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First Responder Overdose Response Training In collaboration with the Massachusetts Department of Public Health, Bureau of Substance Abuse Services and Office of HIV/AIDS Go to getnaloxonenow.org for an online module for first responders (EMTs, firefighters, and law enforcement officers) with post-test The Overdose Problem By 2010, drug overdose deaths outnumbered motor vehicle traffic deaths in 31 states CDC NVSS, MCOD. 2010 More deaths from drug overdose In 2012, 13 Massachusetts residents died each week from drug overdoses 4 National & regional drug threat Source: DEA National Drug Threat Survey, 2015 Prescription opioid sales, deaths and treatment: 1999-2010 National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009 Fentanyl Fentanyl: a synthetic short-acting opioid 40-50x more potent than pure heroin Illicitly manufactured fentanyl is sold in the illicit market often mixed with heroin and/or cocaine as a combination product — with or without the user’s knowledge — to increase its euphoric effects Fentanyl-related overdoses can be reversed with naloxone, however a higher dose or multiple number of doses per overdose event may be required due to its high potency http://emergency.cdc.gov/han/han00384.asp Fentanyl Seizures Current Statistics 2016, the number of fentanyl-related deaths continues to increase. Among the 439 individuals whose deaths were opioid-related in 2016 where a toxicology screen was also available, 289 of them (66%) had a positive screen result for fentanyl. http://www.mass.gov/eohhs/docs/dph/quality/drugcontrol/county-level-pmp/opioid-related-overdose-deathsamong-ma-residents-august-2016.pdf Learning Objectives 1. Understand the overdose crisis 2. Know how opioids work and overdose risk factors 3. Recognize an opioid overdose 4. Respond to opioid overdose 5. Review Good Samaritan/Naloxone Law Passed August 2012 6. Comply with the emergency regulations Passed March 2014 13 https://www.whitehouse.gov/ondcp/national-drug-control-strategy Police and Fire naloxone rescues in MA 2010-2015 Massachusetts DPH First Responder Pilot Rescues and deaths, 2010-2015 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 How Opioids Work and Overdose Risk Factors •There were ads in papers and journals for Bayer’s many products, including aspirin and heroin. 18 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. Opioids Natural Opiates Semi-Synthetic Opiates Fully Synthetic Opioids opium morphine codeine heroin hydromorphone hydrocodone oxycodone fentanyl methadone 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 semisynthetic All categories have overdose risk hours opium opium morphine morphine codeine codeine days heroin heroin hydrocodone hydrocodone oxycodone oxycodone fentanyl fentanyl methadone methadone Demerol Demerol How do opioids affect breathing? Opioid Opioid Receptors How Overdose Occurs • Slow Breathing • Breathing Stops • Lack of oxygen may cause brain damage • Heart Stops • Death What is Narcan® (naloxone)? Narcan knocks the opioid off the opioid receptor, blocking opioid receptors from the opioid 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: • • • nausea/vomiting diarrhea chills • • • muscle discomfort disorientation combativeness How does Narcan affect overdose? What is an Opioid OD? Naloxone Reversing Overdose 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 Medications for Opioid Overdose and Treatment • Narcan® = naloxone • Reverses opioid overdose • Short and fast-acting opioid blocker No street value because they cause • Vivitrol® = naltrexone • Treatment for opioid and alcohol addiction withdrawal symptoms • Long-acting opioid blocker • Suboxone® = buprenorphine + naloxone • Treatment for opioid addiction Street • The naloxone is added to discourage injecting or value sniffing because they can relieve • Subutex® = buprenorphine only withdrawal symptoms • Treatment for opioid addiction in pregnant women • Methadone aka dolophine and methadose • Treatment for opioid addiction or pain 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 Administering Naloxone Reminder • Naloxone is not a controlled substance but is a regulated substance (a prescription medication) that requires a licensed prescriber Office of Emergency Medical Services Pre-Hospital Statewide Treatment Protocols Currently includes only Multi-Step and Auto-Injector http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols2015-1.pdf 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 WEAR GLOVES: Assume all body fluids present a possible risk for infection 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 Just high/overmedicated vs. overdose Just high/overmedicated • Small pupils • Drowsy, but