1. First Responder Overdose Response Training
Welcome participants to the training
Reiterate that the training is sponsored by the MA Department of Public Health
In collaboration with the Massachusetts
Department of Public Health,
Bureau of Substance Abuse Services and
Office of HIV/AIDS

2. Go to givenaloxone.org for an online module for first responders (EMTs, firefighters, and law enforcement officers) with post-test
Note that there has been a significant amount of publicity around this topic recently, but that it has been going on for years.
Interactive: Ask participants to share their own experiences and interactions with people who use opioids

3. The Overdose Problem
Note that there has been a significant amount of publicity around this topic recently, but that it has been going on for years.
Interactive: Ask participants to share their own experiences and interactions with people who use opioids

4. National & regional drug threat
Key Point:
New England has a significantly large percentage of people using heroin and abusing pharmaceuticals compared to the national average.
Interactive: Ask people to name some of the most commonly abused pharmaceuticals and be certain to identify which of them are opioids.

5. Prescription opioid sales, deaths and treatment: 1999-2010
Key Point: Sales of opioids and death rates have been on a steady incline since 1999, fortunately, so has treatment admissions.
Opioid addiction has been recognized as a problem and treatment for addiction has increased, naloxone is a form of harm reduction to prevent people from dying from an overdose and hopefully get them into treatment after.
National Vital Statistics System, ; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), ; Treatment Episode Data Set,

6. In 2012, 13 Massachusetts residents died each week from drug overdoses
By 2010, drug overdose deaths outnumbered motor vehicle traffic deaths in 31 states
Key Point: deaths due to drug overdoses is increasing rapidly throughout and the country
CDC NVSS, MCOD. 2010
More deaths from drug overdose
In 2012, 13 Massachusetts residents died each week from drug overdoses

7. Learning Objectives Understand the overdose crisis
Know how opioids work and overdose risk factors
Recognize an opioid overdose
Respond to opioid overdose
Review Good Samaritan/Naloxone Law
Passed August 2012
Comply with the emergency regulations
Passed March 2014
Review objectives of training

8. Key Point: Office of National Drug Control has identified this as a problem and is promoting drug policy reform that encourages treatment rather than incarceration.
Note: We will get to the Massachusetts Good Samaritan Law later in the presentation

9. Key Point: Quincy Naloxone program has become a model across the country Lt. Detective Patrick Glynn- face for the Quincy Program, law enforcement was training in 2010
The Acting Director of ONDCP is our former Bureau Director

10. Police and Fire naloxone rescues in Massachusetts 2010- July 2014
Town
Rescues
Quincy Police start 2010
255
Revere Fire start 2010
150
Gloucester Police + Fire start 2011 8
Weymouth Fire start 2013 87
Saugus Fire start 2013 15
New Bedford Police start April 2014 24
New Bedford Fire start April 2014
Total
554
Image:
Why does Gloucester have so few rescues?
Their EMS is fire department-based and has short response times.
EMS usually arrives first

11. First Responder Pilot Data: 2010-2014
 Response to Naloxone
Total
Responsive and alert
182 (45%)
Responsive but sedated
162 (40%)
No response to naloxone
61 (15%)
Post-Naloxone Withdrawal Symptoms
Total
None
47 (40%)
“Dope Sick”
27 (23%)
Irritable or Angry
33 (28%)
Physically Combative
6 (5%)
Vomiting
16 (14%)
Other
14 (12%)
95% of victims were responsive to naloxone and much of the time they experienced no withdrawal symptoms after narcan.
Responsive, but sedated is AS GOOD AS or BETTER than responsive, and alert.
It is common for naloxone to cause a person who just overdosed to have withdrawal symptoms

12. DPH Overdose Education & Naloxone Distribution Program Sites
Coming Soon
Learn to Cope
Key Point: There are several distribution sites for bystanders and active users throughout the state, this shows where they are located but they serve surrounding areas as well.
Learn to Cope- Support group for concerned parents, sites around the state distribute naloxone
AIDS Action Committee
AIDS Project Worcester
Lowell House/ Lowell Community Health Center
AIDS Support Group of Cape Cod
Manet Community Health Center
Brockton Area Multi-Services Inc.  (BAMSI)
MAPS/ Health Innovations
Boston Public Health Commission
North Suffolk Mental Health
Greater Lawrence Family Health Center
Seven Hills Behavioral Health
Holyoke Health Center
Tapestry Health
Learn to Cope

