Overdose Prevention
Train-the-Trainer for NYPD
October 29, 2013
Amu Ptah-Riojas
Anne Siegler
NYC Department of Health and Mental Hygiene
Bureau 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.
2.
3.
4.
5.
Why are we talking about overdose?
Who is at risk of overdosing?
What does an opioid overdose look like?
Responding to an opioid overdose
Tools for training others to respond to an
opioid overdose
Epidemiology of drug overdose in NYC
WHY ARE WE TALKING ABOUT
OVERDOSE?
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 NYC
2000-2012
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
“Prescription plague rages: A fatal overdose on
Staten Island every 9 days in 2011”
Staten Island Advance, May 14, 2013
“On Staten Island, painkiller overdoses deadlier
than car crashes, murder”
Staten Island Advance, May 11, 2012
Physiology of opioid overdose – Part 2
WHAT DOES AN OPIOID OVERDOSE
LOOK LIKE?
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 Overdose
1. 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
Physiology of opioid overdose – Part 1
WHO IS AT RISK?
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 nonmedically trained personnel
• Good Samaritan 911 laws
So what do we do?
RESPONDING TO AN OPIOID
OVERDOSE USING NALOXONE
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 not
included (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 nonarrest 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.
What else you need to know
NALOXONE AROUND NEW YORK
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
Progress to date:
2006 - 2012
• 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
Encouraging people to call 911:
NY’s Good Samaritan law
• 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
Pass it on!
TRAINING OTHERS TO RESPOND TO
AN OVERDOSE
30-minute training for NYPD members
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)
Materials you need to do the training
• 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
Agenda for 30-minute training of NYPD
members
1.
2.
3.
Recognizing an overdose: what does an OD look like?
Risk factors for an opioid overdose
Responding to an overdose
a) Sternum rub
b) Rescue breathing/CPR
c) Naloxone
4.
5.
NYS law on naloxone administration and 911 Good Samaritan law
Expectations of NYPD trained in overdose prevention
a) Reporting
b) Storage
c) Refresher trainings
6.
Dispense naloxone and prescription, blue state certification card
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/drugprovider-od.shtml
Contact us for more assistance
Amu Ptah-Riojas
(347) 396-7909
aptahriojas@health.nyc.gov
Anne Siegler
(347) 396-7008
asiegler@health.nyc.gov
And thank you for helping save lives!