overdose basics

For teleconference only: Call 1-866 602 6731 OR 1-416 933 3825 Conference ID: 116 078 8 Please mute your phone:: press *6

Presenters:

Samira Walji, RN, MPH (C)

Kris Guthrie, RN, MPH (C)

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For teleconference only: 1-866 602 6731 OR 1-416 933 3825 Conference ID: 116 078 8

agenda

• Types of Overdose & Response

• Overdose Prevention & Preparedness

• Naloxone: a primer

• Overview of next session

about The Works

• Toronto Public Health harm reduction program, est.1989

• safer drug use equipment & education

• opioid substitution program

• nursing care: testing, vaccination, wound care

• POINT program: “take-home” naloxone

• local access point to harm reduction supplies for agencies

overdose: a public health crisis

• Canada - a world leader per-capita Rx opioid consumption

- Rx opioid related deaths ≈ 50% of annual drug deaths

• Ontario - leads all provinces in opioid prescriptions

- since 2000, >5000 opioid overdose deaths

- est. 20-25 times more non-fatal opioid overdoses

• Toronto - 2004-13, 41% increase in reported overdose deaths

- opioids most frequently lethal drug-type, accidental deaths

- since 2006 consistently high ED visits r/t opioid use

- annual increased demand for take-home naloxone

- client anecdotes about drug quality

overdose: defined

Overdose happens when a drug or combination of substances overwhelm the body and as a

consequence the central nervous system (CNS) is no longer able to control basic life functions (ie. breathing, heart rate, body temperature,

consciousness).

stimulants

Crack Cocaine Amphetamine (speed, crystal, meth) Ecstasy Methylphenidate (ritalin) Khat

substances that speed

up CNS processes

physiology of stimulant overdose

1 • Rising blood pressure and

body temperature

2 • Reduces blood flow to the

brain

3 • Decreased oxygen

5

• Organ failure and death

signs and symptoms

INTOXICATION (really high) OVERAMPING

• body is hot/sweaty or hot/dry

• dilated pupils

• vomiting

• tremors (shaky)

• euphoria (heightened mood)

• impaired judgment

• insomnia (unable to rest)

• paranoia

• elevated body temperature (> 38 degrees Celsius)

• chest pain, chest tightness, pounding heart

• irregular breathing/shortness of breath

• severe agitation, psychosis

• muscle rigidity (teeth grinding, clenched jaw)

• foaming at mouth

•Numbness or paralysis on one side or blindness in one eye

stimulant intoxication response OBSERVE and MONITOR CLIENT IN A SAFE ENVIRONMENT!

• encourage the person to refrain from using any more substance(s)

• move the person to a quiet space if safe to do so, clearing area of other staff/clients

• keep calm, stay with the person, use their name and a calm and reassuring tone

• reduce stimuli and anxiety as much as possible

• place cool wet cloths under armpits, back of neck and head

• monitor and assess regularly for signs of overamping or overdose Should I call 911?

• YES, if client shows signs of overamping or overdose • YES, if other medical complications arise beyond your scope • YES, if your agency is closing or shift is ending • YES, if you are in doubt

stimulant overdose response:

o

If the person is conscious and overamping: • Call 911 • Provide supportive measures: reduce stimuli as much as possible; reduce

anxiety, move the person to a quiet place; place the person lying down on their side

• Stay with the person until help has arrived

If the person is reporting chest pain: • Call 911 • Place the person seated comfortably leaning back against a stable chair • Advise the client to refrain from movements which may exacerbate

symptoms further

stimulant overdose response:

If the person is experiencing a seizure: Prior to a seizure: • If the person is experiencing an aura (feeling) prior to a seizure, move

the person to a safe location and have them lie down on their side During a seizure: • Call 911 • Roll the person onto their side • Do not interrupt the seizure • place a blanket under the head, loosen tight clothing, and remove

nearby sharp objects • Time the seizure If the person is unconscious: • Call 911 • Start CPR

hallucinogens

LSD (acid) Mescaline PCP Cannabis Ecstasy salvia Ketamine Magic mushrooms MDMA DMT 2C-B

substances that cause an

alteration in thought,

processes and mood

signs and symptoms

INTOXICATION (really high) OVERDOSE

• nausea • vomiting • disoriented • psychosis • person may sit in trance like state

• high blood pressure

• seizures

• risk of suicide

• kidney damage

• breathing is, irregular, or has stopped

Hallucinogen intoxication

response OBSERVE and MONITOR CLIENT IN A SAFE ENVIRONMENT!

• encourage person to refrain from taking more substance(s)

• move the person if safe to do so

• clear monitoring area of staff and clients

• know the person’s location within your space

• monitor and assess regularly for signs of overdose Should I call 911?

