Intranasal (IN) Naloxone Training Guide POPP Peer Overdose Prevention Program Ottawa Public Health Site Needle & Syringe Program Created: April 2012 Revised: February 2017 Site Needle & Syringe Program Adapted with permission from Toronto Public Health’s POINT Program Contents Page 1 o Naloxone 2 o Naloxone Kit Contents 3 o Drug Categories 4 o Opioids 5 o Opioid Comparison Graph 5 o Duration of Action 6 o Overdose 7 o Overdose Risk Factors 8 o Recognizing an Overdose 9 o On the Nod vs an Overdose 9 o Signs of an Overdose 10 o Overdose Response Myths 11 o Responding to an Opiate Overdose with Naloxone 12-1 o Recovery Position 19 o Follow-Up/Debriefing 20 o Refills 20 o Naloxone Kit Care 20 o Program Evaluation 21 Ottawa Public Health- Site Needle & Syringe Program Naloxone Naloxone is an antidote to opioid overdose. Naloxone binds to the same receptors in the brain that opioids do. However, naloxone is more effective at binding to these receptors and temporarily removes the opioid(s) and their harmful effects. This action can reverse the harmful effects including respiratory depression that can lead to a fatal overdose. Naloxone is a non-prescription drug in Canada. In Ontario, it is available for free through programs like POPP and over the counter at pharmacies that have opted into the Ontario Naloxone Program for Pharmacies through the Ministry of Health and Long Term Care’s Ontario Public Drug Programs Division. It is available to people who could be at risk of an overdose, or friends/loved ones of someone at risk of an overdose. Naloxone works on opioids. But it is important to remember that any drug can be cut with an opioid without your knowledge. Once given, naloxone will start to work in approximately 2-3 minutes. Naloxone stays active in the body for about 2 hours. Since naloxone only temporarily removes the opioids from the receptor sites in the brain, the opioids will return back to those receptors and the overdose symptoms can return. It is important to call 9-1-1 before giving naloxone. An overdose is a medical emergency and take-home naloxone kits do not replace the need for emergency care. 2 Ottawa Public Health- Site Needle & Syringe Program Naloxone Kit Contents  2 Naloxone nasal spray applicators  Pair of non-latex gloves  Naloxone Identifier Card (identifies participant as trained)  5 Step Instruction Pamphlet  Rescue breathing mask  Narcan Nasal Spray Product Monograph and Patient Information Pamphlet  Health Canada Supplementary Information for NARCAN Sheet 3 Ottawa Public Health- Site Needle & Syringe Program Drug Categories Depressants: Slow down the activity of the brain and nervous system. Stimulants: Stimulate the brain and central nervous system, speeding up communication between the two. Hallucinogens: interfere with the brain and central nervous system in a way that results in distortion of reality and hallucinations. These drugs are sometimes called psychedelics. Examples of Drug Categories: Depressants Stimulants Hallucinogens • Opioids: Heroin, Hydromorphone (Dilaudid), Oxycodone (Oxycontin, OxyNEO), Fentanyl, Morphine, Buprenorphine (Suboxone), Methadone, Codeine, Demerol, Hydrocodone (Vicodin), percocet • Cocaine • LSD (acid) • Crack cocaine • Magic Mushrooms • Amphetamines (speed, crystal, meth) • PCP • Benzodiazepines: Ativan, Halcion, Restoril, Rohypnol, Serax, Valium, Xanax • Bartituates: Amytal, Nembutal, Seconal • DMT • Methylphenidate (Ritalin) • 2C-B • Khat • Ketamine • Caffeine • MDMA* • MDPV (Bath salts) • Ectasy/MDMA* • Zopiclone • Alcohol •GHB 4 *MDMA is considered a cross-over drug with potential to induce stimulant and hallucinogenic effects Ottawa Public Health- Site Needle & Syringe Program Opioids Opioids work on the body by sticking to specific places (receptor proteins) on the brain (and all over the body) – much like a key fits and opens a lock. When too much opioid occupies the receptors an overdose occurs. Examples of opioids include: heroin (smak, junk, dope,H), Fentanyl (Duragesic®), Morphine (Kadian®, MSContin®), Oxycodone (OxyNEO®, Percocet®, Endocet®, Percodan®), Meperidine (Demerol®), Tramadol (Ultram®, Ralivia®), Petazocine (Talwin®), Methadone, Buprenorphine (Suboxone®, Subtex®) Opioid Comparison Graph Adapted from: London Pain Clinic – Opiate Conversion Table – 2008 5 Ottawa Public Health- Site Needle & Syringe Program Duration of Action Duration of action is the length of time that a particular drug is active in the body. The duration of action of naloxone is shorter than most opioids, so the effects of the original opioid taken may return after the naloxone is given. This means the overdose can return! Drug Duration of Action (hours) Codeine 4-6 Fentanyl IV 0.5 - 1 Heroin 3-5 (pain killer effect) Hydromorphone (Dilaudid®) 4-6 Meperedine (Demerol®) 2-4 Methadone 24 - 36 Morphine – immediate release 4-5 12-24 extended release Oxycodone 2-4 Buprenorphine 8-72 Naloxone Up to 2 hours Adapted from Principles of Opioid Management, Fraser Health, 2006; and Opioid Analgesic Chart, Medical University of South Carolina, 2011 edition; Heroin Toxicity, Medscape, 2015 and Narcan (naloxone HCl) Nasal Spary 4mg Product Monograph. Adapt Pharma. Revised 02/2016. 