Get the SKOOP:
Skills and Knowledge on
Overdose Prevention
Bill Matthews, RPA-C
Harm Reduction Coalition
November 2012
1
Objectives
Participants will be able to:
• Discuss the epidemiology and
physiology of overdose; risk factors and
response
• Offer a 10-20 minute overdose
prevention training to other staff and
clients
2
Number of drug poisoning deaths involving opioid analgesics by opioid analgesic
category, heroin and cocaine: 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
Motor-Vehicle & Poisoning Death Rates,
2005- 2006
• Among adults aged 34-56 years, poisoning death rates were higher than
motor –vehicle traffic death rates.
• 92% of poisoning deaths involved drugs.
National Vital Statistics System, mortality data, http://www.cdc.gov/nchs/deaths.htm
5
.
Motor vehicle traffic, poisoning, drug poisoning, and unintentional
drug poisoning death rates: 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
Opioid treatment admissions:
1999-2009 ages 12-24
16000
14000
12000
10000
1999
2004
2009
8000
6000
4000
2000
0
NYC
NYS
NYS OASAS Data Warehouse
7
Opioid treatment admissions:
1999-2009 ages 12-24
3,000
2,500
2,000
1999
2004
2009
1,500
1,000
500
0
Nassau
Erie
Suffolk
NYS OASAS Data Warehouse
8
Counties Reporting Increases in HeroinRelated Overdoses, 2008–2010
9
National Drug Threat Assessment 2011
Percentage of patients and prescription drug overdoses, by risk group
MMWR / January 13, 2012 / Vol. 61 / No. 1
Initial route of opioid abuse versus route of abuse at
admission in a substance abuse treatment center.
Katz, Am J of Drug and Alcohol Abuse, 2011
11
What is the most dispensed
prescription drug in the United
States?
(number of prescriptions filled;
generic and branded products, 2004-06)
12
12
Top 10 Drugs Dispensed in
2010
1.
2.
3
4.
5.
6.
7.
8.
8.
10.
Hydrocodone/Acetaminophen (Vicodin)
Amoxicillin
Hydrocodone/Acetaminophen (Lortab)
Lipitor
Levothyroxine
Lisinopril
Simvastatin
Plavix
Nexium
Singulair
Source: http://www.rxlist.com/script/main/hp.asp
13
13
Opioid pain reliever (OPR) death rates, sales,
and substance abuse treatment admission
rates increased in parallel
OPR Deaths/100,000
OPR Treatment Admissions/1,000,000
OPR sales kg/10,000
8
7
Rate per 100,000
6
5
4
3
2
1
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
National Vital Statistics System (99-09); Automated Reports Consolidated Orders System (99-10); Treatment Admissions Data Set
(99-09)
Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment
admissions, and crude rates per 10,000 population for kilograms of OPR sold.
14
Heroin Overdose
Epidemiology
About 2% of heroin users die each year- many
from heroin overdose
• 1990-98: 5,506 deaths in NYC
• Average of 1-2/day in NYC
• Up to 2/3 of heroin users experience at least
one nonfatal overdose
• 2006: 979 OD deaths in NYC (70% due to
opioids) = ~ 685 opioid deaths
Sporer BMJ 2003, Galea 2003, Coffin Acad Emerg Med 2007
15
What do we know about
overdose?
16
Who overdoses?
• Happens most often in dependent long
term users with 5- 10 years of experience
rather than new users
Sporer 2003, 2006
17
Drug poisoning death rates by age: United States, 1999--2010
45-54
35-44
25-34
55-64
15-24
65 and over
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
Physiology
• Generally happens over course of 1-3 hoursthe stereotype “needle in the arm” death is
only about 15%
• Opioids repress the urge to breath –
decrease response to carbon dioxide -leading
to respiratory depression and death
Slow breathing>Breathing stops>Heart
stops>Circulation of blood to the brain stops
20
Context of Opioid Overdose
• The majority of overdoses are witnessed
(gives an opportunity for intervention)
• Fear of police may prevent calling 911
• Witnesses may try ineffectual things
– Myths and lack of proper training
– Abandonment is the worst response
Tracy 2005
21
An Antidote exists
• Naloxone (Narcan), an injectable opioid
antagonist will reverse the effects of
opioids preventing a fatal overdose.
22
Many opioid overdoses are
preventable!
Get the SKOOP!
23
Legal Status- New 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.
• NYSDOH created regulations for implementation of
opioid overdose prevention programs.
