1. Opioid Public Health Crisis and the Contributing Factors and Solutions: Opioid Overdose Reversal Drug Narcan
Alaska Native Tribal Health Consortium
Substance Abuse Prevention Initiative
Jennifer Summers, Program Manager

2. ANTHC employees approximately 3K plus employees across the consortium and provides services to approximately 166,000 AN people statewide

3. Alaska Tribal Health System
Alaska Native Medical Center
15 BOD representing different regions
180 clinics, CHA
25 sub-regional, PA/NP/CHA
7 tribal hospitals, incl. ANMC
170k+ Alaska Native people statewide

4. Substance Abuse Prevention
The Substance Abuse Prevention Initiative works in collaboration with Tribes and Tribal Health Organizations to prevent substance use and dependence in the communities we serve and encourage enhancement of healthy, supportive community environments.

5. Substance Usage
Substance Use is any consumption of alcohol, drugs or substance. Substance Abuse is when someone continues to use drugs or alcohol even when it cause problems. Harmful Use is when substance use causes damage to a person’s health or wellbeing. Addiction is a chronic brain disease that cause a person to take drugs or alcohol repeatedly, despite the harm they cause
The terms substance Use, Abuse, and Dependence are being used more frequently. Sometimes these terms are used interchangeably, however each one has a specific definition, meaning, and purpose.
When somebody says “Substance Use” they are talking about the consumption (eating, drinking, inhaling) of any substance that we just talked about. While alcohol and illegal drugs are the most common type of substance, legal substances like tobacco, marijuana, and caffeine can all used.
“Substance Abuse” is when someone uses substances even when they cause problems. These problems can be trouble with school or work, issues with family, and problems with personal health. For example, continuing to use drugs knowing you’ll be fired from your job if you fail a drug test is a sign of abuse.
“Harmful Use” is when a frequent substance use causes damage to a person’s health and wellbeing. This damage may be physical such as getting infections after using a drug that is injected, mental damage such as having episodes of depression after a heavy night of drinking alcohol, or even financial by spending all their money on alcohol or drugs instead of necessary things. When someone has Harmful Use they usually also suffer from visual social consequences. Usually it is hard to know from looking at somebody if they are experiencing harmful substance use. Harmful effects of substance use can relate to a single occasion such as an overdose or an injury from being intoxicated, or from longer term issues such as health, social, legal, financial and emotional problems.
“Addiction” is a long-lasting brain disease that causes a person to keep taking drugs or alcohol even though they are causing them physical, mental, emotion, and other types of harm. The first time a person uses drugs, it’s usually a free choice. However, repeated drug use can change the brain, driving a person to seek out and use drugs over and over, despite negative effects such as stealing, losing friends, family problems, or other physical or mental problems brought on by drug use.

