1. 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

2. 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

3. 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

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

5. 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 Intercensal populations

6. 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, Epi Data Brief. Sept 2013 (No.33).

7. Drug overdose deaths in NYC 2000-2012

8. Drugs involved in overdose deaths:
United States,
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

9. 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.

10. Where in NYC are overdose deaths occurring?

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

13. 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

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

15. 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

16. 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

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

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

19. Where there are more opioids available, more people overdose

20. 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

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

22. 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

23. 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

24. 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

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

26. 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

27. 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 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)

28. 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

29. 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

30. 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.

31. Steps to responding to an overdose

32. 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)

33. 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

34. 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

35. 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.

36. 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

37. 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.

38. 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

39. Results: Awake and breathing
Narcan wears off in 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

40. Reporting requirements
Report use of naloxone to Desk Officer
Aided Report Worksheet (PD b) in non-arrest situations or Medical Treatment of Prisoner Form (PD ) 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

41. 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

42. 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

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

44. 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

45. Progress to date:
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

46. 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.

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

48. 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)

49. 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

50. 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

51. 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

52. Resources for the Trainer
Sample PowerPoint presentation
Online audio slideshow
Instructional materials
Infographic assembly instructions
Sample videos
Wallet cards

53. Contact us for more assistance
Amu Ptah-Riojas
(347)
Anne Siegler
(347)
And thank you for helping save lives!