Overdose PreventionTrain-the-Trainer for NYPD

October 29, 2013

Amu Ptah-RiojasAnne SieglerNYC Department of Health and Mental HygieneBureau of Alcohol and Drug Use Prevention, Care and Treatment

Objectives

After today’s session, participants will be able to:

• Discuss the epidemiology and physiology of overdose, including risk factors for overdose

• Properly identify and respond to an opioid overdose using intranasal naloxone

• Develop and offer a 30-minute overdose prevention training to other NYPD members

Schedule for our training

1. Why are we talking about overdose?2. Who is at risk of overdosing?3. What does an opioid overdose look like?4. Responding to an opioid overdose5. Tools for training others to respond to an

opioid overdose

WHY ARE WE TALKING ABOUT OVERDOSE?

Epidemiology of drug overdose in NYC

Comparison of motor vehicle deaths and OD deaths in the United States, 1999-2010

NOTES: Drug poisoning deaths are a subset of poisoning deaths. Unintentional drug poisoning deaths are a subset of drug poisoning deaths. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm. Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm

Drug poisoning is now the leading cause of injury death

•In NYC, drug overdose is the third leading cause of premature death, after cancer and heart disease1

•Almost 2 people die of a drug overdose in NYC every day2

1 Zimmerman R, et al. Summary of Vital Statistics, 2011: Mortality. New York, NY: New York City Department of Health and Mental Hygiene, 2013.2 Paone, et al. Unintentional drug poisoning (Overdose) deaths in NYC, 2000-2012. Epi Data Brief. Sept 2013 (No.33).

Drug overdose deaths in NYC2000-2012

Drugs involved in overdose deaths: United States, 1999-2010

NOTES: Opioid analgesic categories are not mutually exclusive. Deaths involving more than one opioid analgesic category shown in this figure are counted multiple times. Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl.

SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm

Drugs involved in overdose deaths:NYC, 2000-2012

Where in NYC are overdose deaths occurring?

Opioid analgesic deaths are 4 times higher on Staten Island than elsewhere in NYC

Recent headlines from Staten Island

WHAT DOES AN OPIOID OVERDOSE LOOK LIKE?

Physiology of opioid overdose – Part 2

Opioid overdose physiology

• Opioids repress the urge to breath, leading to respiratory depression and death

Slow breathing Breathing stops Heart stops Circulation of blood to the brain stops

• Generally happens over course of 1-3 hours. The stereotype “needle in the arm” death only occurs in about 15% of overdose deaths.

Continuum of Overdose1. Heavy/ uncontrollable nodding

– Still arousable– Snoring or loud breathing– May have excess drooling

2. Overdose– Not responsive– Very shallow breathing, gurgling– Skin changes, blue lips and nails

3. Fatal overdose

Signs of an opioid overdose

• Slow breathing or difficulty breathing• Loud snoring• Blue or grey lips, nail beds• Unresponsive

WHO IS AT RISK?Physiology of opioid overdose – Part 1

Where there are more opioids available, more people overdose

When tolerance decreases, risk of overdose increases

Tolerance goes down if an individual stops using opioids for a period of time.

•Incarceration•Drug treatment/ Detox•Hospitalization

Risk of overdose increases when more than one drug is used at the same time

• Alcohol• Benzodiazepines, i.e.

Xanax, Klonopin• Antidepressants• Cocaine

Overdose deaths in New York City involve multiple drugs (2008)

Nearly all unintentional drug overdose deaths in NYC (98%)involve more than one substance, including alcohol.

•Opioids were the most commonly noted drug type(74%). Types of opioids included heroin, methadone, and prescription pain relievers.

•Other drugs commonly found were: cocaine (53%), benzodiazepines (35%), antidepressants (26%),and alcohol (43%).

NYC Vital Signs, Volume 9, No. 1, NYC DOHMH

Context of opioid overdose

• The majority of overdoses are witnessed (gives an opportunity for intervention)

• Fear of police may prevent calling 911

• Witnesses instead may try ineffectual things– Myths and lack of proper training– Abandonment is the worst response

Strategies to address overdose

• Prescription monitoring programs

• Prescription drug take-back events

• Safe opioid prescribing education for MDs

• Expansion of drug treatment

• Use of naloxone by non-medically trained personnel

• Good Samaritan 911 laws

RESPONDING TO AN OPIOID OVERDOSE USING NALOXONE

So what do we do?

An antidote exists

Naloxone (Narcan®)•opioid antagonist•injectable or intranasal •reverse the effects of opioids •preventing an overdose from becoming fatal•regulated substance (by prescription only) but not a controlled substance

Naloxone’s effects• Usually acts within 2-5 minutes

• If the person was opioid dependent, naloxone will put them into withdrawal

• Naloxone blocks the effects of all opioids

• Naloxone lasts for 30-90 minutes

• Harmless/no effects if the person had no opioids in their system

• Will not reverse overdoses caused by substances that are not opioids (cocaine, alcohol, benzodiazepines, methamphetamine)

Intramuscular (IM) naloxone

• A face mask for rescue breathing

• 2 safety syringes• 2 pre-filled vials of

naloxone• 2 alcohol swabs• 2 latex gloves• 1 brochure reviewing

OD and rescue steps

Intranasal (IN) naloxone

• A face mask for rescue breathing

• 2 needle-less syringes• 2 pre-filled vials of

naloxone• 2 nasal atomizers• 2 latex gloves• 1 brochure reviewing

OD and rescue steps

Legal Status - Overdose Law in New York State (Effective April 1, 2006)

• Protects the non-medical person who administers naloxone in setting of overdose from liability– “shall be considered first aid or emergency treatment”– “shall not constitute the unlawful practice of a profession”

