1. Maryland Opioid Overdose Response Program Training for Potential Bystanders Behavioral Health Administration Department of Health & Mental Hygiene dhmh.naloxone@maryland.gov March 2015 Baltimore City

2. Program Overview 2 I.Understanding Opioids II.Recognizing an Opioid Overdose (OD) III.Responding to an Opioid OD IV.Preventing Opioid OD V.Information & Resources VI.Receive Certificate and Kit

3. Overdose Deaths Overdose deaths have increased nationwide. In Baltimore City, most overdose deaths involve an opioid (like prescription pain medications or heroin). Naloxone (Narcan) is a medicine that can reverse an opioid overdose. 6/11/2016 Maryland ORP Core Curriculum 3

4. Context: Maryland 6/11/2016 Maryland ORP Core Curriculum 4 Source: Maryland Department of Health and Mental Hygiene. Drug and Alcohol Intoxication Deaths in Maryland, 2014. http://bha.dhmh.maryland.gov/OVERDOSE_PREVENTION/Documents/2015.05.19%20- %20Annual%20OD%20Report%202014_merged%20file%20final.pdfhttp://bha.dhmh.maryland.gov/OVERDOSE_PREVENTION/Documents/2015.05.19%20- %20Annual%20OD%20Report%202014_merged%20file%20final.pdf

5. Context: Baltimore City 6/11/2016 Maryland ORP Core Curriculum 5 Source: Maryland Department of Health and Mental Hygiene. Drug and Alcohol Intoxication Deaths in Maryland, 2014. http://bha.dhmh.maryland.gov/OVERDOSE_PREVENTION/Documents/2015.05.19%20- %20Annual%20OD%20Report%202014_merged%20file%20final.pdfhttp://bha.dhmh.maryland.gov/OVERDOSE_PREVENTION/Documents/2015.05.19%20- %20Annual%20OD%20Report%202014_merged%20file%20final.pdf

6. 6 What is an Opioid?

7. Opioids Natural or synthetic drug containing opium (or by- product) Both prescription medications & illegal/street drugs Several forms of drug + routes of administration Manage pain; suppress coughs; treat opioid dependence Effects = euphoria, contentment, detachment Stays in body on avg. 3 to 24 hours 7 Opioids can suppress a person’s urge to breathe.

8. 8 Hydromorphone Dilaudid Oxymorphone Opana Hydrocodone Vicodin Lortab Lorcet Zohydro ER Common Opioids Oxycodone OxyContin Percocet Roxicodone Methadone Morphine Meperidine Demerol Fentanyl Buprenorphine Suboxone Subutex Codeine Tylenol ® 3 and 4 Heroin

9. 9 Recognizing an Opioid Overdose

10. Amount of opioid used—alone or mixed with other substances—overwhelms body’s ability to handle it Often from mixing w/ benzos, cocaine, alcohol How? Lack of enough oxygen in the blood  Organ failure  Unconsciousness, Coma, Death Surviving an opioid OD = Breathing + Oxygen 10 OD can be from using any opioid for any reason

11. Signs & Symptoms of Opioid OD  Loud snoring or gurgling noises  Body very limp  Not responsive  Skin pale/gray, clammy  Lips/fingertips turn blue or gray  Pulse slow or erratic  Breathing very slow, shallow, or not at all  Unconscious Maryland ORP Core Curriculum 11

12. Responding to an Opioid OD 1.Rouse and Stimulate 2.Call 9-1-1 3.Give naloxone (Narcan) 4.Assist breathing 5.Care for the Person 12

13. Step 1: Rouse & Stimulate Noise: Shake person’s shoulders and yell: “[Name!] Are you all right? Wake up!” 13 sternal (sternum) rub Pain: If no answer, do a sternal (sternum) rub: Make a fist, rub your knuckles firmly up and down the breast bone.

14. Step 2: Call 9-1-1 Why call for help? – Complications or other health problems – Naloxone effect is temporary (30-90 mins) – May need to give additional dose. – May be a non-opioid OD situation. 14  Tell 9-1-1 operator: Where you are Person not breathing or not responsive  Tell emergency responder on site: Drugs/substances person used How much naloxone given, when

15. Good Samaritan Law Gives you some legal protections if you seek and/or provide medical assistance (i.e. Call 911) for someone experiencing an OD: Immunity from arrest for certain minor crimes*, if the evidence was obtained solely as a result of your actions in trying to aid the victim. Immunity extends to OD victim *Drug-related misdemeanors only *Does protect against felonies or loss of other benefits (e.g. financial aid, immigration) 15