• Naloxone must be dispensed by MD, PA, NP by
federal regulation
24
Components of Opioid Overdose
Prevention Training
•
•
•
•
•
What is naloxone?
What are opioids?
Prevention and understanding risk factors:
Overdose recognition
Action Call 911
– Rescue breathing- using dummy
– Naloxone administration and how it works
– Recovery position
• Report and get refill
• Legality
25
What is Naloxone?
• Naloxone (Narcan) is an injectable opioid
antagonist which reverses the effects of
opioids preventing fatal overdose
• What else will it do?
26
Naloxone (Narcan)
• Opioid antagonist which reverses opioid
overdose
• Pushes most other opioids off the
receptors, then sits on the receptor
preventing it from being activated for 3090 minutes
• Analogy- getting the wrong key stuck in a
lock
27
NOP Opioid Receptor binding pocket
http://www.nature.com/nature/journal/v485/n7398/fig_tab/485314a_F1.html
Naloxone preparations
• Injectable
– Inexpensive: $4.50 per dose
– Well-documented efficacy
– Requires injection, drawing from a medical
vial into a syringe
• Intranasal
– More expensive: $19.25 per dose
– Less well-documented efficacy
– Requires assembly of spay device with nasal
adaptor and naloxone capsule
30
Intramuscular naloxone
•
•
•
•
•
•
A face mask for rescue breathing
Two safety syringes
2 pre-filled vials of Naloxone
2 alcohol swabs
2 latex gloves
1 brochure reviewing OD and rescue
steps.
• Contact information for program
31
WHAT ARE OPIOIDS?
Papaver Somniferum
“Poppy Plant”
.
33
Most commonly used opioids
•
•
•
•
•
•
•
•
•
Heroin
Codeine
Demerol
Morphine
Darvocet
Fentanyl
Dilaudid
Methadone
Opium
•
•
•
•
•
•
•
•
•
Hydrocodone
Oxycodone
Levorphanol
Vicodin
OxyContin
Tylenol 3
Tylox
Percocet
Percodan
Boston Public Health Commission
34
Naloxone does not work for
substances that are not opioids
• Alcohol
• Benzodiazepines
– Xanax, Valium,
Klonopin
• Tricyclics
•
•
•
•
Cocaine
Amphetamines
Methamphetamine
Ecstasy
– Elavil (amitriptylene)
• GBH
• Ketamine
35
Overdose deaths in New York
City involve multiple drugs
(2008)
Nearly all unintentional drug overdose deaths (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, NYCDOHMH
What are the Risk Factors
for Opioid Overdose?
37
Risk Factors for Opioid
Overdose
• Reduced
Tolerance
• Illness
• Depression
• Unstable housing
• Mixing Drugs
• Changes in the Drug
Supply
• History of previous
overdose
• Using in a new
environment
38
Mixing Drugs: Major Risk for Overdose
• Using an opioid with other depressants
such as alcohol or benzodiazepines
• Cocaine is a stimulant but:
– High doses can reduce the respiratory
drive
– Wears off sooner than heroin in a
speedball
– Involved in about 53% of opioid overdose
deaths in NYC
39
Major risk factor: Lowered
tolerance
• Tolerance- repeated use of a substance may
lead to the need for increased amounts to
product the same effect
• Abstinence decreases tolerance increasing
overdose risk
–
–
–
–
Incarceration
Hospitalization
Drug treatment/ Detox/ Therapeutic communities
Sporatic patterns of drug use
– Sporer 2007, Binswanger 2007
40
Risk factor: Overdose Death
following Incarceration
Cause of Death in the 2 weeks postincarceration
Washington State Corrections – studied 30,237 inmates
released (7/99-12/03)
Former Inmates were:
– 12.7 times more likely to die vs. WS residents of same
age, race, and sex
– 129 times more likely to die of overdose vs WS residents
• Opioids: 60%
• Cocaine and other stimulants: 74%
41
• Binswanger et al., 2007
Illness and overdose
Overdose is more likely in the presence of
significant illness
• Liver disease: notably cirrhosis
• Advanced AIDS
• Coronary disease
• Pulmonary disease: notably pneumonia
•
Wang 2005, Darke 2006
42
Other risk factors
• Major changes in opioid supply/
Variations in strength of street drugs
>1000 deaths USA 2006 with
fentanyl
• Depression
• History of previous overdose
• Injection drug use
Sporer 2006, Wines 2007, Pollini 2006
http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin%5Ff
orum,
43
Prevention Messages
• Use with others who know what to do if an
overdose happens – make a plan
• Be aware of companions at all times when
using
• Be careful if using alone, especially if:
– Mixing different classes of drugs
– Using after abstinence
– (And watch out for others in these situations)
• Use a trusted source – one that you know
• “Taste” (test) your shot
• Control your own shot
44
What does an Opioid
Overdose Look Like?
