TRAINING MANUAL: OVERDOSE PREVENTION AND RESPONSE

Transcription

TRAINING MANUAL:
OVERDOSE PREVENTION
AND RESPONSE
Thank you for taking the time to review this manual which will assist you in educating
individuals about overdose prevention and response. This training includes education about
the use of naloxone, an opioid antidote, to address the morbidity and mortality associated
with opioid overdoses. An overview of naloxone, how it works and other details related to the
Take Home Naloxone program in BC can be found at http://towardtheheart.com/naloxone/
Information in this manual comes from multiple sources including community, medical, and
academic resources. Most importantly, it has come from people who use drugs who have
taken the time to educate and share lived experiences in the ongoing effort to preserve life
and prevent unnecessary deaths.
Table of Contents:
1.
2.
3.
4.
5.
6.
Who should use this training manual?
Purpose of this Training Manual
Who is eligible to receive a Take Home Naloxone kit?
Preparing for a Training Session
Session Introductions
Participant Knowledge Objectives
A. Factors that can increase or decrease risk of overdose
B. How to recognize an overdose; including depressant and stimulant overdoses
C. How to respond to an overdose; using SAVE ME, including:
- how to put someone in the recovery position
- how to communicate with 911and why it is important to call
- how to prepare and administer naloxone
- how and when to evaluate and support
D. Completing the Take Home Naloxone Administration Information form
7. Video: Live! Using Injectable Naloxone to Reverse Opiate Overdose
8. Introduction to BC Take Home Naloxone Kit and Practice Injection
9. Record Keeping and Legal Considerations
10. Appendices
Appendix A: Community Development and Engagement for a successful program
Appendix B: Program Documents and Related Information
I. Program Guide: Initiating & Implementing a Program
II. Backgrounder
III. FAQ’s
IV. Overdose Prevention Training and Kits: Community Information
V. Training Attendance Form
VI. Pre/Post Test Quiz
VII. SAVE ME Poster
VIII. Administration Information Form
IX. Certificate of Completion and Participant Knowledge Checklist
X. Overdose Survival Guide – Tips to Save a Life
XI. Sample Script
XII. Dispensing Record
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1. Who should use this training manual?
This training manual is to be used by the educator, who may be either the prescribing physician or
another health-care professional (e.g. a registered nurse delegated by the prescribing physician) to
perform the training session. The naloxone program webinar (which should be watched prior to
initiating training) can be found at www.towardtheheart.com
2. Purpose of this Training Manual
This manual provides the educator with the core knowledge that must be transmitted to the
participant. This manual contains up-to-date information and resources that may be beneficial.
Training can be modified to meet the requirements of the prescribing physician, available resources,
and the group dynamics (i.e. size, history of use, etc.) or individual circumstances. Guiding questions
are highlighted in sections to facilitate group discussion.
The core information needed to be understood by participants is basic overdose prevention for
stimulants and opioids, identification of an overdose, and response, including naloxone
administration.
3. Who is eligible to receive a Take Home Naloxone kit?
An individual who has received this training, has a history of using illicit opioids (illegal or diverted
prescription), and has a written prescription from a physician is eligible to receive a Take Home
Naloxone kit. Individuals who don’t use opioids, but know someone who does (e.g. support workers,
peers of people who use opioids, family members) are not eligible to receive a kit. They are
encouraged to attend the training to learn how to administer naloxone in an emergency and how to
respond if naloxone isn’t readily available. Morbidity and mortality related to any kind of overdose is
greatly reduced when the community has an increased awareness of how to mitigate risks, recognize,
and respond appropriately in a timely manner.
4. Preparing for a Training Session
The educator should use their professional discretion regarding inclusion of additional content, size of
group, and the appropriate instructional methods to best engage participants. Group training sessions
are encouraged in community and non acute settings and can be longer if appropriate. Allow time
after group trainings for individual support/discussion.
Length of training: individual training 15-20 minutes; group training 1-hour not including
prescribing/dispensing of kits
Resources Required (will depend on the environment, audience, group size, experience, and time):
• Sample THN kit
• Practice ampoules, gauze and VanishPoint® syringes - enough for all participants
• Oranges or very thick sponge to practice injecting into and Sharps container
• Forms (found in the appendix and online at towardtheheart.com)
 Attendance Form
 Certificates with Participant
 Pre/Post Quiz – one for each person
Knowledge Checklist on the back note: print double-sided and cut in ½
one for each participant
 THN Administration Information
 Overdose Survival Guide – Tips to
sample to show form in kit
Save a Life - one for each participant
• Pens and writing paper for participants
• Audio/Video Set-up: laptop computer with internet access or recommended video downloaded
Optional
• Whiteboard or chart paper/markers/tape
• Plastic Page Protectors for participant to put their certificate etc. in
• Dolls to practice rescue breathing
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Suggested tips from training experience:
- Bring out sample THN kit and practice tools after video
- Some paperwork can be filled out by educator/assistant during video to assist completion
- Helpful to have SAVE ME written vertically on chart paper/board with words associated with each
letter of the acronym to refer to
- As the educator you may want to follow up with particular participants to clarify the knowledge
they are taking away with them. The Participant Knowledge Checklist is a good guidance
document to help in this process
5. Session Introductions
“Today we are going to learn how to save a life in the event of an overdose.”
• Let participants know the structure of the session: length, breaks (if any), content etc.
• Introduce who you are, where you come from, and why you are offering overdose training.
Acknowledge your position and the lived experience of the people who are receiving the training.
• Tell participants if you don’t have answers to their questions – you will find out and let them know.
Remember to make a note of questions for follow-up.
If training in a group – suggested round-table of:
Give name (as wish to be identified) and one thing that you would like to learn in the training today?
• If training in a group, consider creating a group agreement by asking participants what is important
to them for effective group functioning (e.g. confidentiality, speaking one at a time, respectful, etc.).
• Encourage participants to take care of themselves; acknowledge that this can be a heavy topic –
they may need to get up to take a quick break or use the washroom, can ask their neighbour to nudge
them if they fall asleep, they may need to debrief after training etc.
• Discussing your role as a facilitator and monitor can make it easier to keep the group on track later
in the session. For example, let people know in advance that as the facilitator you may move the
discussion along to be mindful of everyone’s time and to make sure you get through all the material,
but will be available after the training for extra discussion, questions, and support.
Pre-test Quiz
Can be done individually or used to facilitate group discussion. Going through the questions as a
group may help to address varying levels of literacy. Some people may not take the training if they
think they have to be able to read. The post-test can be done at the end to solidify knowledge.