13. March 27, 2014
The Governor’s Public Health Emergency declaration provided emergency powers to DPH Commissioner Cheryl Bartlett, RN. At the Governor’s direction, the Public Health Council passed a regulation that:
Although we have had our pilot program since 2010, on March 27, 2014 the Governor declared a Public Health Emergency that permits first responders to carry and administer Naloxone
“Universally permits first responders to carry and administer Naloxone (Narcan), a safe and effective opioid antagonist that, when timely administered, can reverse an overdose and save a life.”

14. Why Police Officers? First to the scene of an overdose
Frequent interaction with high risk populations
With the right tools, police can make a public health impact
Builds bridges to active users and their social networks
Overdose is a true crisis and police can help
Key Point: Establish relevance of topic to the of work police officers and other first responders
Anticipate that some first responders may be apprehensive about narcan because they feel as though it is not the responsibility of law enforcement to address the opioid overdose problem

15. How Opioids Work and Overdose Risk Factors

16. Key Point: Opioids are for medical purposes and even heroin was created by Bayer for a pharmaceutical remedy
There were ads in papers and journals for Bayer’s many products, including aspirin and heroin. 16 16

17. What are opioids/opiates?
Medications that relieve pain
Attach to the opioid receptors in the brain and reduce the intensity of pain signals reaching the brain.
Key Point: Opioids attach to the receptors that block pain

18. All categories have overdose risk
Opioids
Natural Opiates
codeine
morphine
opium
Semi-Synthetic Opiates
hydromorphone
hydrocodone
oxycodone
heroin
Fully Synthetic Opioids
methadone
fentanyl
Key Point: There are many types of opioids but they all have similar affects
The term opiate is often used as a synonym for opioid, however the term opiate refers to just those opioids derived from the poppy plant either natural or semi-synthetic
All categories have overdose risk

19. hours days opium heroin fentanyl morphine hydrocodone methadone
Key Point: Different opioids last for different amounts of time with varying strengths
When the state of the medication is altered the strength can increase
opium
morphine
codeine
opium
heroin
hydrocodone
oxycodone
heroin
fentanyl
methadone
Demerol
fentanyl
morphine
hydrocodone
methadone
codeine
oxycodone
Demerol

20. How do opioids affect breathing?
Opioid Receptors
Key Point: An overdose occurs when too much of an opioid, like heroin or Oxycontin, fits in too many receptors slowing and then stopping the breathing
OVERDOSE

21. How Overdose Occurs
Slow Breathing
Breathing Stops
Lack of oxygen may cause brain damage
Heart Stops
Death
Key Point: Overdose process takes time as the breathing decreases, there is time to respond but not time to waist 21

22. What is Narcan® (naloxone)?
Narcan knocks the opioid off the opiate receptor, blocking opiate receptors from the opiate
Temporarily takes away the “high,” giving the person the chance to breathe
Narcan works in 1 to 3 minutes and lasts 30 to 90 minutes
Narcan can neither be abused nor cause overdose
only contraindication is known sensitivity, which is very rare
Too much Narcan can cause withdrawal symptoms such as:
Key Point: Narcan reverses an opiate overdose, to restore breathing
Withdrawal referred to as “dope sickness”
nausea/vomiting
diarrhea
chills
muscle discomfort
disorientation
combativeness 22 22

23. How does Narcan affect overdose?
Restores Breathing
Key Point: Naloxone knocks the opioid off of the opioid receptor to restore breathing

24. What is an Opioid OD?

25. Naloxone Reversing Overdose

27. Key Point: Common right now in Massachusetts is Fentanyl laced in heroin, causing an increase in overdoses because the strength of the heroin is stronger than the user is used to 27

28. Mixing Opioids with Benzos
Combining opioids with benzodiazepines or alcohol leads to a worse outcome
Benzos are psychoactive drugs prescribed for sedation, anxiety, sleep and seizures
The most commonly used benzos are: Klonopin, Valium, Ativan, Librium, and Xanax
Key Points: Also common in Massachusetts is mixing opioids with benzodiazepines
Note that narcan does not work on benzos 28