45
Continuum of Overdose
• Overdose is rarely immediate – can happen
over 1-3 hours
• Heavy/ Uncontrollable Nodding
– Still arousable
– Snoring or loud breathing
– May have excess drooling
• Overdose
– Not responsive
– Very shallow breathing, gurgling
– Skin changes, blue lips and nails
• Fatal Overdose
46
Recognizing a Stimulant Overdose
(Naloxone won’t be effective unless an
opioid is also present)
•
•
•
•
•
•
Fever
Profuse sweating
Rapid, (maybe irregular) heart beat
Chest pain
Seizures
Heart attack, Stroke
47
Stimulate the person overdosing
• Shake, call name loudly
• Sternal rub: rub knuckles hard up and
down breast bone (it hurts!)
(Ice can work but this is easier)
48
What NOT to do if a person is
overdosing
•
•
•
•
•
•
Leave without calling 911
Salt shots
Milk shots
Cocaine shots
Ice on genitals/ Shower
Hitting or burning feet or fingertips
49
RESPONDING TO AN
OPIOID OVERDOSE
50
Step One: Get Help
• Call 911- “My friend is overdosing and not
breathing”
• This phrase is more likely to bring
paramedics with naloxone than EMT, who
don’t carry it
• Give location
• Police may come
• New 911 law
51
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
52
Step Two: Rescue breathing
Rescue breathing alone can sustain
someone until EMS arrives
Mouth to mouth is
using a dummy for
practice (if available)
Chest compressions not
included (unless
Responder is trained
in CPR)
53
Rescue Breathing
• Tilt back head to open airway
• Hold nose, lift chin
• Make a seal over the mouth with your
mouth
• Start with 2 quick breaths then one breath
about every 5 seconds until EMS arrives
or person breathes on their own.
54
Intramuscular naloxone
•
•
•
•
•
•
A face mask for rescue breathing
Two safety syringes
2 pre-filled vials of Naloxone
2 alcohol swabs
2 latex gloves
1 brochure reviewing OD and rescue
steps.
• Contact information for program
55
Administration:
Naloxone Injection
• Inject into a muscle (subcutaneous and
intravenous are also effective)
• Acts within 2-8 minutes
• If no response in 2-5 minutes, give 2nd
naloxone injection
• Lasts for 30 – 90 minutes
• (reminder that if 911 has not been
called do it now!!)
56
Injection Technique
• Inject into muscle of upper arm or front of
thigh
• Inject straight in, not at an angle
• Rapidly push needle through skin into
muscle and then push syringe to inject the
medication
• Depth of whole needle is fine (maybe less
deep if person is skinny)
• DON’T INJECT INTO THE CHEST, even if57
you saw Pulp Fiction…
58
Disposing of the Used Syringe
• If safety syringe, engage sheath
• Ask EMS to dispose of the needle or:
• Take to any SEP, hospital or nursing
home for disposal, call first!
• Sharps accepted by some pharmacies
and health care facilities
• Call DOH for disposal site near you
(800-522-5006)
• Contact local Dept. of Public Works
59
Recovery Position
• If you must leave the overdoser even for
a few minutes put them into the
recovery position so they won’t
choke on vomit
60
Results: awake and breathing
Narcan wears off in 30-90 minutes
• Don’t leave the overdoser alone as
sedation may return
• Reassure the overdoser if s/he is drug
sick- the naloxone will wear off- don’t use
more heroin to feel better!!
• Encourage survivor to go to the hospital
61
Next Steps
• Report use of Naloxone to the program
• Anonymous report of date, place, drugs
used and outcome
• Get a refill of the Naloxone
• Even if just one dose was used
• If kit is lost
• If kit is confiscated
• If naloxone is nearing expiration date
62
TIME FOR HANDS ON
SKILLS PRACTICE
Practice these skills:
1. Rescue Breathing
2. Injection/intranasal
Technique
3. Training a Partner
Naloxone in Action
• Reverses opiate effect of sedation and
respiratory depression
• Causes sudden withdrawal in the opioid
dependent person – an unpleasant
experience
• No psychoactive effects – low potential for
diversion, is not addictive
• Routinely used by EMS (but in larger
doses)
• Has no effect if an opiate is not present 64
More about Naloxone
• It is regulated but not a controlled
substance
• Need to obtain from a licensed prescriber
• Should be stored at room temperature and
away from direct light (in kit is OK)
• Has a limited shelf life. Note expiration
date and obtain replacement
65
More about Naloxone cont.