6. Participant Knowledge Objectives
After completing the training, the participant will demonstrate an understanding of:
A. Factors that can increase or decrease risk of overdose
B. How to recognize an overdose; including depressant and stimulant overdoses
C. How to respond to an overdose; using SAVE ME, including:
- how to put someone in the recovery position
- how to communicate with 911and why it is important to call
- how to prepare and administer naloxone
- how and when to evaluate and support
D. Completing the Take Home Naloxone Administration Information form
As an educator, you will:
 communicate that naloxone and Narcan® are different names for the same drug, that it only
works in overdoses involving opioids. Naloxone is not the same as Naltrexone®
 dispel myths and acknowledge fears
 increase comfort and competency of participants to respond to an overdose rapidly and
appropriately
 acknowledge the value of participants learning this life saving skill
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Everyone will have experience with overdose – from personal experience, work, or other sources.
Some knowledge about how to respond may be incorrect, take more time, and can cause harm. As
the facilitator acknowledge many myths about how to respond to overdose exist and gently correct
misconceptions. If someone in the group reports that an individual was “revived” by being given: an
injection of salt water or milk, “opposite acting substance”, an ice bath or ice on their genitals, or
beaten until they wake up; acknowledge that it may have “worked” in that instance. Any action
someone used in the past to keep that person alive is commendable. Opioids suppress the brains
ability to monitor and react to the lack of oxygen in the body; they need air. The quicker a person’s
oxygen levels are increased or restored, by giving naloxone and/or by giving breaths, the better the
chances are in preventing lifelong damages and death from opioid overdose. Clear the airway, give
rescue breathing, and administer naloxone if you have it.
Naloxone will not cause harm and is scientifically proven to reverse opioid overdose quickly.
6. Participant Knowledge Objective A:
Factors that can increase or decrease risk of overdose
What is an overdose?
An overdose is when the body is overwhelmed by exposure to something, in this case a toxic
amount of drug or combination of drugs which cause the body to be unable to maintain or
monitor functions necessary for life. These are functions like breathing, heart rate, and
regulating body temperature. Not everyone who overdoses will die; however, there can be
long term medical impacts from overdose.
Harm reduction includes creating connections to provide opportunities to discuss with individuals how
they take care of themselves, while sharing knowledge, skills, resources and supports that are useful
to them at that time in their life to promote safety and reduce death, harm, disease, and injury.
Relevant and feasible strategies depend on the situation, are unique to each individual and may
change.
Anyone can overdose no matter their history or age. There is no exact formula. Overdose risk can
increase or decrease depending on variables related to the 3 factors in the following figure:
•
•
•
Mixing
Quantity
Potency
Quality/Cut
•
•
•
•
•
Age
Tolerance
Health Status
Genetic Factors
Other Medications
•
•
•
•
•
Injection
Inhalation
Ingestion
Snorting
Inserting
What are some of the drugs people use?
What are some of the drugs people combine?
What are some things people could do to test the strength of a new batch?
What are some ways to reduce the risks associated with these factors?
What are some things you can do to look after your body to reduce overdose?
When are some times a person’s tolerance might change?
What are some things a person could do if they just got out of jail and bought heroin?
(Possible answers: test drugs, buy from someone they trust, not use alone, be sure to have
discussed OD plan, carry naloxone, smoke instead of inject until they have some tolerance etc.)
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Substances:
Mixing: mixing drugs with other substances, including alcohol, sleeping pills, cocaine
Prescribed medications can also increase overdose risk – for example mixing either Ritonovir (HIV
medication) or anti-depressants with Ecstasy
 Prevention: use one drug at a time, do not mix the highest risk ones (e.g. opioids, alcohol and
pills), if you are going to mix anyway, choose to use opioids before alcohol or pills, and reduce the
amount you take. Alcohol is often an underestimated risk factor; it impairs judgment and has an
additive effect. People often think that mixing stimulants with a depressant will cancel out the risk.
But people who speedball (mix) are at higher risk because the body has to process more drugs.
Stimulants cause the body to use up more oxygen and depressants reduce the breathing rate. Let
people around you know how much and what you are taking
Quantity: amount of drugs used. Some drugs are harder to measure (e.g. GHB) or may have varying
time release mechanisms (immediate vs. extended). Individuals may have taken more drugs
intentionally or by accident, being unaware of the additive effects and the delayed onset
 Prevention: use standardized measuring (harm reduction programs have access to ordering
syringe barrels without needle tips) or devise a readily available measuring method (e.g. pop
bottle cap noting size and if it has the plastic liner or not). Wait before taking another dose,
knowing it can take longer to feel the effects of some drugs. Not all opioids are created equal;
practice caution when substituting or transitioning one opioid for another.
Potency: concentration, quality, cut. Substances can have unknown content/adulterants due to
processing (e.g. PMMA sold as MDMA). Other substances can be added by people who have
handled drugs before the consumer either to expand the amount of product they have or to enhance
the effects of the drugs. Inversely, sometimes drugs are not cut to change hands quickly
 Prevention: test your drugs, some places offer drug testing (raves/festivals) or test drugs by doing
small amount at first, “two in the arm is better than one in the ground, [in the grave]”. Take the
tourniquet off before depressing plunger, stop half way to see effects, inject less if it feels too
strong. Purchase from reliable source (know your dealer). Check with community who might be in
the know about current drugs in the area; people who use drugs, harm reduction service providers
Individual Characteristics:
Research shows having overdosed before, using alone or in an unfamiliar environment, and
increased age are increased risk factors for fatal overdose.
Tolerance: tolerance changes rapidly with even a few days of not using or reduced use. High risk
times include: exiting jail, hospital, detox/treatment, and starting/tapering methadone maintenance
 Prevention: use less, do testers, change route of administration (injecting to snorting or eating
drugs) until tolerance is developed
Health Status: general physical health: liver, kidney, and respiratory function, compromised immune
system, high blood pressure, heart disease, diabetes, smoking, current infections, sleep deprivation,
dehydration, malnourishment, and mental health status can all play a part in overdose situations
 Prevention: eat, drink fluids like water, sleep, seek health care regularly as appropriate, go slow,
take breaks, use less when you have been sick, lost weight, or feeling down – doing more to “feel
better” is a risk factor for overdose
Genetic factors: how an individual breaks down drugs can be influenced by genetic make-up
 Prevention: be informed. Know risks associated with different drugs and be aware the drug may
be something different. Apply as many prevention measures as possible; discuss a plan with
people you are with of what to do if something goes wrong
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Other medications: The liver processes all drugs in a person’s body. A person with a damaged liver
may be more prone to longer or more frequent overdoses
 Prevention: research or discuss with a health care provider you trust about interactions of the
drugs you take; prescribed, over-the-counter, and drugs you get on the street.