6. Stages of Use Addiction Dependence Continued Use Tolerance First Use
Difficult to stop using the substance
The substance and/or their behavior is causing serious life problems
Life-long disease that will take serious effort to heal
Addiction
Persons becomes physically sick when stopping the substance
Brain cannot function properly without the substance
Sign that addiction is taking hold
Dependence
First signs of addiction
Brain and body have adjusted to the substance
It now takes a greater amount of the substance to feel the effects
Tolerance
A perceived requirement or need for the substance
First feelings of not being able to “bounce back”
Continued Use
Experimentation
Peer Pressure
Prescription Use
Learn how a substance make you feel
First Use
Sometimes when we talk about substances disorders we can lump them all together. However, we have to remember that each substance has different effects, and just because someone may have tried one and not had a problem, that doesn’t mean they wouldn’t react to a different one. Just because someone you know may have tried a substance and reacted a certain way doesn’t mean that you will react that way too.
For instance, one person using alcohol can move through the stages in a relatively short time frame whereas another may use over the course of weeks or months or years until they reach addiction. It is important to know that you may be a person who is more likely to reach the end stages of addiction faster.
Addiction is a long-lasting brain disease that makes somebody need a substance in order to live their lives, even though using might cause serious, harmful consequences.
If you know the stages of addiction and can recognize behaviors as warning signs, you have the potential to help somebody from becoming addicted.
Stage 1: First Use includes the experimentation with alcohol or drugs, but it also includes taking medication that a physician prescribed for a specific issue. Whether the first use is out of a sense of adventure, peer pressure or medical necessary, this is when a person can learn how the substance makes them feel.
Stage 2: Continued Use of a substance, in the case of a person with a prescription, might be out of a requirement or feeling the need to use the medication. For an individual that experimented not too long ago and returned to the substance, it’s a little more clear how that substance makes them feel and they want to experience that again. During this stage, a person is likely to notice that they’re not bouncing back as quickly after getting “high.” This is because it’s taking the brain longer to chemically repair itself and return to normal balance.
Stage 3: Tolerance arrives after a period of continued use, the duration of which varies among individuals and whatever substance they are using. This is one of the first signs of addiction. Tolerance means the brain and body have adjusted to the drug and it now takes a greater amount of it to feel the effects of it. A person that’s developed a tolerance to a prescription painkiller their doctor prescribed might start to notice that the same dosage no longer takes care of their pain.
Stage 4: Dependence, as we talked about earlier, is the stage when person who is taking the substance becomes physical sick when they stop taking it. Chemically, the brain has become accustomed to the substance and does not function well without it. This also presents physical, sending a person into withdrawal where they can experience flu-like symptoms or sweats and shakiness. With dependence to drugs or alcohol, people don’t feel “normal” if they’re not using. This stage is a sign that addiction is taking hold.
Stage 5: Addiction.. During this final stage, people find it nearly impossible to stop misusing drugs or alcohol even when they no longer enjoy it or their behavior has caused serious life problems. They might last for periods of time where they don’t use drugs or alcohol (this is when a person is in recovery), but at this stage addiction will always be a life-long disease and will take serious effort to overcome further use.
There are variations within the stages that are unique to every person. For instance, a heavy drinker with a tolerance to alcohol might never develop dependence or addiction, while others might quickly pass through each stage.

7. Stigma & Language Words to Avoid Words to Use
Drug Habit, Alcoholic  Substance Use Disorder Junkie, alcoholic, etc.  Person with Substance Use Disorder Drug abuse  Substance Misuse Former addict  Person in Recovery
Illicit drug use is the most stigmatized health condition in the world, surpassing HIV. This is because for the past several decades’ society has seen drug use and misuse as a personal choice and not a disease or health condition.
The words we use to describe people or actions can have serious indications and consequences. A recent study found that people who heard the term “drug abuser” or “addict” felt that the person experience these disorders where more likely to be socially threatening and less likely to be able to benefit from treatment.
By replacing words that have socially negative implications with words that are associated with health conditions we can reduce the stigma and help individuals towards a path to recovery.
Words to replace include:
Drug abuser, addict  Person who uses substances
Junkie, crackhead, pothead, druggie, stoner, alcoholic  Person with substance use disorder
Drug abuse  Substance misuse
Former addict, alcoholic  Person in recovery
Addiction  Substance Use Disorder

8. Opioid Epidemic
Alaska has seen a dramatic increase in the use of opioids and with it:
Transmission of long-term viral infections (HIV, Hepatitis C and B)
Bacterial infections of the skin, bloodstream and heart
Death due to overdose
Neonatal Withdrawal Syndrome due to prenatal exposure
The # of people who have used heroin in the past year increased 4x between and
The number of heroin-associated deaths more than tripled between
The rate of Neonatal Withdrawal Syndrome increased more than 5x between
In 2014, 77 Alaskans died of opioid (prescription and heroin) overdose and 783 Alaskans were treated for opioid addiction.
In 2012, Alaska prescription opioid pain reliever overdose death rate was more than 2x the national rate.
While most harm reduction strategies focus on preventing the transmission of viral and bacterial infections, Opioid Rescue training focuses on preventing the most serious of harms, death.
In the United States, including Alaska, has seen a dramatic increase in the use of opioids. Because of these there has also been an increase in:
- Transmission of long-term viral infections such as HIV, Hepatitis C and B
- Bacterial infections of the skin, bloodstream and heart
- Neonatal Withdrawal Syndrome due to prenatal exposure
- Death due to overdose
The opioid epidemic is impacting individuals, families and entire communities. While you may not personally know, or be aware, that somebody is suffering from a substance use disorder, it is important to be aware that this epidemic is impacting people all over the state.
In order to help fight the opioid epidemic and the risk associated, ANTHC partners with the State of Alaska and Tribal Health Organizations to provide harm reduction strategies.

