1. Opioid Overdose Reversal & Naloxone Training
Iowa Harm Reduction Coalition

2. 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:

3. 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

4. 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.)

5. 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

6. 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.
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7. 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

8. 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

9. 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

10. 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.

11. 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.

12. 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

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

14. 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
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15. 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.

16. 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.

17. 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:

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

19. 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.

20. 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

21. 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.

22. 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

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

24. Recovery/Waking Up
Remember - Naloxone only lasts 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.

25. 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.

26. 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

27. 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)

28. Free Naloxone Kits for Iowans
(319)