Transcript First Responder Overdose Response Training

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
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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
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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.
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What are opioids/opiates?
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Medications that
relieve pain
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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)?
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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
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Too much Narcan can cause withdrawal symptoms such as:
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nausea/vomiting
diarrhea
chills
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muscle discomfort
disorientation
combativeness
How does Narcan affect
overdose?
What is an Opioid OD?
Naloxone Reversing Overdose
Mixing Opioids with Benzos
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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
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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
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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
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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
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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
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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