• Emergency Medical Services give 1.2 to
1.6 milligrams of Naloxone which
precipitates severe withdrawal in the
dependent person
• Overdose prevention services recommend
starting with 0.4 with an additional dose
readily available – found to be effective in
most instances
66
Role of EMS
Patients receiving naloxone, not being transported to
ER: deaths known to medical examiner
• 998 patients refused transport: none within 12 hours
• 552 patients refused transport: none within 48 hours
• 2241 patients discharged by EMS over 10 yrs: 14
within 48 hours; 3 (0.13%) of potential rebound
overdose
Limitations: some medical evaluation, varying doses of
naloxone; all SKOOP responders instructed to call
EMS
•
San Diego: Vilke Acad Emerg Med 2003; San Antonio: Wampler Prehosp Emerg Care 2011;
Copenhagen: Rudolph Rescusitation 2011
Safety in the field
Over 3,500 kits distributed
319 overdose reversals reported
• 1 unsuccessful revival
• 1 seizure
• 1 vomited
• Only 5 cases with more than 1 injection
• No cases of re-treatment after naloxone wore off
•
Maxwell 2006
68
Overdose fatality prevention
programs that distribute naloxone:
USA, 2010
2010 survey of programs known to the Harm
Reduction Coalition
• 189 local programs in 16 states
• 1996 - 2010:
–53,339 individuals have received kits
–10,194 overdose reversals reported
Personal communication Eliza Wheeler, Harm Reduction Coalition
Cocaine and heroin rates decreased while
opioid analgesic rate increased
Heroin
Cocaine*
Benzodiazepines*
Sedatives
Opioid Analgesics*
Methadone
Anti-Psychotics
* P-Value less than .05; (2005 vs. 2009)
70
Heroin-related Deaths, San Francisco, 1993-2010
160
140
Naloxone distribution begins, 2003
120
100
Heroin-related deaths
80
60
40
20
0
19931994
19941995
19951996
19961997
19971998
19981999
19992000
20022003
*Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org
**no data available for FY 2000-2001
20032004
20042005
20052006
20062007
20072008
20082009
20092010
Effect of naloxone on overdose
death: Chicago, US
Heroin overdoses dropping
Allegheny County Trends in Accidental Drug Overdose Deaths
2000-2006*
*Data is from Allegheny County Medical Examiners Annual Reports and includes all
overdose deaths where these drugs were present at time of death, not necessarily cause of
death.
Heroin Use in Allegheny County by Fiscal
Year
*Data from Pennsylvania Department Of Health
Opioid maintenance and
mortality
• Prospective study of opioid dependent
patients applying for methadone treatment
in Norway
• 3,789 subjects followed for up to 7 years
• Clausen Drug Alc Dep 2008
Results
Pre-treatment
In treatment
Post-treatment
Total mortality
Odds ratio
1
0.5
1.43
Total overdose
Odds ratio
1
0.20
1.40
Percent
of deaths due to
overdose
79%
27%
61%
Clausen 2008
Maintenance therapy prevents
overdose
•Since the institution of buprenorphine and methadone
maintenance in 1996 in France heroin overdose has dropped by
79%
600
French population in
1999 = 60,000,000
No. of deaths
500
400
Patients receiving buprenorphine
(1998): N= 55,000
300
200
Patients receiving methadone
(1998): N= 5,360
100
0
1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999
Year
77
Auriacombe et al., 2001
78
• "I did SOMETHING, you know, that made a difference. The
whole world can’t see it but I know it made a difference. And
that’s important . . . to me."
--quote collected by Suzanne Carlberg-Racich, Chicago
“You get nervous, you know – someone’s blue, someone’s
dying. But you do it because we are all out here together and
people are going out right and left.”
--Boston man, age 29
"If you ever get in a meeting with some professional type
people, tell ‘em that, you know, people like us–
no, we’re not professionals, but if we have it at hand we can
save somebody’s life with this stuff [naloxone]. . . it’s a
lifesaver, there’s no question."
--Program participant in Chicago; Maxwell S, et al. J
Addict Dis. 2006;25(3):8996.
79
RESOURCES
• Harm Reduction Coalition
(harmreduction.org)
NYSDOH(www.health.state.ny.us search for overdose)
• On-line CASAC training and credit
– www.oasas.state.ny.us
80