6 Ottawa Public Health- Site Needle & Syringe Program Overdose An overdose occurs when a person uses more of a drug, or combination of drugs, than the body can handle. As a result, the brain is not able to control basic life functions, like breathing. Who can overdose?  Anyone can overdose: first time users, long-time users, seniors, young people, people who only use once and awhile- overdose doesn’t discriminate. There is no exact formula for determining how much of a certain drug or combination of drugs will lead to an overdose.  An individual's physical characteristics play a role: weight, health, tolerance for a drug at that particular time.  Other factors: drug potency (how strong it is), how it is taken (swallowed, snorted, injected), and how often and how much of a drug is used.  Overdose risk is higher when you haven’t used in awhile (whether you took a break, or were in treatment, hospital, or jail). Statistically, there is an increased risk of overdose during the first 2 weeks after release from prison. What are the possible consequences of an opioid overdose? • choking on vomit • coma • breathing stops, heart failure and heart attack • death If someone experiences multiple overdoses, this means that their brain is also being deprived of oxygen multiple times. Over time this can contribute to brain injury. Administering Naloxone in an opioid overdose can reverse the overdose effects long enough for the person to receive medical attention and have their life saved. 7 Ottawa Public Health- Site Needle & Syringe Program Overdose Risk Factors Overdose risk factors are the circumstances, characteristics or experiences that could increase the risk of someone overdosing. Four significant areas of risk of overdose include: mixing drugs, drug tolerance, social context of use and drug strength/quality, and method of drug taking. Overdose Prevention Mixing Tolerance Inconsistent Drug Quality & Potency -Avoid mixing drugs or mixing drugs with alcohol. -Tolerance is the body’s ability to increasingly withstand (“handle”) the effects of the substance being use. -The amount of a drug a long-time user needs to feel a drug’s effect is greater than a new user. -The quality of street drugs is unpredictable. Fentanyl is being cut (mixed) into both opioid and non opioid drugs: ° mixed as a powder in cocaine, heroin, and crack. ° pressed in to pills and being sold as “oxycodone” (eighties, oxys) or other pills including ecstasy/MDMA. -Tolerance will change depending on: weight, size, illness, stress, age, lower immune system (from hepatitis for example). * Drugs can be tampered with at any point. People buying or selling drugs may not be aware if it has been cut with anything before they sell it to you. -Drug tolerance can decrease when somebody has taken a break from using whether intentionally or unintentially (while in jail or hospital). -You may not be able to taste, smell or see it. Even very small amounts can cause an overdose. -Most overdose deaths occur when multiple drugs have been taken. Prevention: Use one drug at a time or use less of each drug if you are mixing. -Tolerance to a drug develops over time. Prevention: Use less drugs when tolerance is lower. 8 Using Alone -If you overdose when you are alone there will be no one there to help you Prevention: Fix with a friend* and have a plan for what to do if someone ODs. If you do use alone leave the door unlocked and let somebody know to check in on you. *Do not share any gear/drug equipment with friends/ acquaintances you fix with- this can put you at risk of HIV, hepatits and other infecftions. Prevention: -Start using in small amounts and do “testers” (or test doses) to check the strength of what you are using. Ottawa Public Health- Site Needle & Syringe Program Recognizing an Overdose Not all opioid overdoses will look the same but there are common signs to look out for. It is important to remember that there are some overdose signs that are common across drug categories. Keep in mind that drugs may be combined, and therefore you may see a combination of different symptoms. Create an overdose response plan with your peers/family: Talk with your friends or partners about overdose and create a plan that you can realistically use in the event of an overdose. Encourage people in your support