoring)  Blue skin color  DO NOT give naloxone:  Unconscious  Breathing adequately  Deep or normal breaths  Breathing rate > 8  Airway open – no noises  Skin color normal TO GIVE OR NOT TO GIVE?

23.  May wake up a potentially violent drug abuser  Occasionally causes vomiting  If this happens, turn patient on their side and attempt to keep the airway clear of vomit SIDE EFFECTS (CAUTIONS)

24.  Naloxone’s effects will usually last between 30 and 90 minutes, the effects of the opioid can last much longer  Because of this, the naloxone may wear off before all of the opioid does  This is why it is extremely important to monitor the patient for a period of time after receiving naloxone  Rapid opiate withdrawal may cause nausea and vomiting  Continue to provide respiratory assistance and keep airway clear CAUTION

25.  Naloxone only reverses the effects of opioid medications  It will have no effect on other depressant substances  Sedatives  Tranquilizers  Alcohol NOTE

26.  Treatment is aimed at restoring the breathing  IT IS NOT INTENDED TO WAKE THE SUBJECT UP!  As long as they maintain an open airway and keep breathing, this patient will survive to more advanced care  Waking them will only increase the danger they present to responders as they may become violent TREATMENT OF OPIATE OVERDOSE

27.  Use caution approaching patient  Take necessary universal precautions  Don gloves  Eye protection  Survey scene for signs of drug abuse PATIENT APPROACH

28.  Scene Safety/BSI is a top priority  You may know you’re responding to a suspected overdose, or you may be told upon arrival  Check responsiveness  Remain non-judgmental and non-confrontational  Ask bystander(s) what and when the patient injected, ingested, or inhaled (or if a transdermal patch has been used)  Consider additional resources INITIAL SIZE-UP

29.  Check signs of circulation  Open the patient’s airway  Ensure breathing  Ventilate using a barrier device if necessary  If signs of trauma  Manage the cervical spine as needed BEGIN BASIC CARE

30.  If patient is not breathing after opening the airway, or  If patient’s breathing is inadequate  Slow  Irregular  Noisy ADMINISTER NALOXONE

31.  Prepare equipment  Administer medication to patient  Monitor for effect  Repeat if required ADMINISTER NALOXONE-INTRANASAL

32.  1 mg, per nostril (1 ml) naloxone given intranasal  A fine mist produced in the nostril  Works relatively quickly  Large amount of blood vessels inside nostril  Absorbs medications very easily  Avoids use of needles  Very quick to administer  Easy WHY INTRANASAL?

33. ASSEMBLE THE EQUIPMENT

34. WHEN ASSEMBLED THE NALOXONE WILL LOOK LIKE THIS

35.  Quickly depress plunger of syringe to deliver 1 ml of medication into patient’s nostril ADMINISTER NALOXONE TO PATIENT

36. WHEN PLUNGER IS PUSHED RAPIDLY, MEDICATION WILL BE DISPENSED AS A MIST

37.  If patient has not resumed breathing, begin rescue breathing  Use pocket mask or barrier device MONITOR FOR EFFECT

38.  If patient begins breathing, place them in the recovery position  Knee is extended to support body  Elbow is flexed to support head  Helps maintain open airway WHEN BREATHING IS RESTORED

39.  The goal of naloxone IS NOT to wake the patient  It is meant only to restore their breathing  If the patient is still not breathing after two minutes, another 1 mg dose of naloxone may be given in the opposite nostril REPEAT IF REQUIRED

40.  Prepare equipment  Administer medication to patient  Monitor for effect  Repeat if required ADMINISTER NALOXONE- INTRAMUSCULAR

41.  Consistent delivery of medication  Simple and fast acting  Similar to other auto-injectors used by EMS WHY INTRAMUSCULAR?

42.  Ventilate patient with BVM  Pull naloxone auto-injector from case  Device will now provide voice- prompt guidance  Grasp firmly and pull off red safety guard INTRAMUSCULAR ADMINISTRATION

43.  Place black end against patient’s outer thigh  Press firmly against patient’s outer thigh and hold in place for five seconds.  Remove auto-injector and dispose of in sharps container  Continue to ventilate patient with BVM INTRAMUSCULAR ADMINISTRATION

44.  After receiving Naloxone, patient may wake up and become violent!  Be prepared and stay vigilant  (Law Enforcement) Do not allow the patient to leave care before the arrival of EMS  Naloxone may wear off sooner than the opiate CAUTION

45.  Continue to manage the airway until breathing is adequate  Be alert to vomiting and prepare to suction CAUTION

46.  (Law Enforcement) Transfer care of patient to EMS  (EMS) Transfer care of patient to receiving facility  (Law Enforcement)Report to attending EMS provider  Conditions under which the patient was found including suspected cause of overdose  Treatments rendered by law enforcement  Dose of naloxone administered, if any, and time of treatment TRANSFER OF CARE

47.  Opioid use is rampant  Opioid overdose is common  Opioids depress the breathing and nervous system  Depression of breathing leads to death if not rapidly treated  Naloxone reverses the effects of the opiate and can restore breathing  If given early, naloxone can maintain the patient’s breathing and keep them alive until further help arrives SUMMARY

48.  Naloxone is meant to increase respiratory effort  IT IS NOT A WAKE UP DRUG  Do not wake up an unconscious overdose patient who is breathing adequately  The subject may become violent and place responders at great risk AND ONE MORE TIME!

49.  Initial point of contact is your department’s training officer  Further questions may be directed to the Delaware Office of Emergency Medical Services QUESTIONS?