arousable – Responds to sternal rub • Speech is slurred • Drowsy, but breathing – 8 or more times per minute >> Stimulate and observe Overdose • 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 >> Rescue breathe + give naloxone Overdose Suspected Check Pulse No Pulse Pulse 1) 2 min of CPR, 5 Cycles 1) Administer Naloxone 2) Administer Naloxone 2) Rescue breathing 3) Apply Defibrillator 3) If no change after 3 – 5 min repeat naloxone 4) Follow Defib. prompts 5) Continue CPR 4) Rescue breathing until help arrives Updated OpioidAssociated Life Threatening Emergency (ADULT) Algorithm – American Heart Association Guidelines, October 2015 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) Naloxone formulations Nasal with separate atomizer “Multi-step”* NEW: Nasal Spray “Single-Step” Auto-injector* Intramuscular Injection * In OEMS Clinical Protocols for First Responders Nasal Naloxone with atomizer – Multi-step • 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 Give Naloxone: Nasal with atomizer 1. 2. 3. 4. 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 Give Naloxone: Nasal with atomizer • 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 NEW: Nasal Spray NEW: Nasal Spray Administration Four important points for the New Nasal Spray Single Step • Do not prime the spray – you will end up wasting it • Insert the tip until your fingers are against the nose • One dose is one nostril • Nasal trauma will reduce the effectiveness 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 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 Give Naloxone: Auto-injector Give Naloxone: Auto-injector Give Naloxone: Auto-injector Give Naloxone: Auto-injector How does a person respond to Naloxone? Range of responses: 1. Gradually improves breathing and becomes responsive within 3 – 5 minutes 2. Immediately improves breathing, responsive, and is in withdrawal 3. Starts breathing within 3 – 5 minutes but remains unresponsive 4. Does not respond to first dose and naloxone must be repeated in 3 – 5 minutes (keep rescue breathing) 5. No response to multiple doses of naloxone Withdrawal symptoms after naloxone rescue (2010-2014) Program data – 2008-2016 Other = confused, disoriented, headache, aches and chills, cold, crying, diarrhea, happy, miserable After Administering Naloxone • Continue rescue breathing with 1 ventilation every 5 seconds until EMS arrives • After 3-5 minutes, if the patient is still unresponsive with slow or no breathing, administer another dose of naloxone If victim is breathing, but unresponsive place in recovery position Naloxone Storage • Nasal with separate atomizer: Storage between 59°F to 86°F – Avoid extremes in temperatures for long periods of time – Replace every 6-12 months, before expiration date • New Narcan Nasal Spray: 59°F to 77°F – Replace before expiration • Auto-injector: 59°F to 77°F – – – – 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 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 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? – No. Naloxone only works on opioids • 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. 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 Good Samaritan & Naloxone Law Passed August 2012 OEND program rescues: 2006-2016 Active use, in treatment, in recovery N=4,854 Non-User (family, friend, staff) N=551 911 called or public safety present 40% 68% Stayed until alert or help arrived 91% 95% Program data Help-seeking (calling 911 or EMS present) by people reporting rescues with MDPH naloxone 42% 34% 32% 2009 2010 37% 37% 2011 2012 49% 46% 47% 2014 2015 2016 to date 26% 2007/8 2013 Program data 911 Good Samaritan Campaign “Make the Right Call” Collaboration between DPH and the Office of the Attorney General. Campaign includes a Roll-Call video done in collaboration with the Mass Chiefs of Police Association. https://youtu.be/oNFnsPygjx8 www.mass.gov/maketherightcall 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 Acts of 2012, Chapter 192, Sections 11 & 32 Good Samaritan Law Policy Example of incorporating MGL c.94C s34A into Department Policy Bulk Purchasing Program • As a First Responder department, you may purchase naloxone directly from the State Office of Pharmacy Services (SOPS) • The legislation establishing the trust fund authorizes DPH to reduce the cost of naloxone for municipal first responder agencies below the negotiated SOPS purchase price • Contact: Edward Cavallari – [email protected] – 978‐858‐2153 Technical Assistance Online Resources: MassTAPP Page: http://masstapp.edc.org/first-responder-naloxonenarcan-technical-assistance DPH-BSAS Page: http://www.mass.gov/eohhs/gov/departments/dph/pr ograms/substance-abuse/prevention/naloxoneaccess.html Thank You