network to get naloxone training and get a naloxone kit. Let them know where you keep your naloxone kit. On the Nod vs. Overdose It is important to be able to recognize if someone is overdosing versus on the nod (intoxicated). When someone is on the nod they are actually really high and may or may not overdose. It is important to stay with them, make sure they are responsive, still breathing normally, and in a safe space if they go under. If someone is on the nod, they do not need naloxone. It might seem difficult to differentiate between an overdose and being on the nod, especially if you are stressed out that someone has gone under. These are some signs that someone is on the nod: • Muscles become relaxed • Speech is slowed/slurred • Sleepy looking • Head nodding- head drops as if falling asleep then spontaneously or with stimulation props head up again Someone that’s on the nod will: • Respond to stimulation like “shake and shout” • Able to verbalize (have a conversation) • Able to walk around with or without help • Breathing is normal and regular 9 Ottawa Public Health- Site Needle & Syringe Program Signs of an Overdose Opioids Stimulants Hallucinogens • Breathing is very slow, erratic or not there at all • Fingernails and/or lips turn blue or purple •Body is limp •Deep snoring/gurgling/choking sounds • Vomiting •Loss of consciousness • Unresponsive to stimuli • Pinpoint pupils • Seizures • Pressure/tightness in chest • Foaming at the mouth • Racing pulse • Extreme sweating •Vomiting • Headache, dizziness, ringing in ears • Difficulty breathing • Sudden collapse • Loss of consciousness • Psychosis • Catatonic syndrome (person may sit in a trance-like state) • Seizures • Nausea, vomiting If someone overdoses while using opioids with other depressants, stimulants or hallucinogens naloxone will still work against the opioids. It will have no effect on the other substances. If naloxone is given to someone who appears to be experiencing opioid overdose, but is actually overdosing on a non-opioid, the naloxone will have no effect. This is why 911 must always be called in an overdose situation. An overdose is a medical emergency. 10 Ottawa Public Health- Site Needle & Syringe Program Overdose Response Myths DO NOT WHY NOT? Put the person in a bath or Could drown or put person cold water into shock Make the person vomit Could choke Inject them with anything other than naloxone (salt water, cocaine, milk, etc) Will not help and could cause serious harm Slap or shake too hard. Could cause serious harm Attempt to wake them up by kicking, burning, or any other way that could cause harm Let them sleep it off 11 Could stop breathing and die Ottawa Public Health- Site Needle & Syringe Program Responding to an Opioid Overdose with Naloxone This training guide shows you how to give naloxone in the event of an opioid overdose. It is not intended to be a CPR course. We strongly encourage that you become certified in CPR. This can be done for free through:  Ottawa Paramedic Service (call 613-580-2424, ext. 32434 or visit http://ottawa.ca/en/health_safety/emergency/firstaid/courses/index.html to search for CPR schedules)  Sandy Hill Community Health Centre, Oasis Program (drop-in at 221 Nelson street, call 613-789-1500 or visit http://www.sandyhillchc.on.ca/mainEngl/oasis_engl.html) 12 Ottawa Public Health- Site Needle & Syringe Program 1. Stimulation Can you wake them up? - Shout their name - Shake their shoulders 2. Call 9-1-1 Talking with emergency services: When calling 9-1-1:  Quiet the scene down, speak clearly and calmly, tell the dispatcher that the person is not responding to shake and shout. You do not have to tell them your name, but let them know that you think an overdose has happened or that drugs are involved.  Tell the dispatcher exactly where you are: the address and room number. If you are outside, give them the nearest street intersection and a landmark. If you can, get someone else to watch for the ambulance while you stay with the person who is overdosing.  Once the paramedics arrive, tell them as much as you know about what drugs the person was using and what you did, including how much naloxone you gave. This will ensure that they can provide the best care and response.  If police arrive on scene, try to calmly redirect them to the medical emergency at hand. 13 Ottawa Public Health- Site Needle & Syringe Program 3. Give Naloxone How to administer naloxone nasal spray:  Remove the nasal spray from the box. Peel back the tab with the circle to open the naloxone nasal spray.  Hold the naloxone nasal spray with your thumb on the bottom of the plunger and your first and middle fingers on either side of the nozzle. 