9. The Opioid Epidemic
To update:
By partnering with the State of Alaska, detailed data is able to be regularly reported and pulled that can help us further understand the opioid epidemic.
From October 2018 to the end of October 2019, there were 73 reported deaths due to opioid overdose in Alaska. While this number may not seem drastic, keep in mind these are only reported deaths, or ones were the cause of death was clearly due to overdose. The number of overdose deaths in Alaska each year is most likely much higher.
This scorecard can also show us other useful information such as the number of arrests due to opioids, the number of health care providers who are using the Prescription Drug Monitoring Program, as well as the number of opioid overdose response kits and medicine disposal bags that are being distributed throughout Alaska.

10. What Are Opioids? Generic Name Trade Name Street Name Hydrocodone
Lortab, Vicodin
Hydro, Norco, Vikes, Watsons
Oxycodone
Oxycotin, Percocet
Ox, Oxy, Oxycotton, Kicker, Hilbilly Heroin
Morphine
Kadian, MSContin
M, Miss Emma, Monkey, White Stuff
Codeine
Tylenol #3
Schoolboy, T-3s
Fentanyl
Duragesic
Apache, China Girl, China White, Goodfella, TNT
Carfentanil
Wildnil
Drop Dead, Flatline, Lethal Injection, Poison, TNT
Hydromorphone
Dilaudid
Dill, Dust, Foodballs, D, Big-D, M-80s, Crazy 8s
Oxymorphone
Opana
Blue Heaven, Octagons, Pink, Pink Heaven
Meperidine
Demerol
Dillies, D, Juice
Methadone
Dolophine, Methadose
Junk, Fizzies, Dolls, Jungle Juice
Heroin
Diacetylmophine
Dome, Smack, Big H, Black Tar, Dog Food
Buprenorphine
Bunavail, Suboxone, Subutex, Zubsolv
Sobos, Bupe, Stops, Stop Signs, Oranges
Opioids are a class of drug that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription. Take a moment to look at this list of opioids, making sure to note the slag terms used for each type of opioid. It’s important to at least be aware of the other names associated with each opioid so you, as a response personal, are aware of what substance a person might be overdosing on.

11. Harm Reduction
Harm reduction is a respectful non-judgmental approach to reducing harms of drug and alcohol use that meets people “where they are at”.
Harm reduction is a set of ideas and interventions that seek to reduce the harms associated with both drug use and drug policies. It is a respectful non-judgmental approach to reducing harms of drug and alcohol use that meets people where they are at.
It is important to recognize how Alaska Native culture can work as a type of harm reduction strategy. In addition to modern harm reduction resources, cultural and traditional practice such as dancing, singing, hunting, cooking, and storytelling can play a huge role in helping lower substance use disorders and providing harm reduction strategies. Indigenous harm reduction incorporates cultural teachings and values while encouraging conversations around substance use disorder and harm reduction in a manner that is sensitive and appropriate for Alaska Natives.
There have been multiple studies that have evaluated harm reduction approaches and have found them to be not only effective and preventing future harm but provide avenues for collaboration and treatment.

12. Occupational / Financial Harms
Drug Related Harms
Infections– abscess, HIV, STIs
Poor nutrition, weight loss
Overdose, death
Physical Harms
Absenteeism from work
Frequent change of jobs, loss of job
Losses suffered / debts incurred
Occupational / Financial Harms
Separation, divorce
Loss of reputation, social outcast
Stigma and discrimination
Family / Social Harms
Guilt, shame, lack of motivation
Depression, anxiety
Other mental disorders
Psychological Harms
Involvement in illegal activities
Arrests, imprisonment
Drug dealing
Legal Harms
There are several types of harms that can occur to a person when they use substances. While physical harms are usually the most noticeable in a person it is important to be aware of the other types of harms that substance use can bring. Job loss, loss of reputation, depression, and imprisonment are all common harms that we need to recognize are happening to being who misuse substances

13. ANTHC Harm Reduction Strategies
Community resources
Trainings, Education Lessons, Condom Distribution, Peer Support
Prescription Drug Monitoring Program
Harm Reduction Kits
Medication Storage and Disposal
Opioid Overdose Rescue and Narcan® Training
Both The State of Alaska DHSS and ANTHC work closely with partners around the state to provide harm reduction strategies to individuals in need. These types of strategies include Community Resources such as trainings, providing harm reduction kits, and condom distribution, Medically Assisted Treatment using methadone or other prescribed medications, Safe Medication Disposal Bags that safely deactivate prescription drugs, as well as Opioid Overdose and Narcan® Training, which is what we are all here for today.