• YES, if client shows signs of overdose • YES, if other medical complications arise beyond your scope • YES, if your agency is closing or your shift is ending • YES, if you are in doubt

depressants

Opiates: Heroin Methadone, Bup Morphine Hydromorphone Oxycodone Fentanyl Alcohol Benzodiazepines: diazepam, lorazepam, clonazepams

substances that slow

down CNS processes

physiology of opioid overdose

1 • Slow breathing

2 • Breathing stops

3 • Heart stops

4 • Death

signs and symptoms

INTOXICATION (really high) OVERDOSE

• muscles become relaxed • speech is slowed/slurred • sleepy looking • will respond to stimulation like yelling, sternum rub, pinching, etc. • nodding off

• deep snoring or gurgling (“death rattle”) or wheezing

• blue skin tinge- usually lips and fingertips show first

• pale, clammy skin

• will not respond to stimulation (“heavy nod”)

• breathing is very slow, irregular, or has stopped

Adapted from: Overdose Prevention and Response, Harm Reduction Coalition, Dope Project, 2015

opioid intoxication response

OBSERVE and MONITOR CLIENT IN A SAFE ENVIRONMENT!

• encourage person to refrain from taking more substance(s)

• move the person if safe to do so

• clear monitoring area of staff and clients

• know the person’s location within your space

• monitor and assess regularly for signs of overdose Should I call 911?

• YES, if client shows signs of overdose • YES, if other medical complications arise beyond your scope • YES, if your agency is closing or your shift is ending • YES, if you are in doubt

opioid overdose response

What to do How to do it

Check for responsiveness Responsive to voice? Physical stimulation? Pain? Can you wake them up?

Check airway Deep snore? Gurgling? “death rattle?” Wheezing?

Check breathing Chest rise and fall? Erratic/Slow/Irregular? Gasping?

Call 911 & start CPR as trained Send someone to call 911 Chest Compressions/Rescue Breaths/Full CPR

Place person in recovery position if breathing resumes or you need to leave the scene

Bend knee forward to prevent body from rolling onto stomach

recovery position

overdose risk factors

• lowered tolerance - after a break in use (detox, treatment, jail, voluntary) - new to use - other: sickness, run-down, liver disease, dehydration, age

• mixing/using substances in combination

• quality: stronger drugs than usual - new supply/dealer/cut

• using alone

• route

• previous survived overdose

overdose prevention MIXING

- avoid using different drugs at the

same time

- if you mix, try to use less of each

TOLERANCE

- be self-aware

- “start low, go slow” after breaks and

with different drugs

- be wary of your route and transition

DRUG QUALITY

- ask trusted sources about new dope

- do a tester

- check your pills

USING ALONE

- fix with a friend

- have a plan

- snort or inject slowly

- have someone trusted check on you

- keep your naloxone close

overdose response myths busted!

DO NOT: RATIONALE/RISK

put the victim in a bath/cold water

drowning; hypothermia

induce vomiting choking

inject victim with anything (milk/saline/cocaine) except naloxone

does not work; can make overdose worse

punch/kick in testicles/burn soles of feet further injury

let them sleep it off could stop breathing and die without help

what you can do

…

With people who use drugs • Talk about it: informal conversations, intakes, assessments, care

planning, discharge planning [reduce stigma] • Peer to peer knowledge transfer • Educate clients about overdose prevention techniques • Educate clients about the signs and symptoms of (opioid) overdose • Provide first aid and CPR training to clients • Educate clients about how to respond to an overdose including

calling 911 • Refer and ensure eligible and at risk clients are trained on… use of

naloxone Strike, C., et al. Best Practice recommendations for Canadian Harm reduction Programs that Provide Service to People Who

use drugs and are at risk for HIV, HCV, and Other Harms: Part 1. Toronto, On: Working group on Best Practice for Harm

reduction Programs in Canada. 2013

MyOverdosePreventionPlan

□ IfIhaven’tusedforawhile/havebeensick/injailortreatmentIwillstartwithalowdose

□ IfIhaveanewdealerorbatchIwilltestmydoseand/oraskothersaboutthesupply

□ Iwillbecarefulifmixingdrugsandmixingdrugswithalcohol:oneatatime,smalleramounts

IfIUsewithsomeoneelseIwill:

□ Talkaboutoverdosebeforeweuse

□ MakesureoneofushasbeentrainedonCPRand/orNaloxone(andhaveitonhand!)