Route:
Determines how quickly the drug takes effect. A fast injection into the vein will affect the body more
quickly and intensely than ingesting. In general, the faster a drug hits blood stream (i.e. smoking or
injecting), the greater the risk of overdose. You can still overdose even if you don’t inject.
 Prevention: Be careful when changing routes – you may not be able to handle the same amount.
Consider snorting or ingesting if you are using alone or may have decreased tolerance.
General Prevention messages:
 Don’t use alone, or use in a place where people can help if needed (leave doors unlocked etc.). A
harm reduction strategy from someone who always uses alone is to know their limit and only buy
drugs with consistent manufacturing methods
 Talk to an experienced person or trusted healthcare provider about reducing risk. If you have a
relationship with health care provider or person you trust – let them know you are going to use and
to ask them to check on you shortly
 Learn overdose response training, and carry naloxone
 Create an overdose plan with peers or family members so in the event of an overdose there is a
quick and effective response, with no hesitation in calling 911. Talking about this before an
emergency happens can clarify what needs to be done and reduce the responder’s anxiety;
allowing them to act quickly and effectively, with no hesitation in calling 911
A checklist of suggested things to discuss in creating an overdose response plan include:
 Knowledge of overdose prevention
 If and when individual (who overdosed) wants






techniques
When to start OD response – colour and #
of breaths per minute (<12breaths)
When to call 911
When to administer naloxone
Where is best to administer (shoulder or
thigh)


to go to the hospital
Who else to call
What to do with belongings while individual is
treated for overdose
Agreement to stay until naloxone wears off
A commitment to not use again after being
administered naloxone
Potential for risk is created and heightened by social-structural environments; homelessness, having
to inject in public, poverty, irregular drug supply, incarceration, and unsupported mental health; all
these put people at greater risk for overdose. These are very important issues, but will not be
addressed in today’s workshop.
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6. Participant Knowledge Objective B: How to recognize an overdose
How do you recognize an overdose? (upper vs. downer)
What does it look like when someone is overdosing on heroin?
Who has seen an overdose? How did you know that it was different than a heavy nod?
“The line between being someone being high and overdosing is unresponsive.”
Call their name. Tell them to breathe. A medical emergency is when they do not respond to:
someone calling their name, telling them to take a breath, or pain from a firm sternal rub (demonstrate
taking knuckles and rubbing on breast bone). Call 911.
Signs of overdose to look for are:
Depressants (downers - including opioids)
e.g. Alcohol, GHB, benzodiazepines
Opioids*: morphine, dilaudid, heroin, methadone
- Person can’t stay awake, walk or talk
- Slow or absent pulse
- Slow or absent breathing, snoring or
gurgling. Less than 10-12 breaths per
minute (a breath every 5 seconds is
normal)
- Skin looks pale or blue, especially nail
beds and lips, feels cold
- Pupils are pinpoint or eyes rolled back
- Vomiting
- Body is limp
- No response to noise or knuckles being
rubbed hard on the breast bone
- Unresponsiveness
Stimulants (uppers)
e.g. Cocaine, crack, Ritalin®, methamphetamine,
ecstasy
- Fast pulse or no pulse
- Short of breath
- Body is hot/sweaty, or hot/dry
- Racing pulse, shortness of breath
- Confusion, hallucinations, unconscious
- Clenched jaw
- Shaky
- Chest pain
- Seizures, loss of consciousness
- Vomiting
- Cannot walk or talk
- Rigid or jerking limbs
*The term “opioid” is inclusive of the entire class of drugs, whether natural, semi-synthetic, or synthetic, that activate the body’s existing
opioid receptors. “Opiate” refers only to drugs derived from opium.
6. Participant Knowledge Objective C: How to respond to an overdose
The Recovery Position
If you have to leave an unconscious/unresponsive person at any point, put them in the recovery
position. This helps to keep the airway clear from their tongue or vomit. During an opioid overdose,
the depressed breathing can cause the lungs to fill up with excess fluid – if you are not actively
working on an individual (giving breaths or administering naloxone) put them in the recovery position.
The potential for the lungs to fill up with fluid can happen quickly; this is another reason why calling
911 and the individual seeking medical attention is important.
Demonstrate and practice the recovery position– pick the same leg as the hand that goes across the
body to the opposite cheek. In the picture below it is the left leg and the left arm that get bent
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In all overdose events it is recommended:
To call 911, stay with the person, remain calm,
use the person’s name when talking to them
and calmly let them know what you are doing
as you are doing it (even if they appear
unresponsive).
People who have overdosed have said
someone using their name and talking to them
calmly has made a big difference.
Responding to a Stimulant Overdose:
Stimulant Over-amp: If the individual
is conscious and experiencing “over-amping”
or mental distress (i.e. crashing from sleep
deprivation, anxiety, paranoia) linked to
stimulant use and you are sure this is not
medical in nature, they may just need support
and rest. Call Poison Control 1-800-567-8911
to help assess. Encourage them not to take
any more substances. If possible move away
from activity and noise, open a window, and
place cool wet cloths on forehead, back of
neck, and under armpits. Being careful not to
over-hydrate; give water or other non-sugary,
non-caffeinated drink to help replace lost
electrolytes. If aggressive/paranoid ask if it
helps if they close their eyes and be aware of
their personal space. Call 911 at any point you
are not comfortable.
Stimulant Toxicity: If the individual has
symptoms of stimulant toxicity, including rigid
or jerking limbs, in and out of consciousness,
seizures, rapidly escalating temperature and
pulse, or chest pains this is a medical
emergency. Call 911 immediately. The
person needs immediate acute medical
attention! This cannot be dealt with at home.
Stay with the individual for support, encourage
hydration, and stay calm. Do not give them
anything by mouth if they are unconscious. If
they are having a seizure make sure there is
nothing around them that can hurt them. Do
not put anything in their mouth or restrain them.
There is no antidote to stimulant overdose.
Naloxone will not help. If the heart has
stopped provide chest compressions. Tell
medical professionals as much as possible so
they can give the right treatment to prevent
organ damage and death.
Responding to a Depressant Overdose:
Support the person similar to an opioid overdose response without the administration of naloxone.
