1. Overdose Prevention and Naloxone Training
Amanda Muller and Ji’ Lynda Brown
Florida Department of Children and Families
Office of Substance Abuse and Mental Health

2. Semi-Synthetic Opiates
Opioids
Natural Opiates
opium
morphine
codeine
Semi-Synthetic Opiates
heroin
hydromorphone
hydrocodone
oxycodone
Fully Synthetic Opioids
fentanyl
methadone
Not exhaustive list, just some examples of opioids

3. Harm Reduction AKA risk reduction Meet people where they’re at
Ask people what they need
Provide access to tools/services to enable people to make safer/healthier choices
Harm reduction AKA risk reduction
Seatbelts, sunscreen, fire extinguishers, we use harm reduction in our lives all the time
Safe sex education good example of harm reduction. We are not encouraging people to have sex by teaching sex edu. We know that when young kids receive abstinence ONLY sex edu they still have sex, don’t know how to protect themselves, and as a result have higher rates of unintended teen pregnancies and STDs.
Providing naloxone to people who might overdose is harm reduction. Does not condone drug use. Realistic that people use drugs and we want to keep people alive and as healthy as possible until they are ready to stop (if ever).

4. Harm Reduction

5. Naloxone FDA approved Opioid Overdose ONLY Rx med EMS Use for 40 years
Opioid antagonist
Not MAT
Opioid Overdose ONLY
Not MAT which treats opioid use disorder, this just treats acute opioid OD
Not a new drug, new concept for FL is making it available to non medical people (people who use drugs, friends/family, law enforcement, etc.)
Epi pen for opioid OD
Only works on opioid ODs, but a lot of ODs are a combination of drugs. So if someone OD’d on heroin and alcohol, you can give them naloxone and it can reverse the heroin part of that OD and revive them.
Not psychoactive, if you have no opioids in your system, nothing happens. So if you don’t know what someone took but they look like they are OD, administer naloxone and call 911.

6. Naloxone Onset: Duration: 30-90 min. 2-3 min. Withdrawal Symptoms
After waking up from an overdose, a person must be educated to not use opioids while the naloxone is still in their system – they will get no effect. If the person refused medical care, they should at the very least not be left alone (friend or family member to stay with the person and monitor them, administer more naloxone and call 911 if they overdose again)

7. Intranasal and intramuscular naloxone products available (some generic, some brand name). Every naloxone kit comes with 2 doses.

8. Nasal naloxone works to reverse an overdose even if you are not breathing – it gets absorbed into the nasal mucosal membrane.
DO NOT test the dose or anything – only press the plunger once it’s in someone’s nostril and you are ready to administer. If you press this before you are ready to administer the entire dose will be wasted.

9. Opioids bind to mu receptors in your brain – the more receptors occupied by opioids, the more effects you feel (pain relief, intoxication, eventually respiratory depression and possible death)

10. Naloxone = opioid antagonist, so it kicks the opioids off of those brain receptors, occupies the receptors instead, and blocks opioids from reattaching. This is what revives someone during an OD, but also puts them into withdrawal.

11. Florida Overdose Prevention Laws
911 Good Samaritan Act
893.21, F.S.
Emergency Treatment and Recovery Act
, F.S.
FL 911 Good Sam Act:
Person who seeks help during overdose (calls 911 for example) and the person overdosing in need of medical assistance, only those 2 people, cannot be:
Charged or prosecuted for drug possession
Technically not protected from arrest in FL, but many law enforcement departments make it their policy to not arrest people at the scene of an OD
Good Sam laws get passed because someone is usually at an OD who can call 911, but in 50% of the time no one was seeking help, and the #1 reason is fear of arrest / fear of police involvement
Emergency Treatment and Recovery Act
FL naloxone law
Provides liability protections to prescribers and dispensers who prescribe and dispense naloxone to anyone at risk of experiencing an OD or witnessing one (3rd party rx – allowing friends/family/caregivers to access naloxone in the event they need to use it on someone else)
Also allows naloxone to be dispensed under standing orders (blanket / general prescriptions, don’t have 1st get a script from your DR)