□ Useoneatatimesowecanhelpiftheotherpersongoesdown

□ Makesuretocall911soIhavebackupincasethingsgetworse

IfIamusingaloneIwill:

□ LetsomeoneknowwhereIam

□ Findoutifsomeonenear-byhasanaloxonekitorkeepminecloseat-hand

□ Havesomeonecheckonme______minutesafterIhaveused

□ MakesuremydoorisunlockedsothatsomeonecanhelpmeifIneedit

OtherthingsIcando:_____________________________________________________________

______________________________________________________________________________

what you can do

With staff: • Develop policy for overdose response in your setting • Ensure all staff are trained in basic life support (CPR) • Ensure ALL staff know overdose signs & symptoms • Ensure that your agency has a emergency kit that is easily accessible

(contents to include: rescue breathing mask, naloxone, syringes, gloves……)

• Regularly and systematically check your agency’s bathrooms and other secluded locations where people might use

• Bathroom doors should be easy to open in case someone goes down • Do mock overdoses to practice your response • Ensure all staff are adequately trained to respond and talk about

overdose

911 call script example

“I am calling from Toronto Public Health at 277 Victoria

Street. We have a client here with ____________________”

(nature of emergency, eg. seizure)

Specify location: “1st floor, entrance on the right hand side

of the lobby doors”

Other considerations: • state what you are not equipped handle at your organization • share pertinent information only (eg. signs and symptoms, treatment

administered, client’s status) • if opioids involved, let dispatch know (naloxone needed)

what you can do

Within service space: • Posters: - prevention messages - how to recognize and respond to overdose - invitation to discuss overdose risks and prevention with program staff • Educational Materials: - pamphlets & fact sheets on overdose & substances - drug alerts

health promotion

drug alerts

Tips for communicating drug advisories: 1. Make them relevant 2. Make them timely 3. Utilize multiple formats/media 4. Alert as frequent as necessary 5. Discontinue when issue ends

“take-home” naloxone

what’s in the naloxone kit?

• Syringes -Safety engineered

• 2 ampoules of Naloxone(.4mg/1cc/amp)

• Alcohol swabs (assist with breaking ampoule)

• Prescription identifier Card

• Overdose Response steps pamphlet

naloxone

• World Health Organization: essential medicine

• antidote to opioid overdose, temporarily reversing respiratory

depression

• injectable formulation & Rx only in Canada

• IM: onset of action is between 2-4 minutes & duration of action is up to 45 minutes

• only contraindication to receiving Naloxone would be previous hypersensitivity (allergy)

Naloxone has a stronger affinity to opioid receptors than opioids like heroin and fentanyl, so it knocks the opioids off the receptors

for a short time. This allows the person to breathe again and reverses the overdose.

Opioid receptor on brain

Naloxone

Naloxone

Opioid

Is naloxone safe?

• naloxone is very safe

• main risk of giving naloxone to someone who is opioid-dependent, is that it will cause withdrawal, which would be distressing, but not fatal

• no other uses apart from reversing the effects of a opioids.

• only contraindications in administering naloxone is hypersensitivity (allergic reaction)

naloxone as your first aid response

• it can be part of your agency’s overdose response plan!

• >POINT kits are medically directed for clients in the community and not community agency staff while working

• implementing naloxone in your agency requires a medical directive, naloxone prescription as well as purchase

• our next webinar will cover the process for naloxone implementation: November 5, 2:00pm (invite to follow, please contact Kris if not on original webinar series invite)

source list Best Practice Recommendations for Canadian Harm Reduction Programs, Part 1 http://www.catie.ca/sites/default/files/bestpractice-harmreduction.pdf Communicating Drug Alerts, BCCDC http://www.bccdc.ca/NR/rdonlyres/9C65F445-EC37-43DE-A2C5-8FC26BCE35EB/0/CDAGuidleines_FINALwolink.pdf Staff report for action on Overdose in Toronto: Trends, Prevention and Response http://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-83429.pdf Opioid Overdose Prevention and Response in Canada, CDPC http://drugpolicy.ca/wp-content/uploads/2014/07/CDPC_OverdosePreventionPolicy_Final_July2014.pdf Prescription for Life, Municipal Drug Strategy Coordinators Network of Ontario http://www.drugstrategy.ca/uploads/5/3/6/2/53627897/prescription_for_life_june_1_2015.pdf CCCENDU Bulletin: Deaths Involving Fentanyl , 2009-2014 http://www.ccsa.ca/Resource%20Library/CCSA-CCENDU-Fentanyl-Deaths-Canada-Bulletin-2015-en.pdf Opioid Overdose Basics, Harm Reduction Coalition http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/

Thank-you!

Webinar evaluation: https://www.surveymonkey.com/r/Q38V9BD

…………………………………………………………………………………..

Kris Guthrie Samira Walji kguthri@toronto.ca swalji2@toronto.ca

416-338-7809 416-392-0517 …………………………………………………………………………………………………..

To subscribe to Toronto Drug Alerts: drugstrategy@toronto.ca