Respond with the SAVE steps until the help arrives. Emphasize calling 911. Naloxone has no effect
on depressant overdoses that do not involve opioids. However, if the overdose involves multiple
substances including opioids, it will temporarily take opioids out of the picture.
Responding to an Opioid Overdose:
Fatal opioid overdoses are rarely instantaneous – they usually happen over 1-3 hours, are frequently
witnessed but may not be recognized as an overdose. Therefore it is important to wake someone up
if they are making unfamiliar snoring or gurgling noises. Many instances occur of individuals losing a
loved one after hearing them “snore”, making unfamiliar sounds, and leaving them to sleep, to find out
too late it was an overdose. Take the chance of them being upset that you woke them up.
Give Breaths:
If medical assistance or naloxone is not available – give breaths and stay with the person. Often this
is enough to save someone’s life.
Canada and US CPR Guidelines recently changed to “hands-only” CPR. However, in instances
where a child or an adult has stopped breathing (choking, strangulation, drowning, or other
respiratory issues) mouth-to-mouth improves survival. Most OD response programs recommend
giving breaths in opioid OD because the person lacks oxygen. Only if the person has been oxygen
deprived for a very long time or are without a heartbeat should they receive chest compressions.
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Tell responder to go slow, continuously evaluating the impact of their actions on the individual, remembering to take breaths for themselves.
Professionals are the best equipped to deal with an overdose situation - find extra support (if available) until they arrive.
SAVE ME
S
A
V
E
M
E*
Stimulate. Can you wake them? Call their name,
give sternal rub (demonstrate), tell them to breathe.
If you cannot wake them call 911. If you have to
leave them, put them in the recovery position.
Calmly, tell the operator that person is not breathing
and not responsive.
When approaching a stranger – use foot to nudge their foot, yelling at them to
wake up. Be wary when approaching people who appear to be “sleeping” or
“unresponsive”– be sure to say out loud the actions you are doing.
Airway. Make sure nothing is in their mouth that
keeps them from breathing – gum, food, pills, rig cap,
etc.
Ventilate. Breathe for them. Tilt head back, place
barrier over mouth, plug nose, and give 2 breaths.
Breath should be big enough to make person’s chest
rise. Continue to breathe for the person – one breath
every 5 seconds.
Evaluate. Are they any better? If not, prepare
naloxone. If you are the only responder, you can stop
breaths temporarily while you get naloxone ready.
In training: can ask participant to tuck chin down on their chest and try to
breathe – demonstrating how a relaxed tongue can block airway. Moving head
can sometimes get someone breathing again.
Muscular Injection. Inject 1cc of naloxone into a
muscle at a 90° angle. Outer thigh or the meaty part
of the shoulder. Can give through clothing.
Evaluate and Support. Is the person breathing on
their own? Has their colour improved? If the naloxone
has no effect within 5 minutes and opioids are
involved* administer another dose of naloxone. Tell
the person not to use anymore drugs for at least 2
hours. If person is feeling dope sick, tell them it will
start to wear off in about 30 minutes and opioids in
the system can reach the receptors again.
Check breathing. A person needs to take a breath every 5 seconds.
If person responds keep them moving and awake – watch them for several
hours.
Look, listen, feel if they are breathing. Head above mouth, look towards chest.
Remind the individual that instructions are on the barrier.
You cannot catch HIV by giving mouth to mouth. If you are still concerned
about touching someone’s mouth and do not have a breathing mask – can
give rescue breaths through a shirt placed over their open mouth and plugged
nose.
10 second pulse check if (10-12 heartbeats in this time)
Has breathing improved? Colour?
If you do not have naloxone – just breathe. Keep breathing for them until
the ambulance arrives. This can be very effective.
Suggest individual takes a deep breath before administering naloxone.
If this is not an opioid overdose naloxone will have no effect.
Explain they may have to continue breathing normal sized breaths, every five
seconds into person until the naloxone starts to work, and person starts to
breathe on their own or until the ambulance arrives. Suggest counting out
loud if it helps: one one thousand, two one thousand, three one thousand, four
one thousand, breathe.
Put needles in sharps container or plastic pop bottle with lid to dispose of
safely.
When the paramedics arrive – be sure to tell them as much as possible – what the person has taken and what steps you have taken.
*If you haven’t called 911 yet, call NOW. It’s important to call 911 because:
 There might be another medical emergency that naloxone will not work for, or the overdose may not have been from opioids alone
 the person may overdose again when the naloxone wears off
 there is a small chance of side effects from the naloxone, such as a hypersensitivity (allergic) reaction
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Acknowledge that there may be fears about calling 911. For example fear of legal risks (outstanding
warrants, loss of children or housing), judgment from family or community, shame, past experiences,
or other things they may have heard (being deported, murder charge, etc). But the person could die
or suffer long-term consequences of an overdose if they do not receive adequate medical treatment.
Stress the importance of staying with the individual after giving naloxone because:
 when the person wakes up they may have no memory of overdosing or receiving naloxone –
explain to them what happened
 the person should be discouraged from using more opioids for at least 2 hours. Symptoms of
withdrawal sickness will start to wear off in half an hour. Using more opioids will be a “waste”.
While naloxone is in their system it blocks opioids from getting to receptors and they will
continue to feel sick; it will also make the overdose more likely to return
 to tell the emergency response team as much as you know – what they took and what you
have done so far
6. Participant Knowledge Objective D: Completing the THN Administration Information form
A form is included in the kit to record the use of the naloxone. It can be filled out by the individual who
received or administered the naloxone. Please fax all forms to the BC Harm Reduction Program
(604.707.2516). This information is important to evaluate the kits, training, and the impact of the
provincial initiative. Please complete as accurately as possible.
If individuals need help filling out the form, someone at a local harm reduction site can help them to fill
it out. The form can also serve as a tool for discussing the potentially traumatizing event.
Acknowledge that using a naloxone kit can be a stressful experience for many individuals and talking
to someone about it right away or days after the event may be helpful. Ask them to take care of
themselves by doing this if needed.
Involvement in an overdose can bring up memories of previous overdoses or deaths where if
naloxone was available a life might have been saved. It can bring up grief and loss and mortality. It is
important to acknowledge that an individual has taken the time to learn a very valuable skill to save
someone’s life. This is a skill that everyone should have, but not everyone does.
7. Video: Live! Using Injectable Naloxone to Reverse Opiate Overdose (13:13 minutes)
A great resource from the Chicago Recovery Alliance:
http://www.youtube.com/watch?v=U1frPJoWtkw
Explain that the naloxone used in the video is different than the naloxone in the BC THN kits.