12. How to Get Naloxone from Pharmacy
Call pharmacy FIRST and ask:
Do you have naloxone in stock?
Do I need a prescription for naloxone / does your pharmacy operate under a naloxone standing order?
How much will it cost?
I would like to request a naloxone kit – when should I pick it up?
All CVS and all Walgreens pharmacies in FL operating under naloxone standing orders – but many pharmacists working at these pharmacies still turn people away / are uninformed about their policy. Other pharmacies in FL that are not CVS or Walgreens may not be operating under standing orders so you would still need a prescription before being able to get it from those pharmacies.

13. Risk Factors for Overdose
Mixing Drugs
Quality of Drug
Low Tolerance
Using Alone
Mixing drugs amplifies each other’s effects (if you are mixing drugs, take a little less of each substance, space it out a bit, don’t use alone, have naloxone)
Quality of drug = much of the heroin supply laced with fentanyl or other stronger substances – don’t use alone, have naloxone, do a test shot before your full dose, especially if buying from a new dealer / new batch
Low tolerance = people leaving drug treatment or jail/prison who have been abstinent have a very low tolerance, with opioids it only takes about 3 days for your tolerance to get pretty low. You will not need as much of an opioid to get the same effect as you used to. If someone relapses after a period of abstinence, fatal overdose risk is very high due to low tolerance. If relapse occurs, do a test amount / use a small amount, have naloxone, don’t use alone / have someone check on you
Using alone = still a lot of stigma, many people relapse in secret / use behind locked doors. Try to find someone you can have check up on you and make sure naloxone is around

14. Signs of Opioid Overdose
Blue skin, lips, nails
Not breathing
Death rattle
Slow heartbeat
Pinpoint pupils
UNRESPONSIVE
Death rattle can sound like snoring, but person is actually not getting any oxygen
Main sign is that someone is unresponsive
DO NOT administer naloxone to someone who is just really high. Only give them naloxone if they are completely unresponsive.

15. What NOT to do “Sleep it off” Cold bath/shower Induce vomiting
Punch/kick
Give the person other substances (saltwater, stimulants, milk, etc.)
People resort to these types of reversal myths when they are not given proper overdose recognition and response training, when they are scared to call 911, and when they do not have access to naloxone
None of this will truly work if experiencing a fatal overdose - THE PERSON NEEDS NALOXONE to reverse the respiratory depression and allow them to start breathing again

16. Responding to an Opioid Overdose
Sternal Rub
Call 911
Naloxone / Rescue Breathing
Recovery Position

17. Check Responsiveness – Sternal Rub
Lay person on their back (make sure nothing in mouth/throat)
Make a fist with your hand, and press on chest of unresponsive person
If no response, call 911
Make sure nothing is in mouth/throat of the person (clear air passage)
Very quick test to check for responsiveness. Should replace putting someone in a cold shower, putting ice on them, etc., which take a lot of time, and every second the person is not getting oxygen is critical. If someone doesn’t wake up from a sternal rub in 5-10 seconds, immediately call 911.

18. Call 911 Person is unresponsive and not breathing
Clearly state address
“someone is not breathing / unresponsive”
Do not have to say it is a drug OD
Florida has a 911 Good Samaritan law that protects the person who calls 911 (caller/help-seeker) and the person overdosing (overdose victim) from charge or prosecution for possession of controlled substances, if the substances are found as a result of help-seeking for the overdose.