16. 16 Step 3: Give Naloxone

17. Naloxone (Narcan®) restoring breathing Reverses opioid OD, by restoring breathing – No effect on someone who has not taken opioids Wears off in 30 - 90 minutes – Works by temporarily knocking opioids off receptors in brain No potential for abuse or getting high Side effects minimal and rare Safe for children + pregnant women Intranasal (“nasal”), Intramuscular, or IV 17

18. How To Administer Nasal Naloxone Step 1: Step 1: Remove 2 yellow caps from syringe Step 2: Step 2: Screw nasal atomizer into top of syringe Step 3: Step 3: Remove cap from vial Step 4: Step 4: Twist naloxone vial into syringe until it “catches” 18 Atomizer Needle-less syringe (delivery device) Naloxone vial 1mg/1mL

19. 19 Administering Nasal Naloxone, cont’d Step 5: Step 5: Tilt back the head so naloxone does not run out of nose. Maryland ORP Core Curriculum Step 6: Spray one-half Step 6: Spray one-half (1cc) of the naloxone up each nostril.

20. Administering Nasal Naloxone, cont’d 20 Step 7: Step 7: Begin rescue breathing while you allow 1- 3 minutes for naloxone to work. Step 8:give a second dose of Step 8: If no breathing after 2-3 minutes, give a second dose of naloxone. Step 9: Continue rescue breaths until person wakes up or EMS arrives.

21. Step 4: Rescue Breathing If person not breathing, or breath is shallow or short,  Give rescue breaths right away and/or  Follow 9-1-1 dispatcher’s instructions Continue breaths until person wakes up or medical help arrives. 21 If no naloxone or waiting for it to work… Rescue breathing Rescue breathing is the quickest way to get oxygen into the body.

22. Maryland ORP Core Curriculum 22 Rescue Breathing – Step by Step Step 1: Step 1: Lay the person on his/her back on a flat surface. Step 2: Step 2: Tilt the chin to open the airway. Step 3: Step 3: Remove anything blocking the airway.

23. 23 Step 4: Step 5: Blow 2 regular breaths (chest should rise) Step 4: Pinch person’s nose closed completely. Step 5: Blow 2 regular breaths (chest should rise) Step 6: Breathe again: 1 breath every 5 seconds. Rescue Breathing – Step by Step

24. Step 5: Care for the Person Stay until medical help arrives Stay until medical help arrives. recovery position If breathing, put person in recovery position. After receiving naloxone, person may experience unpleasant withdrawal symptoms (not life-threatening) Encourage person not to take more opioids for a while. If overdose re-occurs, give another dose 24

25. “Old School Remedies” that can cause harm: (aka how not to respond) Anecdotal Remedy Possible Consequence Use ice to cool down body→ Slowed heart rate, arrhythmia, frost bite Put person in bath/shower → Drowning Hit/slap/burn fingers/feet → Bruising, broken bones, infection, amputation Give drink; induce vomiting → Choking to death Inject person w/ cocaine, → High blood pressure, infection salt water, milk, epinephrine 25

26. Recovery Position recovery position If you have to leave the person—even briefly—put him/her into the recovery position. Maryland ORP Core Curriculum 26 Bent knee supports body Hand supports head Face & body turned to side airway clear prevents choking This keeps the airway clear and prevents choking if vomiting occurs.

27. 27 Used your naloxone to save a life? Call the MD Poison Center: 1-800-222-1222 and contact training entity that issued certificate *all info will be kept confidential*

28. Naloxone Storage & Disposal Storage: Keep in clean package until ready to use Room temperature; avoid exposure to light Store in a safe but easy to access location Expiration: Check exp. date on label Effectiveness decreases after 2 yrs Disposal: This is medical waste and should be treated appropriately Sharps container; other hard, lidded container 28

29. 29 Preventing Opioid OD  Use with someone else  If you have not used in a couple days or more, use less opioids than you normally would. Greatest risk for OD after abstinence!  Create overdose prevention plan  Create overdose prevention plan  share plan w/ someone to give you Narcan if needed  Be extra careful if you have breathing problems (asthma; sleep apnea)  Try not to mix with other substances Ask doctor or pharmacist about potential interactions  Seek treatment for substance use issues, if willing.  Always keep naloxone on hand.

30. Today you will receive a certificate and a prescription for naloxone – A certificate ≠ a prescription Certificate expires after 2 years – Keep certificate in a safe place. It provides legal protections. For another free kit: – 410 396-3731 (Baltimore City Health Dept.: Staying Alive) – 410-637-1900 (Behavioral Health System Baltimore [BHSB]) Can fill script for naloxone at any pharmacy Can take certificate to a doctor or NP for another prescription More resources in handout 30 Information & Resources

31. What We Learned 31 I.What are Opioids II.What is an Opioid OD III.How to Respond to Opioid OD - 5 steps IV.Tips to Prevent Opioid OD V.Information & Resources