29. Medications for Opioid Overdose and Treatment
Narcan® = naloxone
Reverses opioid overdose
Short and fast-acting opioid blocker
Vivitrol® = naltrexone
Treatment for opioid and alcohol addiction
Long-acting opioid blocker
Suboxone® = buprenorphine + naloxone
Treatment for opioid addiction
The naloxone is added to discourage injecting or sniffing
Subutex® = buprenorphine only
Treatment for opioid addiction in pregnant women
Methadone aka dolophine and methadose
Treatment for opioid addiction or pain
No street value because they cause withdrawal symptoms
Street value because they can relieve
withdrawal symptoms
Key Point: Medications for opioid overdose and treatment, some like subutex and methadone are more desired by active users because they can relieve withdrawal symptoms

30. Revolving door???
As it is for tobacco and weight loss, it takes multiple attempts before achieving success
By definition, addiction is a chronic condition where people make risky choices despite negative consequences
With time, treatment works - people get better
With treatment, crime is less common and therefore they interact with police less often
Law enforcement because its law enforcement is more likely to see the relapses than recovery

31. Administering Naloxone

32. Office of Emergency Medical Services
First responders are authorized to administer nasal naloxone as a standing order, under Statewide Treatment Protocol 2.14
Key Point: OEMS Treatment Protocol 2.14 is the "Standing Order" for first responders to administer naloxone. 32

33. Scene Safety and Potential Hazards
Oncoming traffic
Unstable surfaces
Leaking gasoline
Downed electrical lines
Potential for violence
Fire or smoke
Hazardous materials
Other dangers at crash or rescue scenes
Crime scenes
NEEDLES
PEOPLE
Key Point: Remind police to consider scene safety, look for drug paraphernalia, talk to others at the scene to determine if this is a drug overdose and to keep you and everyone on the scene safe
WEAR GLOVES: Assume all body fluids present a possible risk for infection

34. Recognize Overdose
If a person is not breathing or is struggling to breath: call out name and rub knuckles of a closed fist over the sternum (Sternum Rub)
Signs of drug use?
Pills, drugs, needles, cookers
Look for overdose
Slow or absent breathing
Gasping for breath or a snoring sound
Pinpoint pupils
Blue/gray lips and nails
Ensure EMS is activated
Key Points: Upon arrival to scene, to determine if victim has overdosed, call out persons name (If known) and sternum rub in an attempt to arouse the victim. Look for envirnomental clues of drug use, check victims breathing, and ensure that EMS has been activated.

35. Just high/overmedicated
Just high/overmedicated vs. overdose
Just high/overmedicated
Overdose
Small pupils
Drowsy, but arousable
Responds to sternal rub
Speech is slurred
Drowsy, but breathing
8 or more times per minute
Small pupils
Not arousable
No response to sternal rub
Not speaking
Breathing slow or stopped
< 8 times per minute
May hear choking sounds or a gurgling/snoring noise
Blue/gray lips and fingertips
Key Point: Someone who is really high and someone who is overdosed can look similar, it is an overdose if person is not arousable, and breathing is less than 8 times per a minute. Even if the person is really high and not overdosed they should not be left alone because they may slip into an overdose
>> Stimulate and observe
>> Rescue breathe + give naloxone

36. 3) If no change after 3 – 5 min repeat naloxone
Overdose Suspected
No Pulse
Check Pulse
1) Administer Naloxone
2) Rescue breathing
3) If no change after 3 – 5 min repeat naloxone
4) Rescue breathing until help arrives
1) 2 min of CPR, 5 Cycles
2) Administer Naloxone
3) Apply Defibrillator
4) Follow Defib. prompts
5) Continue CPR
Pulse
If you suspect an overdose (not breathing or slow breathing, blue lips or finger tips ect.), check the pulse
If no pulse and with 2 or more responders, administer naloxone during first 5 cycles of CPR
Also, if you have another person with you, one person can be putting together the narcan and/or doing crowd control and keeping area safe, while another is doing the rescue breathing