The video uses multi-dose vials; the BC initiative uses single dose glass ampoules to eliminate
contamination risks and simplifies the dosage for administration.
While the video is playing it may help to state the SAVE ME steps out loud as they occur in the video:
Stimulate, Airway, Ventilate, Evaluate,
Muscular Injection, Evaluate.
8. Introduction to BC Take Home Naloxone Kit and Practice Injection
During the training, practice the skills important to respond to an overdose:
• Show kit. Show SAVE ME instructions in the lid. Remove contents to discuss various pieces.
• Explain the kit contains gloves and a breathing mask to practice universal precautions –
creating a barrier and protecting both individuals.
• Alcohol swab package – can use swab to wipe off skin prior to injecting or to cover ampoule.
• Show that naloxone is wrapped in gauze in the labeled pill bottle in accordance with
pharmaceutical regulations. The pill bottle is to protect the naloxone.
• Taking Care of the Naloxone: Keep out of the sunlight and at room temperature. Don’t
put in the refrigerator.
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•
Check the expiry dates of the naloxone periodically, it lasts about 2 years. If the naloxone
gets close to the expiry date, suggest they bring it back for a new kit. The old kit can be used
for demonstration.
Demonstration and Practice with VanishPoint® syringe and water ampoule:
• Remove VanishPoint® syringe from packaging. Explain it is an intra-muscular safety syringe.
Compared to syringes used for intravenous injections, it has a larger needle (the lower the
gauge the bigger the tip), and automatically retracts when the plunger is depressed all the way.
• Holding practice glass ampoule (filled with water) upright by tip, swirl in a circular motion to
gather all liquid in the base of the ampoule. This is an important step.
• Put narrow tip of glass ampoule in open swab package or use the gauze provided. Hold the
base with one hand and the covered top with the forefinger and thumb of the other hand and
pull covered ampoule top towards you – thus breaking ampoule away from body.
• Put the top aside and set ampoule down. Demonstrate that the ampoule is designed such that
if it is inverted or tipped over, fluid will not come out.
• Take the needle cover off the VanishPoint® syringe; draw up all the liquid from the ampoule.
The 25g tip helps to avoid drawing any glass shards into the syringe. If there is air in the
syringe, try to remove it without losing “naloxone”. Because the injection is going into a large
muscle, having a small amount of air or glass in the syringe will not matter. The urgent need to
restore breathing is more concerning. Show participant where muscular injection should go.
• Hold an orange or dense sponge steady in one hand, hold the syringe like a dart insert into
“flesh” at a 90° angle. Slowly depress the plunger of the VanishPoint® syringe all the way until
the needle retracts.
• Suggest safe disposal of syringe and ampoule into a sharps container or plastic bottle with lid.
9. Record Keeping and Legal Considerations
Naloxone is not a controlled substance, and is specifically excluded from the Controlled Drug and
Substance Act Schedule 1. It is regulated under the Federal Food and Drugs Act (Schedule F)
making it a Prescription Only Medication (POM). As part of prescription regulations, patient
information must on the prescription (full name, etc) and collected. Similar to any prescription
medication at a pharmacy, the individual’s information is kept confidential. The BC Harm Reduction
Program keeps a confidential record of this information. In the rare case a batch of medication is
compromised from the pharmaceutical company, the individuals and the associated batch #’s need to
be traceable. Data collection ensures accountability and will inform the program evaluation and
potential expansion. None of the unique identifiers (names, birthdates, etc.) will be used for this part
of the process.
Individuals should keep the naloxone in the case in which it was dispensed with the paperwork; thus
the naloxone container will have the individual’s name on it. Liability related to various aspects of
naloxone is a common concern. There are no known cases of legal action related to naloxone. Many
places have legislation protecting people who prescribe, dispense, or administer naloxone from
liability, including 11 US states (see http://towardtheheart.com/naloxone/service-providers/ for
references). Ask participants to let you know if they experience any problems from carrying naloxone.
As part of implementing a successful naloxone program it is the THN teams’ role to work with their
community to reduce potential barriers for people carrying naloxone. Please see Appendix A for
considerations.
For more information please see the legal opinion from PIVOT on www.towardtheheart.com
End of training session content.
More resources can be found on www.towardtheheart.com in the Naloxone section including links to
papers, videos, games, and shorthand training documents from other programs.
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10. Appendix A: Community Development and Engagement for a Successful Program
A key strategy of any successful program is assessing your local environment and building strong
partnerships. Engagement in the early stages of development will provide opportunities to address
concerns, help to increase community understanding and support; reduce the potential roadblocks in
the future. Comprehensive and inclusive partnerships offer benefits such as: consistency in program
development, increased support and uptake of new initiatives, reduced duplication of activities, cost
effectiveness, increased reach and impact, and increased levels of information and knowledge about
the issue in the community. Multi-agency collaboration, utilizing different expertise in the community,
will help build a program that is best suited to the community needs. Engaging multiple partners in
meaningful ways about drug use can help to build capacity within a community to provide coordinated
care and reduce drug-related harm including stigma.
All of these components are particularly important in increasing accessibility of harm reduction
measures for all individuals. The more people that know about the THN being offered in the
community the greater the chances that it reaches someone who is at risk. Enabling more individuals
to become aware of how and where they can access resources to support their health and reduce
social barriers (shame and stigma) that perpetuate isolation.
Preventing and responding to overdose is often met with less opposition than other harm reduction
initiatives. This may be a good framework to forge new partnerships and garner support. Overdose
happens in all communities and populations who deal with pain. Naloxone education may be a way to
engage communities that are resistant to acknowledging drug use or may have strict rules about
substance use, or are less willing to talk about harm reduction.
Law Enforcement and Emergency Responders
People report not calling 911 due to fear of legal ramifications, therefore engaging law enforcement
prior to program initiation is important. Developing communication strategies and working
relationships with local law enforcement may reach beyond these key objectives and outcomes
related to overdose:
• Increase awareness about the overdose prevention initiative and naloxone kits. Highlight the
program operates within provincial, federal, and medical professional regulations to train
people who use opioids to prevent an overdose. Thus preemptively addressing legal concerns
from policing/legal perspectives, to reduce problems for those carrying naloxone, and prevent
confiscation
• Discuss their current overdose response protocol
• Police may have contact with individuals that are not connected to harm reduction
programming – they may assist in referring individuals that may benefit
• Communication plan between groups that support people who use drugs – i.e. overdose alerts
and dissemination, feedback and updates about naloxone kits in the community
• Potential for development of a memorandum of understanding/agreement e.g. Vancouver
Police Department stating they would not attend overdoses that did not involve death or
violence, agreements similar to Good Samaritan Legislation that provided limited immunity for
individuals that provide assistance in overdose to encourage people to call 911
Inform emergency response networks within your region about the naloxone initiative. It is useful for
paramedics, fire and rescue, and emergency room nurses and physicians to know of the support that
their patient may have been given prior to their care.