19. Give Narcan Spray 1 dose into 1 nostril
Continue rescue breathing while waiting for naloxone to take effect and EMS to arrive
If no response after 3 minutes, give 2nd dose in other nostril
Administer 1st dose, continue rescue breathing, if person not awake within 3* minutes then administer 2nd dose, continue rescue breathing, repeat until person wakes up, then put them in recovery position
*Each Narcan dose is 4mg of naloxone, which is VERY strong. There is a lot of hysteria about fentanyl ODs right now, saying it definitely takes multiple doses of naloxone to be revived or that naloxone doesn’t work at all. This is not necessarily true. It is common for more than 1 dose of generic intramuscular naloxone to be needed, so panicking saying multiple doses were needed when only 2 generic doses were given is a little misleading, as it is common to need 2 doses of generic products (which are not as strong). Narcan Nasal Spray is 4x the strength of generic naloxone products. Some people indeed do need more than 2 doses of generic naloxone. Since Narcan is very strong, it can cause more painful withdrawal symptoms. Sometimes we hear of people being revived with 2 Narcan doses, but it turns out to be that the person using Narcan being scared from the media reports and panicked and administered 2 doses, so 2 doses were probably not needed.
Another myth is that you can overdose on fentanyl simply by touching it – also NOT true. The stories in the news are usually someone who touched fentanyl but then also touched their eyes or mouth or accidentally inhaled it. The American Toxicology Association has refuted the claim that you can get enough fentanyl in your system to overdose simply by touching it.
When EMS arrives, inform them that you gave the person naloxone

20. Rescue Breathing Tilt head back, clear air passage Pinch nose
Open mouth
2 quick breaths, then 1 breath every 5 seconds
Chest should rise
Perform rescue breathing while waiting for naloxone to take effect or if you have no naloxone
Can do chest compressions or CPR if you are CPR certified (but we teach rescue breathing if someone is not breathing)
Meant to be done while preparing naloxone to be administered and after naloxone was administered while waiting for it to work since it takes a few minutes
If no naloxone at the scene, do rescue breathing or CPR/chest compressions until EMS arrive

21. Recovery Position Knee prevents person from rolling onto stomach
Never leave someone alone when they are overdosing or after they wake up from an overdose.
Knee prevents person from rolling onto stomach
Hand supports head

22. Naloxone Myth vs. Fact
Access to naloxone does NOT: Send the wrong message Encourage or increase drug use Prevent people from going to tx Cause violence
From 1996 – 2014, over 26,000 OD reversals have been recorded in the US. These reversals are from community naloxone programs, and the reversals are from active drug users and friends/family. The 26,000 reversals does not include reversals by EMS or law enforcement. Only message naloxone sends is that we value your life. OD deaths are completely preventable even if you use opioids multiple times a day every day.

23. Settings for Naloxone Distribution
Upon release from jail/prison (increased OD risk)
Waiting list/assessment/enrollment/discharge from tx (increased OD risk)
Hospital EDs
Community paramedicine
Community-based organizations
Harm reduction programs
FQHCs/CHDs
Not exhaustive list, but targeted examples on settings where take-home naloxone kits should be distributed to at risk people and their friends/family
Orange County Jail in Orlando is providing Narcan to inmates upon release who agree to take a kit
Many treatment centers now providing take-home naloxone kits to their patients upon assessment, enrollment, discharge, etc. Also for people on waiting lists to receive treatment.

24. DCF’s Narcan Program
Florida State Hospital purchases and ships Narcan Nasal Spray to approved organizations
Organizations must be:
Non-profit
Willing to hand out free Narcan kits directly to people at risk of overdose and to their friends/family that may witness an overdose
Some kits can be kept on-site for staff to use in case of emergency (overdose at facility, in parking lot, etc.)
Due to limited funding, Narcan kits are not for EMS, fire departments, or law enforcement agencies

25. DCF’s Narcan Program
Complete required forms in DCF Narcan Enrollment Packet
Identify pharmacy to receive shipments of naloxone
Identify a prescriber to sign a non-patient specific naloxone standing order
Create plan for who naloxone will be handed out to (standing order)

26. DCF’s Narcan Program Place Narcan orders as needed
Submit monthly reports
# kits distributed to at-risk people/family/friends
# overdose reversals reported
No identifying information
Ensure process for people to get replacement kits
Ex: Sticker on kits “if you need a free replacement, call/text/visit us at ________”

27. Amanda Muller
Overdose Prevention Coordinator
Ji’ Lynda Brown
Grant Coordinator, Partnership for Success