38. Remember “Four Rights” for medication administration
Massachusetts Office of Emergency Medical Services Minimum Standards for First Responder Training in First Aid, Epinephrine Auto-Injector and Naloxone Use AR-2-100
Right Patient (opioid overdose)
Right Medication (Naloxone-check for clarity)
Right Date (check expiration)
Right Dose (spray half (1ml) in each nostril)

39. Naloxone formulations
Intranasal
Auto-injector

40. Intranasal Naloxone
Intranasal naloxone needs to be dispensed with the mucosal atomization device
If there is nasal trauma or bleeding, do not administer naloxone
Benefits of Intranasal Naloxone
Nose is an easy access point
Painless
Eliminates risk of contaminated needle sticks and needle dispensing
Key Point: Benefits of intranasal naloxone

41. Give Naloxone: Intranasal
Remove both yellow caps from the ends of the syringe
Twist the nasal atomizer onto the tip of the syringe
Remove the purple cap from the naloxone
Twist the naloxone on the other side of the syringe
Review how to put together naloxone kit.
Interactive: have participants put together demo naloxone kits

42. Give Naloxone: Intranasal
Push 1ml (1mg) of naloxone into each nostril
Administer the entire contents of the 2ml syringe with approximately one half (1ml) administered in each nostril
Administering one half in each nostril maximizes absorption

44. Auto-injector Naloxone
Each auto-injector contains only 1 dose
Inject into muscle or skin of the outer thigh
Can be injected through clothing if needed
Device injects intramuscularly or subcutaneously, delivers the naloxone, and retracts the needle fully into its housing
Needle not visible before, during, or after
Key Point: Benefits of intranasal naloxone

45. Auto-injector Naloxone
Practice with the Trainer to make sure you are able to safely use the auto-injector in an emergency
The Trainer does not contain a needle or medicine
It can be reused to practice your injection
The red safety guard can be removed and replaced on the Trainer
Key Point: Benefits of intranasal naloxone

46. Give Naloxone: Auto-injector
Review how to put together naloxone kit.
Interactive: have participants put together demo naloxone kits

47. Give Naloxone: Auto-injector
Review how to put together naloxone kit.
Interactive: have participants put together demo naloxone kits

48. Give Naloxone: Auto-injector
Review how to put together naloxone kit.
Interactive: have participants put together demo naloxone kits

49. Give Naloxone: Auto-injector
Review how to put together naloxone kit.
Interactive: have participants put together demo naloxone kits

51. How does a person respond to Naloxone?
Scenarios:
Gradually improves breathing and becomes responsive within 3 – 5 minutes
Immediately improves breathing, responsive, and is in withdrawal
Starts breathing within 3 – 5 minutes but remains unresponsive
Does not respond to first dose and naloxone must be repeated in 3 – 5 minutes (keep rescue breathing)
Very often those who become responsive won’t immediately realize they just overdosed

52. Reactions to Naloxone
Post-Naloxone Withdrawal Symptoms in First Responder Rescues:
Total
None
47 (40%)
“Dope Sick”
27 (23%)
Irritable or Angry
33 (28%)
Physically Combative
6 (5%)
Vomiting
16 (14%)
Other
14 (12%)
Key Point: Although many are concerned about severe withdrawal where the victim becomes physically combative, this is uncommon. The risk of combativeness can be reduced by administering only enough medication to re-start breathing.

53. After Administering Naloxone
Continue rescue breathing with 1 breath every 5 seconds until emergency responders arrive
After 3-5 minutes, if the patient is still unresponsive with slow or no breathing, administer another dose of naloxone
Key Point: Continue rescue breathing, if still unresponsive and EMS has not arrived administer second dose of naloxone after 3-5 minutes

54. If victim is breathing, but unresponsive place in recovery position
If for any reason the victim needs to be left along place in recovery position

55. Naloxone Storage Intranasal: Storage between 59 degrees to 86 degrees.
Avoid extremes in temperatures for long periods of time
Replace every 6-12 months, before expiration date
Auto-injector: 59°F to 77°F (15°C to 25°C)
Temperature excursions are permitted between 39°F and 104°F
Keep in outer case until needed
If solution through viewing window is discolored, cloudy, then replace
Replace before expiration date
Keeping inventory is important. Narcan has month shelf life
Storage in recommended temperatures is important

