1. Opioid Overdose Prevention and Reversal via Peer-Administered Narcan
Healthy Streets Outreach Program
a program of Northeast Behavioral Health
280 Union Street
Lynn, ma

2. First things first…slang
Jammed, jambox, jam sandwich: really high
Falling out: overdosing
Fell out: overdosed
Dope: heroin
Narcon or Narcain: Narcan pronounced incorrectly
Beaned out: on a lot of benzos

3. Opioid OD Stats:
Two people die from opioid overdoses every day in Massachusetts.
More people are killed by opioid overdoses in Massachusetts than by car accidents.
In 2007, there were over 6 times more deaths due to opioid-related overdoses than in 1990.
For every death due to an opioid overdose in 2007, there were 47 people who were treated for an overdose and lived.
*Sources:  “Opioids: Trends and Current Status in Massachusetts,” Massachusetts Department of Public HealthBureau of Health Information, Statistics, Research, and Evaluation and the Bureau of Substance Abuse Services, 2009
DAWN data “Massachusetts Oxycontin Commission: Final Report” 2009

4. MDPH Pilot Details:
Standing order authorizes Approved Opioid Overdose Trainers to possess nasal naloxone and to distribute it to Approved Opioid Overdose Responders.
Trainers and Responders are authorized to administer naloxone to person experiencing a drug overdose.
Approved by MDPH Drug Control Program and the Commissioner of DPH, overseen by medical director Dr. Alexander Walley.
DPH General Counsel’s Office determined the legality of the pilot programs. Once efficacy of the pilots has been established, Public Health Council will be asked to pass regulation to make the program permanent.

5. Expanded Access
Currently providing OD prevention in additional venues:
Detox
Methadone clinics
Suboxone programs
Homeless shelters
Other HIV P&E programs
Parent support groups
Corrections

6. Opportunity for Family Intervention
Majority of ODs occur in the presence of others
ODs can be reversed by rescue breathing and/or Narcan (Naloxone) administration
Many younger drug users are still living at home or are still allowed to visit the home.
Treatment options can be discussed at the hospital with family present in the case of an overdose.
Realistic and useful education for families.

7. Narcan Training Components
20-minute session (or longer)
Enrollment form (used for data collection, risk assessment, risk reduction)
Review of overdose risks, prevention, response, calling 911, rescue breathing, refill procedure
Participant repeats information back, demonstrates ability to assemble Narcan

8. Overview of Opioid Overdose

9. What is an Opioid Overdose?
Opioid fits exactly in receptor
The brain has many, many receptors for opioids. Too much opioid fitting in too many receptors slow and stop the breathing.
Opioid receptor on brain

10. Narcan reversing an OD Heroin
Narcan has a stronger affinity to the opioid receptors than the heroin, so it knocks the heroin off the receptors for a short time and lets the person breathe again.
Narcan
Opioid receptor

11. Opioid ODs, continued ODs are rarely instantaneous!
ODs happen as a process- someone slowly stops breathing
They usually happen 1-3 hours after the drug was used
Someone “found dead with a needle in their arm” is a rare event that is sensationalized

12. Recognizing and Responding to Opioid Overdose

13. What are the Signs/Symptoms of an OD?
REALLY HIGH
OVERDOSE
Muscles become relaxed
Deep snoring or gurgling (death rattle)
Speech is slowed/slurred
Very infrequent or no breathing
Sleepy looking
Pale, clammy skin
Nodding
Heavy nod, not responsive to stimulation
Will respond to stimulation like yelling, sternal rub, pinching, etc.
Slow heart beat/pulse
Blue skin tinge- usually lips and fingertips show first
Body very limp
Face very pale
Pulse (heartbeat) is slow, erratic, or not there at all
Throwing up
Passing out
Choking sounds or a gurgling/snoring noise
Breathing is very slow, irregular, or has stopped
Awake, but unable to respond

14. What puts people at risk for ODs?
Mixing Drugs
Variation in strength and content of ‘street’ drugs (purity)
Tolerance changes (coming out of jail/TX)
Using alone
Physical Health (liver functioning, weight loss, etc.)
Transient living – new dealers/new product
Thinking you “know everything”
Switching from sniffing/eating to injection.

15. How can you avoid an opioid overdose?
Know your tolerance
Know your supply
Control Your Own High
Be Aware of the Risks of Mixing Drugs
Try not to use alone
Make a plan
Talk with other users
Stop Using

16. Prevention Messages for Families
I want to remind you that (BECAUSE OF) your tolerance is very low, you are at high risk for an overdose.
Do you have an overdose plan? Do you and your friends know about Narcan?
I love you but not what you do and I do not want anything to happen to you.
If you relapse please do not do it alone.