The FAQ’s (Appendix B: lll) and Overdose Prevention Training and Kits (Appendix B: lV) are useful
documents to introduce the initiative and inform people about the project. These and other helpful
resources are found on www.towardtheheart.com including links to police training resources and a
sample letter from an outreach organization informing police of the program.
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Suggested Communication Contacts:
Aboriginal Orginizations
Pharmacies – particularly ones that
dispense methadone
City (Mayor’s office etc.)
Physicians that prescribe opioids
Correctional Institutions including:
release planners, officers, medical staff,
probation offices
Services that Support People Who Use
Drugs
Coroner’s Office
Shelters
Defense Lawyers’ Offices
Street Nurses
Detox
Supportive Housing
Drop-in Centres
Drug and Alcohol Treatment Offices,
Centres, Recovery Housing
Support Groups for people who use drugs
and for those that love them
(ie AA/NA, Al-anon, LifeRing, Parent
Support Groups)
Drug User Groups
________________________________
Emergency Response Personel:
 911 Call Centre
 Fire and Rescue
 Law Enforcement
 Paramedics
________________________________
Emergency Room Departments
________________________________
________________________________
________________________________
Health Authority
Organizations and communities have different roles in addressing overdose deaths depending on
their engagement with people at risk of overdose, their capacity, organizational mandate, and
community readiness.
The Canadian AIDS Aboriginal Network has a helfpul
downloadable resource to assist in evaluating
community readiness in implementing risk reduction
strategies here:
http://caan.netfirms.com/wpcontent/uploads/2012/05/CR-manual-eng.pdf
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10. Appendix B: Program Documents and Related Information
For conveinence of making copies, the following documents do not have page numbers in the training
manual. Click the title to jump to a specific document.
Document PDF’s can also be accessed on www.towardtheheart.com/naloxone/
Provides information about the requirements needed to
Program Guide:
l.
start distributing naloxone. Helpful in clarifying roles and
Initiating & Implementing a Program
associated responsibilites.
Provides global and BC specific overdose and naloxone
ll.
Backgrounder
information. Helpful to learn more about BC’s THN
program and in approaching community partners.
General FAQ’s for community not as familiar with how
lll.
FAQ’s
preventable overdose can be and with people who use
drugs. For more specific FAQ’s www.harmreduction.org
Community information 1-pager with picture of kit.
Overdose Prevention
lV.
Designed to inform stakeholders. Could add agency
Training and Kits
contact information if appropriate.
Form for the Educator (s) to fill out and fax back to the
BC Harm Reduction Program. Measures in filling out
V.
Training Attendance Form
form and storing should be taken to ensure participant
confidentiality. Helpful for training organizations to
record numbers for community impact and funders.
Print double-sided and cut in half. General overdose
Vl. Pre/Post Training Quiz
prevention and response questions to guide training and
assess knowledge of group.
Illustration shows the acronym SAVE ME as found in
Vll. SAVE ME Poster
the THN kit. Each letter lays out the action steps in an
overdose response.
Form in THN Kits to be shown to people being trained.
To be filled out after an overdose event by individual
Vll. Administration Information Form
who responded to overdose or who overdosed and
faxed back to BC Harm Reduction Program to assist in
program evaluation.
Print double-sided. Filled out by the educator. If the
participant is eligible for a naloxone prescription, the
Certificate of Completion
form can be used to show the prescriber they have
Vlll. and Participant Knowledge
completed training. The checklist on the back serves as
Checklist
an overview of information the educator needs to cover
and a reminder for participant of what they learned.
Overdose Prevention and Response information
suggested to be given to each particpant with with
Overdose Survival Guide
lX.
certificate. Includes stimulant over-amp and toxicity info.
– Tips to Save a Life
If looking at the front cover – pamhlet is folded in “Z”
fashion.
Physicians will often have their own Rx pad. Some
programs may make their Rx form for naloxone. Replace
X.
Sample Prescription (Rx)
all components of this sample with your program’s
prescribing physican information.
Form to be completed by the THN Dispenser and faxed
Xl. Dispensing Record
back to the BC Harm Reduction Program to account for
the kits that are sent to THN team.
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TAKE HOME NALOXONE:
PROGRAM GUIDE
Initiating & Implementing a Program
A considerable proportion of people at risk of illicit opioid overdose make little or no contact with
primary health care services and service providers due to perceived barriers of initiating a relationship.
Community organizations that have established relationships with people who use illicit opioids are an
integral component of increasing access to naloxone in British Columbia (BC).
In BC, naloxone, an opioid antagonist, must be prescribed for a specific person by a physician.
Therefore significant challenges arise when developing a dissemination protocol that involves
community-based organizations that may not have affiliated medical staff. The current
dissemination protocol is designed to navigate the present policy environment as per federal,
provincial and medical professional regulatory bodies. The long-term goals include the possibility of
addressing policy changes.
Delivering Take Home Naloxone (THN) kits to the target population entails collaboration between
the educator, prescriber, and dispenser; however, an individual health care professional may take
on more than one of these roles. The educator will educate participants using the curriculum
developed by the BC Harm Reduction (BC HR) Program (found on www.towardtheheart.com) and
evaluate the participants’ knowledge on behalf of the prescriber and dispenser. Each professional
retains their respective responsibilities; the prescriber must be confident that the participant has the
appropriate knowledge before prescribing naloxone. Therefore having reviewed the training
curriculum and assessment the prescriber can delegate the training to the educator.
THN collaborative team of educator, prescriber and dispenser will arise in a diversity of
environments across the province and will function in ways best suited to the population they serve
and individual circumstances. Teams may take varying forms; however, all tasks and deliverables
outlined in the following table must be completed.