14. Harm Reduction Kit
The kit was developed to address substance use- related harms - such as HIV, Hepatitis C and drug overdose - in rural Alaska communities.

15. Medicine Storage & Disposal
Medication Storage Devices
Medication Disposal Sites
Medication Mail Back Bags
Medication Disposal Products
In 2017, there were 102 overdose deaths involving opioids throughout the state of Alaska– a rate of 13.9 per 100,000 persons. Prescription opioids (like hydrocodone, oxycodone, and morphine) are prescribed by doctors to treat moderate to severe pain, however they have serious risks and side-effects including dependency, addiction, overdose, and accidental poisoning. In order to protect ourselves and our loved ones from these risks we have to practice safe medicine storage and proper medicine disposal.
Safe Medicine Storage Includes:
Keeping medications in original containers, which should have a label with the name of person prescribed, medication name, instruction for use, and expiration date.
Keeping medication out of reach of children, and if necessary in locked boxes
Keeping refrigerated medication separate from food
Safe Medication Disposal includes:
Neutralizing medicine using drug deactivation bags or buckets
Returning unused medications to your local pharmacy
Participating in medication mail back programs
The medication deactivation bags provided FREE by ANTHC are effective in deactivating drugs and are safe to throw away in your local landfill or dump. Using these bags is a great solution to safely dispose of old, expired, or unused medicines an can easily be implemented in rural, remote villages or urban areas.

16. Safe Medication Disposal Bags & Buckets
ANTHC provides free medicine disposal supplies
Small (SM) bags
Medium (MP) bags
XL bags
3.5 and 5-gallon buckets
Buckets are encouraged for community “take- back” events

17. Benefits Proven mechanism in deactivating drugs
Narcotics
Antibiotics
Transdermal patches, pills and liquids
Proprietary activated carbon renders drugs non- retrievable
Works on all organic compounds
Reduces accidental medical emergencies
Eliminates the need for harmful incineration
Renders chemical compounds safe for landfills
Prevents youth from accessing unused and expired medication

18. How To Use the Bags
Pills, Liquids, and Patches

19. I Know Mine www.iknowmine.org

20. Opioid Overdose Rescue and Narcan Training
Alaska Native Tribal Health Consortium
Substance Abuse Prevention Initiative
Taylor Holsinger, AmeriCorps VISTA

21. Opioid Overdose Rescue Kit
Instructions for use
2 doses of Narcan®
Face shield for rescue breathing
Rubber gloves
In 2016, Alaska passed legislation SB23 which aimed to help reduce barriers associated with overdose rescue by providing a standing prescription for free lifesaving medication, Narcan. Through this legislation, The State of Alaska Department of Health and Social Service developed a statewide Opioid Response Program called Project HOPE, this program allows public and private entities the ability to distribute, dispense, and administer Project HOPE’s opioid overdose Rescue Kits.
The Opioid Overdose Rescue Kits, which all of you will walk away with at the end of this training, contains several items…
- Instructions for use: even though we will be going over each step, this instruction guide can serve as a refresher if needed
- 2 doses of Narcan® which is an opioid overdose-reversing drug
- A face-shield for rescue breathing
- 1 pair of latex-free rubber gloves
We’ll go over why and how to use each of these items.

22. How Naloxone Works Opioids being knocked free of receptors Naloxone
Naloxone has a stronger attraction to the brain’s opioid receptors than the opioid. It knocks the opioid/heroin off the receptors for a short time, letting the person breathe again.
The human brain has lots of opioid receptors. An overdose occurs when too much of an opioid fit on too many receptors. When these receptors are blocked by opioids, the brain’s signal is disrupted, stopping a person’s breathing.
Naloxone’s bond to the brain’s opioid receptors is stronger than the bond of opioids. When a person is given Naloxone, it travels to the brains receptors and knocks the opioids off the receptors for a short time.
By removing the opioids from the receptors, Naloxone blocks the effects of the opioid overdose, allowing the person to breathe again.
Opioid receptor in the brain

