1. Northeast Tennessee Naloxone Pilot David Kirschke, MD Medical Director Northeast Region Health Office

2. Tennessee Overdose Deaths YearODMVAHomicideSuicide 20121,094958456956 20131,1661,0084051,017 Total2,2601,9668611,973

3. Epidemiology of Overdose Deaths 2013 data 54% men Median age 46 years (75% 30 - 59 years) 9 were 15 - 19 years Most white (90%) 72% high school diploma, GED certificate or less education

4. Naloxone Rescue Act (SB1631/HB1427) Allows a licensed healthcare practitioner to prescribe naloxone to a person at risk of having an opiate related overdose, or a family member or friend of the at risk individual Requires training in administration of naloxone prior to drug being prescribed (Training being prepared by TDH) Provides immunity from civil prosecution for both prescribing practitioner and individual administering naloxone Public Chapter 623 Went into effect July 1, 2014

5. “If you, a friend or a loved one is at risk for an opioid overdose, talk with your healthcare provider about a very safe antidote that anyone can learn to administer,” said TDH Commissioner John Dreyzehner, MD, MPH. “In many opioid overdoses, death can be prevented by administering the drug naloxone, almost immediately reversing the deadly effects of opioids and allowing time to reach further medical treatment.”

6. Naloxone Antidote; Opioid Antagonist Significant adverse reactions: – Related to reversing dependency and precipitating withdrawal – Withdrawal symptoms are the result of sympathetic excess

7. How does naloxone work? Naloxone has a stronger affinity to the opioid receptors than the opioid, so it knocks the heroin off the receptors for a short time and lets the person breathe again. Opioid receptor Naloxone Opioid

8. Naloxone Safety Naloxone requires a prescription Opioid antagonist - no potential for abuse Little to no effect on person unless they are experiencing an opioid overdose Accidental administration poses no threat or danger – Including to children or pregnant women

9. Naloxone Safety WHO’s List of Essential Medicines >50,000 people in US trained to administer naloxone >10,000 opioid overdoses have been reversed with naloxone from 1996 to 2010 Studies suggest laypersons trained in administration can do so as effectively as EMS personnel

10. Other States >19 states and the District of Columbia have laws allowing for distribution and administration of naloxone Some states provide for an open, standing order for the prescribing of naloxone Some states offer criminal amnesty for a person calling 911 to seek assistance for an opioid overdose

11. Naloxone Training Mandated in legislation Developed by TDH http://health.tn.gov/Naloxone/ Understand: – Opioid overdoses – How to identify them – Who may be at higher risk – What to do in an opioid overdose emergency

12. Recognizing an Overdose Unresponsiveness to yelling or stimulation, like rubbing your knuckles on breast bone – Effectively draws the line between overdosing and being really high but not overdosing Slow, shallow, or no breathing Turning pale, blue or gray (especially lips and fingernails) Choking sounds

13. Risk Factors Overdose is most common when: History of prior overdose Tolerance is down due to not using – like after being in jail, detox or drug-free treatment Drugs are mixed, especially with alcohol or benzos Person uses alone

14. What NOT to do During an Overdose DO NOT put the individual in a bath – They could drown. DO NOT induce vomiting or give the individual something to eat or drink – They could choke. DO NOT give over-the-counter drugs or vitamins (eg, No-Doz or niacin) – They don’t help and the patient could choke.

15. Responding to a Suspected Opioid Overdose

16. Step 1 - Rub to wake Rub your knuckles on the bony part of the chest (sternum) to try to get them to wake up and breathe.

17. Step 2 - Call 911 Tell them The address and where to find the person A person is not breathing When medics come tell them what drugs the person took if you know Tell them if you gave Naloxone

18. Step 3 - If the person stops breathing, give breaths mouth to mouth or use a disposable breathing mask Put them on their back Pull the chin forward to keep the airway open put one hand on the chin, tilt the head back, and pinch the nose closed Make a seal over their mouth with yours and breathe in two breaths. The Chest, not the stomach, should rise Give one breath every 5 seconds

19. Step 4 - Give naloxone Injectable: Give naloxone (discard any opened naloxone within 6 hours of using) Injectable naloxone: inject into the arm or upper outer top of thigh muscle 1cc at a time always start from a new vial Intranasal: Squirt half the vial into each nostril, pushing the applicator fast to make a fine mist.

20. Injectable Naloxone

21. Intranasal Naloxone

22. Step 5 - Stay with the person and keep them breathing Continue giving mouth to mouth breathing if the person is not breathing on their own after that administration of naloxone Give second dose of naloxone after 2-5 minutes if they do not wake up and breath more than 10- 12 breaths a minute Naloxone can spoil their high and they may want to use again, make sure they are aware that overdosing is still possible when naloxone wears off

23. Step 6 - Place the person on their side People can breathe in their own vomit and die. If a person is breathing put them on their side to prevent this. Naloxone can induce vomiting, this position will help protect them from inhaling that vomit.

24. Step 7 - Convince the person to follow the paramedics advice If paramedics advise to proceed to an emergency room then health care staff can Relieve symptoms of withdrawal Prevent a second overdose Observe and administer naloxone as needed Assess risk of the person for other overdoses brought on by drugs other than opioids

25. Step 8 - What if police show up? Tennessee Naloxone Rescue Act allows bystanders to administer naloxone if they suspect an overdose No immunity to prosecution for drug use in TN

26. REVIVE! Kits Kits include: Mucosal atomizer Latex-free gloves Rescue breathing shield Information card (includes naloxone and rescue position graphics) Return cards Stickers

27. References For more information about naloxone, visit the American Public Health Association website www.ncbi.nlm.nih.gov/pmc/articles/PMC266 1437/ www.ncbi.nlm.nih.gov/pmc/articles/PMC266 1437/ To view a video about naloxone and how it is used, visit http://prescribetoprevent.org/video/ http://prescribetoprevent.org/video/