• Allows the medical provider to provide naloxone for secondary administration

• Naloxone must be prescribed by MD, DO, PA, or NP

STEPS TO RESPONDING TO AN OVERDOSE

Step 1. Stimulate

• Shake, call to the person loudly• Sternal rub: rub knuckles hard up and down

breast bone (It hurts them, but won’t cause damage)

Step 2. Check for breathing

• Chest rising and falling• Nostrils moving in and out• Mirror or glass by nose or mouth will fog up• Touch moistened finger next to nostrils, feel

for cool draft of inward breathing

Administer rescue breathing or CPR

Rescue breathing alone can sustain someone until EMS arrives

Mouth-to-mouth

Chest compressions notincluded (unless Responder is trained in CPR)

How to perform rescue breathing

• Tilt back head to open airway with hand under neck or chin lift

• Pinch nose shut• Make a seal over the mouth with your mouth• Start by giving 2 quick breaths. Then give one

breath about every 5 seconds until EMS arrives or person breathes on their own.

More on rescue breathing• American Heart Association recommends hands-only

resuscitation for sudden cardiac arrest

• In opioid overdose (and drowning), oxygen is depleted. Breaths are vital for survival!

• Few overdose victims survive if the heart stops

ADVICE: Rescue breathing should always be included in a suspected overdose.

harmreduction.org/article.php?id=1186

Step 3. Administer naloxone

• Assemble your naloxone dose.

• Tilt victim’s head back.• Spray half of the vial up

nostril. Spray the remainder of the vial up the other nostril. Spray until all of the liquid has been expelled.

• If no response in 2-5 minutes, administer the 2nd naloxone vial.

• Continue rescue breathing until response.

Recovery Position

If you must leave the victim even for a few minutes, put them into the recovery position so they won’t choke on vomit

Results: Awake and breathing

Narcan wears off in 30-90 minutes• Don’t leave the victim alone as sedation may

return• Reassure the victim if s/he is in withdrawal

that the naloxone will wear off and the effects of the opioids will return. (And if s/he uses more drugs they won’t have any effect.)

Dispose of used naloxone into trash receptacle

Reporting requirements• Report use of naloxone to Desk Officer

• Aided Report Worksheet (PD 304-152b) in non-arrest situations or Medical Treatment of Prisoner Form (PD 244-150) in arrest situations

• NYSDOH Opioid Overdose Reporting Form

• NOTE: location, type of substances used if known, condition of aided, if CPR was administered, if victim survived

• Submit reports to Desk Officer within xx hours/days

Replace your naloxone

• Get a refill of naloxone• Even if just one dose was used• If kit is lost• If naloxone is nearing expiration date (ever 2 years)

• Store naloxone at room temperature and away from direct light

Stay up on your skills

• Receive a Refresher Training every year.

• Every so often, take out your kit, review instructions, and practice assembling your naloxone dose quickly.

NALOXONE AROUND NEW YORKWhat else you need to know

State-certified “Opioid Overdose Prevention Programs”

Over 80 sites registered in New York including:– Hospitals – Drug treatment programs– HIV programs– Homeless shelters– Syringe exchange programs

• Over 10,000 overdose rescue kits (IN and IM) have been dispensed to NYC residents at risk of overdose, as well as their friends and loved ones

• Nearly 750 reports of overdose reversals

Progress to date:2006 - 2012

• This law protects the overdose victim and those who call 911:– From arrest in the presence of misdemeanor

possession and/or underage drinking– From prosecution in felony possession

• Went into effect in September, 2011• NY is one of several states to pass such laws

Encouraging people to call 911: NY’s Good Samaritan law

TRAINING OTHERS TO RESPOND TO AN OVERDOSE

Pass it on!

Goals:•Instruct :

– How to identify an overdose (when should I use naloxone?)

– How to respond, including administering naloxone– Protocol: Reporting use of naloxone, safe storage,

when and where you must carry it with you, refresher trainings, replacing used or expired naloxone

•Dispense: Overdose prevention kit with 2 doses of IN naloxone (prescribed by NYPD surgeon)

30-minute training for NYPD members

• An Overdose Rescue Kit for demonstration (can be vial filled with water, or expired naloxone)

• Overdose Rescue Kits for each member attending training (to be dispensed by surgeon), which includes:– 2 doses of naloxone– 2 nose pieces– Face mask– Instruction sheet

• Blue New York State certification cards

• PowerPoint presentation, laptop, projector

• Other informational materials: e.g. fact sheets, brochures, Operations Order

• Optional: dummy to demonstrate rescue breathing

Materials you need to do the training

1. Recognizing an overdose: what does an OD look like?2. Risk factors for an opioid overdose3. Responding to an overdose

a) Sternum rubb) Rescue breathing/CPRc) Naloxone

4. NYS law on naloxone administration and 911 Good Samaritan law5. Expectations of NYPD trained in overdose prevention

a) Reportingb) Storagec) Refresher trainings

6. Dispense naloxone and prescription, blue state certification card

Agenda for 30-minute training of NYPD members

By the end of the 30-minute training, each trained responder should:

• Have hands-on practice with naloxone device (intranasal assembly)

• Receive blue Certificate of Completion card• Meet with medical provider for short medical

history, receive Overdose Rescue Kit with naloxone

• Receive prescription to keep in Kit• Understand new Operations Orders, and

expectations for use of naloxone

Resources for the Trainer

• Sample PowerPoint presentation• Online audio slideshow• Instructional materials

– Infographic assembly instructions– Sample videos– Wallet cards

http://www.nyc.gov/html/doh/html/mental/drug-provider-od.shtml

Contact us for more assistanceAmu Ptah-Riojas(347) 396-7909aptahriojas@health.nyc.gov

Anne Siegler(347) 396-7008asiegler@health.nyc.gov

And thank you for helping save lives!