23. How Naloxone Works
Naloxone blocks and reverses the effects of opioids.
Naloxone has no potential for abuse
Naloxone’s use is supported by many national organizations
Again, Naloxone knocks opioids off the brain’s receptors, in most cases this happens immediately, within 45 seconds. However, sometimes there are so many opioids latched onto the receptors that Naloxone takes longer to take effect, or a second dose is needed for extra effect.
Remember that Naloxone has no potential for abuse, it does not provide any time of high for any user, and even a person not experiencing can take it.
Naloxone is supported by many national organizations, including the Office of National Drug Control Policy and the World Health Organization. It has been used for decades to reverse opioid overdoses and save lives.

24. Recognizing an Opioid Overdose
Really High
Overdosed
Muscles become relaxed
Pale, clammy skin
Speech is slowed or slurred
Breathing is infrequent or has stopped
Sleepy-looking
Deep snoring or gurgling (death rattle)
Responsive to shouting, ear lope pinch, or sternum rub
Unresponsive to any stimuli
Normal heart rate and/or pulse
Slow or no heart rate and/or pulse
Normal skin tone
Blue lips and/or fingertips
The main difference between someone who is high and someone who is overdosing is that someone who is overdosing is UNRESPONSEVE. Other differences include:
*See Chart*
If a person shows any of these symptoms, especially lack of response to stimulus or no breathing/pulse, the person may be experiencing an opioid overdose emergency. Today you will learn how to use Narcan® to respond to an opioid overdose and saves someone’s life. It is important to remember that naloxone will only work to reverse an overdose that is the result of opioid use. It will have no impact on someone that has overdosed on alcohol, cocaine, benzos, or methamphetamine.

25. Opioid Overdose Risk Factors
Prior overdose
Reduced tolerance
Mixing drugs– combining opioids with other drugs including alcohol, stimulants or depressants.
Using alone
Variations in strength or quantity
Individual medical conditions
There are a number of risk factors that can place someone at increased risk for an opioid overdose. These include:
- Prior overdose
- Reduced tolerance—previous users who have stopped using due to abstinence, illness, treatment, incarcerations, etc.
- Situational tolerance
- Mixing drugs—combining opioids with other drugs including alcohol, stimulants or depressants. Combining stimulants and depressants do not cancel each other out
- Using alone
- Variations in strength/quantity or changing formulations (switching from quick acting to long lasting/extended release)
- Medical conditions such as chronic lung disease or kidney or liver problems

26. Opioid Overdose Myths DO NOT put the individual in a bath.
DO NOT induce vomiting or give the individual something to drink.
DO NOT try and cool the individual down.
DO NOT try and stimulate the individual in a way that could cause harm.
DO NOT inject them with any substances or force them to eat or drink anything.
There are many myths about actions you can take to respond to an opioid overdose emergency. Here are some, and why you should NOT DO THEM.
Do not put the individual in an ice bath. They could drown
Do not induce vomiting or give the individual something to eat or drink. They could choke
Do not put the person in an ice bath or put ice in their clothing or in any bodily orifices. Cooling down the core temperature of an individual who is experiencing an opioid overdose emergency is dangerous because it can further depress their heart rate.
Do not try and stimulate the individual in way that could cause harm, such as shaking them, slapping them hard, kicking them, or other more aggressive actions that may cause long-term physical harm
Do not inject the individual with any foreign substance (salt water or milk) or other drugs. It will not help reverse the overdose and may expose the individual to bacterial or viral infection, abscesses, endocarditis, cellulitis, etc.

27. Opioid Overdose Emergency
Naloxone is the only effective response to an opioid overdose!
Reiterate that Naloxone is the only effective response to an opioid overdose.