14 Ottawa Public Health- Site Needle & Syringe Program  Insert the tip of the nozzle into either nostril. Tilt the person’s head back and provide support under the neck with your hand.  Insert the tip of the nozzle into one nostril, until your fingers on either side of the nozzle are against the bottom of the person’s nose.  Press the plunger firmly to give the dose of naloxone nasal spray  Remove the naloxone nasal spray from the nostril after giving the dose. Intranasal images used with permission from Adapt Pharma 15 Ottawa Public Health- Site Needle & Syringe Program 4. Start Chest Compressions or Rescue Breathing and/or CPR as trained Compressions:  Push hard and fast with both hands on the center of the chest  Position arms in locked position  Push down at least 2 inches with each compression  Continue chest compressions until Paramedic Service arrives  If able, switch persons doing compressions every 2 minutes to avoid fatigue 16 Ottawa Public Health- Site Needle & Syringe Program Rescue Breathing: • A mask is available in the Naloxone kit to provide a barrier • Keep the person’s head tilted back, pinch their nose, and give them 2 breaths • You should be able to see their chest rise with each breath • Continue to give 1 breath every 5 seconds until the person is breathing on their own or first responders arrive If you know how and are willing, you can provide full CPR. 17 Ottawa Public Health- Site Needle & Syringe Program 5. Assessment i. Is it working? If the person does not start breathing on their own within 2-3 minutes, administer the next dose of naloxone following the same procedure as before and continue chest compressions/rescue breathing and/or full CPR until ambulance arrives. If the person still does not start breathing normally on their own and additional doses of naloxone are available, more doses of naloxone nasal spray can be administered every 2-3 minutes using a new nasal spray with each dose until emergency medical assistance arrives. Each dose should be given in alternating nostrils if you are able. When the naloxone starts working the individual may: o o o o o Wake up suddenly Wake up slowly Be confused Be agitated or aggressive (try to hit you) Want to use more drugs Naloxone may cause mild to severe withdrawal symptoms: agitation, anxiety, muscle aches, sweating, nausea, vomiting. Once the naloxone wears off, these withdrawal symptoms tend to go away. ii. How can you help? o Stay with the person until ambulance arrives o When they wake up, explain that they overdosed o Urge them to not use drugs right after they wake up o Using more will not make them feel any better and will increase their chance of overdose once the naloxone wears off 18 Ottawa Public Health- Site Needle & Syringe Program o Watch for signs and symptoms of the overdose returning Recovery Position If at any point you need to leave the person alone, place them in the recovery position. Placing a person in the recovery position helps keep the person’s airway open so they can breathe and can prevent them from choking on vomit or spit. 19 Ottawa Public Health- Site Needle & Syringe Program Follow up – Debriefing Being part of an overdose can be a very traumatic experience, whether you’re the person overdosing or the witness:  Talk with your friends and/or family  Contact a nurse/counselor in the Site office or Site van  If you are connected, seek support from a worker or health care provider Refills Visit your local pharmacy, the Site office or Site van, or Sandy Hill CHC’s Oasis Program for a refill. Naloxone Kit Care  Your naloxone should be stored at around room temperature (15-25˚ C) and in the dark (keeping it in the kit is a great way to keep it out of sunlight). Make sure it is with you at all times when you are using.  Watch expiry date. If it’s getting close to the expiry date go to your local pharmacy or visit the Site office or call the Site van for a refill.  Routinely check that all supplies are in your naloxone kit. 20 Ottawa Public Health- Site Needle & Syringe Program Program Evaluation In order for us to provide the most useful and effective training we appreciate the input from people who are using the program. This feedback is important to help us adapt our program to reflect the needs of the community. When you refill a naloxone kit at the Site program you will be asked to complete a short evaluation form. This form is confidential and the feedback you provide will help improve the program. This is also a good time to get support or any help you may feel you need after experiencing an overdose situation. 21 Ottawa Public Health- Site Needle & Syringe Program Publlc?a?h Anything can Le fentanyl pent - tetra utilise pour he cut :ouper n'iiwrte Fentanyl. quelle substance. 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