56. Naloxone Deployment Options
Vehicles, front desk, booking area, holding area
Vehicle glove compartment
Vehicle pelican case
Attached to AED case in passenger compartment
First in bag
Issued per shift
Issued per officer
Keeping inventory is important. Narcan has month shelf life
Storage in recommended temperatures is important

57. Questions and Answers Will Naloxone work on an alcohol overdose?
No. Naloxone only works on opioids
What if it is a crack/cocaine or speed/methamphetamine overdose?
What is the risk period for an overdose to reoccur after giving Naloxone?
Depends on how long acting the opioid is and how much they took
If the person isn’t overdosing and I give them Naloxone will it hurt them?
No. If in doubt give naloxone.
Answers:
Will be effective for opioid aspect only - if opioids were also used

58. What if a person refuses care and transport after Naloxone is administered?
Inform the person of the risk of re-overdosing
Inform the person naloxone is only temporary
If person still refuses consider the mechanism of injury or Illness
Do you believe he/she can refuse treatment with a sound mind and clear understanding of the circumstances? Remember they just overdosed!
If no, the person can not refuse treatment

59. Reminder
Naloxone is not a controlled substance but is a regulated substance (a prescription medication) that requires a licensed prescriber
We will go over how to comply and obtain a prescription a little bit later in presentation

60. Good Samaritan & Naloxone Law
Passed August 2012
Review that improving 911 call rates and the relationship between public safety and the people who are using is one of the strategies to address overdose.
Law enforcement play a key role in encouraging people to call for help.
The fact that people do not call for help is one of the reasons people are dying, so we want to address this specifically.

61. OEND program rescues: 2006-2013
Active use, in treatment, in recovery N=2,052
Non-User (family, friend, staff)
N=195
911 called or public safety present
33%
60%
Stayed until alert or help arrived
90%
93%
67% users
33% non-users
Program data
Alex Walley Fellows Report
Alex Walley Fellows Report 61 61

62. Encouraging people to call for help
First responders play a key role
Bystanders not calling is one of the reasons people are dying
Fear of public safety reduces 911 call rates
Interactions at overdose scenes with people who use drugs can reduce fear of public safety
Review that improving 911 call rates and the relationship between public safety and the people who are is using is one of the strategies to address overdose.
Law enforcement play a key role in encouraging people to call for help.
The fact that people do not call for help is one of the reasons people are dying, so we want to address this specifically.

63. Acts of 2012, Chapter 192, Sections 11 & 32

64. (d) Naloxone or other opioid antagonist may lawfully be prescribed and dispensed to a person at risk of experiencing an opiate-related overdose or a family member, friend or other person in a position to assist a person at risk of experiencing an opiate-related overdose. (emphasis added)
Third party prescribing is permitted

65. (a) A person who, in good faith, seeks medical assistance for someone experiencing a drug-related overdose shall not be charged or prosecuted for possession of a controlled substance under sections 34 or 35 if the evidence for the charge of possession of a controlled substance was gained as a result of the seeking of medical assistance.
(b) A person who experiences a drug-related overdose and is in need of medical assistance and, in good faith, seeks such medical assistance, or is the subject of such a good faith request for medical assistance, shall not be charged or prosecuted for possession of a controlled substance under said sections 34 or 35 if the evidence for the charge of possession of a controlled substance was gained as a result of the overdose and the need for medical assistance.
Protects both victim and bystander who called for help

66. (c) The act of seeking medical assistance for someone who is experiencing a drug-related overdose may be used as a mitigating factor in a criminal prosecution under the Controlled Substance Act,1970 P.L , 21 U.S.C. section 801, et seq.
(d) Nothing contained in this section shall prevent anyone from being charged with trafficking, distribution or possession of a controlled substance with intent to distribute.
(e) A person acting in good faith may receive a naloxone prescription, possess naloxone and administer naloxone to an individual appearing to experience an opiate-related overdose.
- Doesn’t exclude search for existing warrants

67. Thank You

68. Go to givenaloxone.org for an online module for first responders (EMTs, firefighters, and law enforcement officers) with post-test
Note that there has been a significant amount of publicity around this topic recently, but that it has been going on for years.
Interactive: Ask participants to share their own experiences and interactions with people who use opioids