17. A few words about benzos:
They are long acting (at least a day, usually)
They impair your short-term memory. So you can actually forget how many benzos or how much heroin you have used in the last 24 hours- this could put someone in danger for an OD!!
Very common and easy to find on the street
Cheaper than heroin
They are frequently necessary for mental health reasons- there is a high comorbidity between substance abuse disorders and mental illness like anxiety, depression, and post-traumatic stress disorder
Make people who are in withdrawal feel better
People use benzos to get jammed- enhances the effects of heroin (or methadone, etc)
Drugs could be cut or enhanced with benzos without the user knowing

18. Responding to an Overdose
“Are you alright? You ok?”
No response try a STERNUM RUB
Call 9-1-1
Give the person AIR using rescue breathing
Give 2 or 3 breaths and set-up the Narcan
Spray the Narcan
Continue rescue breathing
Spray second dose if necessary

19. If an OD happens…
Recovery Position

20. Overdose Prevention Using Nasal Narcan
Simple device, medication and nasal spray
Narcan is a pure opiate antagonist
No physiological effect other than blocking opiates
No adverse reactions
No potential for abuse or potential for OD

21. Narcan Kit components

22. What are barriers to calling 911 from the perspective of a substance user?
Fear of legal risk (outstanding warrants, DSS involvement, loss of public housing)
Fear of judgment from family/ community
Personal embarrassment/shame
Other punitive measures (students loose federal financial aid)
Manslaughter charges if someone dies on the scene

23. What about families?
Are there fears about calling among families?
How will YOU handle this discussion if it comes up without judging the person in front of you?

24. Frequently Asked Questions and Street Myths about ODs

25. Street Methods now have safer alternatives
Don’t leave the person alone--they could stop breathing
Don’t put them in a bath--they could drown
Don’t induce vomiting--they could choke
Don’t give them something to drink--they could throw up
Don’t put ice down their pants- it’ll make their pants wet! Cooling down the core body temperature of someone who is ODing is dangerous because it will slow down their body function even more than just the OD.
Don’t try to stimulate them in a way that could cause harm- slapping too hard, kicking in the testicles, burning the bottom of the feet, etc. can cause long-term damage
Don’t inject them with anything (saltwater, cocaine, milk)--it won’t work any more than physical stimulation and can waste time or make things worse depending on what you inject; a salt injection, for instance, could cause someone to go into cardiac arrest if they already have high sodium levels in their system. Also, every injection brings a risk of bacterial infection, abscesses, endocarditis, cellulitis, etc.

26. Does Speedballing balance you out?
“Speedballing” refers to any combination of a stimulant (upper) and a depressant (downer) taken together, esp. a mixture of heroin and cocaine or heroin and methamphetamine injected into the bloodstream.
No- speedballing does not cancel out OD risk
The more different drugs someone’s body has to process, the harder it is on their body
People who speedball usually use much more frequently that people who use only heroin- this increases OD risk

27. Will using Narcan help someone give a clean urine?No
Narcan knocks opiates off the opiate receptors, but the drug is still floating around in the body (AND urine!)

28. Can you use Suboxone to reverse an OD?
Not a good idea, probably not enough Naloxone in a Suboxone to reverse and overdose, will not act fast enough
Suboxone is a drug that contains both Buprenorphine (a partial agonist) and Naloxone (antagonists, same thing as Narcan)
Suboxone is supposed to be taken sublingually, and if taken this way, the Naloxone has no effect
If crushed and snorted, or injected, the Naloxone is “activated” and acts as an antagonist

29. The Paperwork

30. Enrollments BLUE or BLACK Pen
Non-users do not get asked any questions below the lot number.
Must fill in all information
If you do not have an answer use X’s or a zero
Use leading zeroes
If someone is not sure they are enrolled please fill out another enrollment
DO NOT FORGET THE BSAS CODE
All codes are on the back of the enrollment

31. Refills Never give a kit without doing the refill form.
Only answer all the questions if they are reporting an overdose.
ALWAYS write comments, especially if it is a reversal.

32. The Hard Part.

33. I used the Narcan.
Trauma associated with witnessing an OD may not manifest immediately.
Be open to hearing the details but never ask for the details.
Positively reinforce all actions performed by the responder.
Refill Narcan

34. Contact Information
Mary Wheeler
Program Director – Healthy Streets Outreach Program
a program of Northeast Behavioral Health