Training documents and additional information can be found on the naloxone page on
www.towardtheheart.com
You may contact the BC Centre for Disease Control Harm Reduction Program to discuss your plan
and program model at 604.707.2400 or email [email protected]
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Steps, roles, responsibilities, and deliverables when initiating and implementing a
Take Home Naloxone program
Identify
Educate
Who: Community Organizations & Health Care Professionals
• Community-based partner organizations; outreach, clinic and hospital staff, work in
collaboration with health care professionals to increase capacity to respond to overdose in
the community and to identify individuals who would qualify for a THN kit
BC HR Program Guiding Statement: People who are at risk of opioid overdose are eligible for a
THN kit once appropriately trained
Who: Educator
• Conduct a training session with participants (usually 15-20 minutes for individual training)
• Record those who have been trained using the Attendance Form and FAX it BC HR
Program at 604.707.2516
• Assess knowledge and provide participants with a certificate of completion of training
The educator assumes the education responsibilities on behalf of the prescribing physician. A
standardized curriculum is used, but the physician may modify the curriculum or test the
participant’s knowledge accordingly
BC HR Program Guiding Documents: Service Provider Webinar, Training Video for Participants,
Training Manual for Overdose Prevention & Response, Attendance Form, Pre & Post Quiz,
Certificate of Completion and Participant Knowledge Checklist
Deliverable Paperwork to BC HR Program: Attendance Form
Who: Physician
• Must establish or have a pre-existing, professional relationship with the participant and
Prescribe
confirm that the participant uses opioids
• Upon receipt of the participant’s training certificate (or the physician performs the training
themselves), write a prescription for naloxone
• The physician holds all responsibility associated with the prescription
BC HR Program Guiding Statement: Example Script: Naloxone 0.4mg IM q 5 minutes prn x 2 doses
(1ml ampoule = 0.4mg)
Dispense
Track
Who: Dispenser
• Receive the original, hard copy of the prescription
• Before dispensing the THN kit, remove the kit ID sticker from inside the naloxone container
(matches the ID on the container, the kit, and the Administration Information form) and
attach it to the prescription
• Complete the naloxone label on the container:
 Fill in the date when naloxone is dispensed (not prescribed)
 Fill in the participant’s name, the physician’s name, address, and telephone number
 Some prescriptions may have a prescription number (‘Rx#’). If so, record the
prescription number in the Rx# box, if not, leave it blank
• Inspect the contents of the kit, including expiry date of the naloxone
• Record information on the Dispensing Record
• FAX Dispensing Record and associated prescriptions to BC HR Program at 604.707.2516
BC HR Program Guiding Documents: Program Guide (this document), Dispensing Record
Deliverable Paperwork to BC HR Program: Dispensing Record and associated prescriptions
Who: Take Home Naloxone teams; BC HR Program team
• Upon use of the kit, the participant is requested to return the Take Home Naloxone
Administration Information form to the site where they received the kit or nearest possible
alternative. If the participant does not have a form, provide a blank form to complete
• It is the responsibility of the site to FAX the form to BC HR Program at 604.707.2516
Deliverable Paperwork to BC HR Program: Take Home Naloxone Administration Information
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TAKE HOME NALOXONE:
BACKGROUNDER
Opioid Overdoses in BC
Opioid overdose is a public health issue in BC, contributing to significant mortality and morbidity. Province-wide
in 2011, provisional data suggest over 275 deaths were attributed to illicit drug overdoses (96 in Fraser and 97
in Metro Vancouver regions). In 2011, the BC coroner’s service reported a cluster of drug overdose deaths
related to an increase in heroin potency. Prescription opioids contributed to over 70 deaths in 2009. Total
overdose events are likely higher than what has been reported as overdose does not necessarily result in
death. However the lack of oxygen to the brain during an overdose event can lead to lifelong harms.
Naloxone can prevent opioid morbidity and mortality
Unintentional deaths from opioid overdose are preventable with overdose and naloxone education. Naloxone,
or Narcan®, has been used in emergency settings for over 40 years in Canada and is on the WHO List of
Essential Medicines. The BC ambulance service administered naloxone 2,367 times in 2011. It is a pure opioid
antagonist which will quickly reverse life-threatening respiratory depression of opioids to restore breathing,
usually in 2-5 minutes. Naloxone is not a controlled substance, it cannot be abused, and in the absence of
narcotics has no pharmacologic activity. Research has shown having naloxone available does not increase risk
taking behavior. Naloxone is a safe drug with minimal side effects, even less than an epi-pen. The American
Medical Association adopted policies in 2012 supporting greater community access to naloxone:
healthnewsdigest.com/news/Forecast_630/AMA_Adopts_New_Policies_at_Annual_Meeting.shtml
Naloxone can be given by injection (into the vein or muscle or under the skin) or intra-nasal (sprayed into the
nose). Naloxone for injection is currently the only formulation approved by Health Canada. The intra-muscular
injection can be given through clothing into the muscle of the upper arm or upper leg.
Naloxone Take-Home Programs in Canada and around the world
Take Home Naloxone (THN) programs provide naloxone to people who use opioids (legally prescribed or
illegally obtained) and are at risk of an overdose. It is not intended to replace emergency care or minimize the
importance of calling 911. But because 85% of overdoses happen within the company of others, having
naloxone offers the opportunity to save a life and reduce harms related to the overdose while waiting for the
paramedics to arrive. Mathematical modeling in the US has demonstrated that naloxone, in conjunction with
overdose education, has a synergistic effect; having a greater effect on reducing overdose events than if
provided individually.
Numerous programs already exist globally, including more than 180 programs in the US:
www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm. Edmonton started the first program in Canada in
2005, Toronto began in 2011, and in 2012 Ontario launched a provincial initiative to provide naloxone
education and kits at harm reduction distribution sites:
www.health.gov.on.ca/en/news/bulletin/2012/hb_20120404_1.aspx. BC’s Overdose Prevention Program is
modeled on the successes of such programs and combines education (prevention, identification, and response
to overdose) with a Take Home Naloxone (THN) kit for individuals who are using opioids, thus individuals can
reduce overdose risks and be prepared in the event of an opioid overdose.
BC’s Harm Reduction Program
Since the BC Centre for Disease Control started preparation in January 2012, we have met with numerous
stakeholders all of whom are supportive of the initiative. Letters of support have been received from Dr. Perry
Kendall -the Provincial Medical Health Officer, the City of Vancouver, the Vancouver, Fraser, Interior, and
Vancouver Island Health Authorities. The THN program Community Advisory Board includes people who use
drugs, representatives from the BC Centre for Excellence in HIV/AIDS and the Vancouver Police Department.
For more information visit www.towardtheheart.com
2012/08/29 [1 of 2]
An article was published in the BC Medical Journal to increase awareness among physicians about the
utilization of naloxone and the BC initiative: www.bcmj.org/bc-centre-disease-control/increasing-accessnaloxone-bc-reduce-opioid-overdose-deaths.