28. Responding to an Opioid Overdose
Check for signs of an opioid overdose
Administer Narcan®
Call 911 or Emergency Assistance
Initiate rescue breathing (if needed)
Conduct assessment and respond appropriately
There are 5 key steps to take when responding to an opioid overdose. We will go into detail on how to conduct each steps. These steps are:
1. Check for signs of an opioid overdose
2. Administer Narcan®
3. Call 911 or Emergency Assistance
4. Initiate rescue breathing if needed
5. Conduct assessment and respond appropriately

29. Step 1: Check of opioid overdose signs
Put on gloves
Check for breathing and overdose signs
Try to stimulate the person
If the person does not respond or is not breathing, proceed to step 2
Put on gloves from Rescue Kit—it is important to keep yourself safe during an opioid overdose response. You may not be sure what substance were taken to result in an overdose. Substances like fentanyl can be deadly to you, if touched with bare skin.
Check for breathing. Put your ear to the person’s mouth and nose so that you can also watch their chest. Feel for breath and watch to see if the person’s chest rises and falls.
Try to stimulate the person. You can shout their name, tap their shoulder, or pinch their ear lope
Give a sternal rub. Make a fist and rake your knuckles hard up and down the front of the person’s sternum (breast bone). This is sometimes enough to wake the person up.
If the person does not respond or is not breathing, proceed with the next steps.’

30. Step 2: Administer Narcan®
Place the person on their back, tilting their head back
Administer the full dose of Narcan® into one nostril
Place the individual in the
Recovery Position
Narcan® is intranasal and easy to use. Place the person on their back, tilt their head back and spray the full dose into one nostril.
Once you have administered Narcan® roll the person onto their side and place them into the recovery position. This position keeps the person safe—preventing them from choking on their own vomit, or rolling and injuring themselves.

31. Step 3: Call 911 or Emergency Services
Speak calmly and clearly.
Give the exact address and location.
Tell them there is an overdose emergency and you have administered Narcan®
Complications may arise during an opioid overdose response including withdrawal. Calling 911 to request Emergency medical services is critical.
Speak calmly and clearly. State that someone is unresponsive and not breathing due to an overdose
Give the exact address and location. If you’re outside, use an intersection or landmark
When emergency assistance arrives, tell them it is an overdose and what drugs the person may have used, and what you have done so far to respond.
Please note that complications may arise during or as a result of an opioid overdose. Also, naloxone only work son opioids, and the person may have overdosed on something else. Calling 911 to request emergency medical services is critical. And remember, the Good Samaritan Law is in place to protect you. If somebody has already called for emergency assistance, proceed to Step 4.

32. Step 3: Initiate rescue breathing or CPR (if needed)
Roll the individual onto their back to begin rescue breathing
Administer 1 breath every 5 seconds for 3-5 minutes until EMS arrives
Brain damage can occur after 3-5 minutes without oxygen. Once you give Narcan®, it may take some time for it to be take effect, so the person may not start breathing on their own right away.
If the person has not started breathing on their own. Roll them onto their back, tilt their head back and lift their chin.
Place breathing mask on person’s face, covering their mouth and nose.
Pinch the person’s nose and give normal breaths—not quick or overly powerful breaths
Give one breath every five seconds for 3 minutes or until emergency assistance arrives.

33. Step 3: Conduct assessment and respond as needed
There are two cases in which you may need to administer a second dose of Narcan®:
If the individual has not responded to the initial dose within two minutes
If the individual has relapsed into an overdose again after having previously recovered with the initial dose
Most individuals will recover after a single dose of naloxone is administered. When this occurs the person will be in withdrawal, which may include abrupt waking up, vomiting, diarrhea, sweating and nausea. They may not remember overdosing. In rare cases, the person may recover into acute withdrawal, which in addition to the above, may include aggressive, combative, or violent behavior. Remember to keep yourself safe, and remove yourself from the scene if you believe you are in harm’s way.
There are two cases in which you may need to administer a second dose of Narcan®
1. If the individual has not responded to the initial dose within 2 minutes
2. If the individual has relapsed into an overdose again after having previously recovered with the initial dose

34. Opioid Overdose Response with Narcan®
VIDEO: watch from minute 1:00 to 2:00– shows checking for signs/symptoms, Narcan, and “rescue breathing”

35. Opioid Overdose Response Summary
Naloxone has a short working life once administered and a person can relapse
Calling for emergency assistance is critical
You cannot end your response with administering Narcan®
Naloxone has a very short half-life (30-45 minutes). In some cases, there is so much opioids in the system that the person can relapse back into overdose after naloxone has worn off.
- Calling 911 after administering Narcan® is vital. An individual who has overdosed needs to be assessed by medical professionals
- The administration of Narcan to an individual is not the last step in respond to an opioid overdose. Further attention an action is necessary.
- Resume rescue breathing/cpr if the person has not started breathing on their own

36. ANTHC
Substance Abuse Prevention