The BC pilot program
Distribution of naloxone kits will be piloted through the BC Harm Reduction Program. In BC naloxone is a
prescription only medication (POM); therefore it must be prescribed to a specific individual with indications for
personal use by a physician. BC has a unique challenge unlike other Canadian provinces that continue to
utilize pre-written orders where a nurse can sign-off on a prescription or Medical Directives are in place. In BC,
training can be performed by a health care provider (i.e. nurse) however; a physician must prescribe the kit to a
named patient. Resources to assist organizations wanting to address overdose in their community are
available from our website at: www.towardtheheart.com
Considerations
Naloxone is relatively safe with minimal potential adverse effects. The only contraindication to naloxone is
hypersensitivity. Naloxone may precipitate withdrawal in individuals with opioid dependency. Naloxone should
be used with caution in patients with a history of seizures and cardiovascular disease. However, the harms
associated with oxygen deprivation during an opioid overdose are likely far more serious. Naloxone only works
to take the opioids out of an overdose scenario; individuals may have confounding medical factors and
substances that need acute clinical care. Therefore medical professionals are the best individuals to deal with
an overdose.
Calling 911 is an important component of the overdose response. Responders are taught to call 911 and stay
with the individual for multiple reasons: to inform the person what has happened, to ensure that the person
does not take more substances, to inform the medical response team of individual’s current state, and to
administer a second dose of naloxone if the overdose returns. The effect of naloxone begins to wear off after
30 minutes, therefore the overdose may return. This will depend if the drug taken has a long half-life (e.g.
methadone), how much was consumed, the individual’s metabolism (ability to break down the drugs) and other
medical conditions.
Conclusion
Overdose and naloxone education programs are effective in communicating risks about substance use and will
save lives. We believe there is a strong ethical responsibility to provide such services to individuals in BC who
are at risk. We encourage people in BC affected by opioid overdose, physicians, policy makers, people who
take opioids and their family members, and service providers, to identify ways they can reduce the occurrence
and harmful consequences of opioid overdoses through education, and requesting and prescribing naloxone.
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TAKE HOME NALOXONE:
FREQUENTLY ASKED
QUESTIONS
What is naloxone?
Naloxone is an antidote to an opioid overdose. An overdose of opioid drugs such as morphine, heroin,
methadone, or OxyContin® can cause a person’s breathing to slow or stop. Naloxone is an injectable
medication that can reverse this so the person can breathe normally and regain consciousness.
Naloxone does not work for overdoses such as cocaine, ecstasy, GHB or alcohol. However, if an overdose
involves multiple substances including opioids, naloxone will help by temporarily taking the opioid out of the
equation.
Naloxone is also known by the trade name Narcan®.
How is naloxone given?
Naloxone can be given by injection (into the vein or muscle or under the skin) or intra-nasal (sprayed into the
nose). In BC, the naloxone project is distributing injectable naloxone which is approved by Health Canada
and is more effective than intranasal form. The injection can be given through clothing into the muscle of the
upper arm or upper leg. Safety needles are provided with the naloxone to avoid needle-stick injuries.
How does naloxone work?
Naloxone and opioids bind to the same sites in the brain that effect breathing. While naloxone is active in the
body, it binds more closely than the opioids; pushing the opioids off the sites in the brain and breathing is
restored. Naloxone acts quickly, usually within five minutes. Its effect starts to wear off after 30 minutes and
is gone by 90 minutes. By 90 minutes the body will have metabolized (broken down) some of the opioid and
the person is unlikely to stop breathing again. Naloxone does not destroy opioids in the body. With large
doses or long acting opioids, such as methadone, or in individuals with damaged livers, the person may
need another dose of naloxone.
What does overdose and naloxone training involve?
Training provides knowledge about how to: reduce overdose risk, recognize different types of overdose,
address myths, provide the correct emergency response and understand the importance of calling 911 and
perform rescue breathing, place someone in the recovery position, and give naloxone.
The knowledge and skills are not intended to replace emergency care. However, knowledge about
overdose and administering naloxone can help keep someone alive while waiting for paramedics to arrive.
Can naloxone cause harm or be abused?
Naloxone is a very safe drug. It only works to block the effects of opioids in the brain and cannot get a
person high. For individuals who are dependent on opioids it may cause them to go into withdrawal. This
effect is minimized by the small doses of naloxone in the community kits. Naloxone does not encourage
opioid use. It has no effect on someone who has no opioids in their system.
Naloxone has been approved for use in Canada for over 40 years and is on the World Health Organization
List of Essential Medicines.
Does someone need to be a medical professional to recognize opioid overdose and
administer naloxone properly to save a life?
Research and experience show, if people are given basic training they are able to recognize an overdose
and administer naloxone to save someone’s life just as well as a medical professional.
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If people who use drugs are given naloxone will they continue using and use more drugs?
Research has shown having naloxone available does not increase risk taking behaviour. Providing overdose
training with naloxone is a practical strategy to prevent death, focusing “on what is, as opposed to what
should be”. Scotland has noted overdose initiatives offer the chance to save a life, and send a clear
message to individuals that their lives matter. It is an important intervention, within comprehensive treatment
and support, which can help reduce harm, encourage engagement with services and support people in
improving their health.
Are there risks associated with using naloxone?
As with all drugs, the only contraindication to naloxone is hypersensitivity. Naloxone may precipitate
withdrawal in individuals with opioid dependence; symptoms may include pain, hypertension (high blood
pressure), sweating, agitation and irritability. It can be unsettling for someone to come out of an overdose
situation unaware of events leading to that moment. People who have health conditions (heart, liver,
respiratory etc) and/or have taken other substances need medical attention in an overdose situation. For
these reasons, calling 911 is an important component of the overdose response.
Why is it important to stay with an individual after giving them naloxone?
Stay with an individual following naloxone use since the duration of action of some longer acting opioids may
exceed that of naloxone. This means overdose may return, though it is usually less severe than the initial
event as the body metabolizes or ‘breaks down’ the opioids. This is also why it is important that they do not
take any more drugs for at least 2 hours. You may need to tell them what happened when they become
conscious as they may be confused. It is important to tell the paramedics all that you know to inform their
treatment plan.
Where are Take Home Naloxone programs already established?
The US has over 180 THN programs and many places have best practice policies that support coprescribing naloxone with any opioid. The American Medical Association adopted policies supporting further
implementation of community naloxone programs to prevent unnecessary deaths. In the UK, people who
have used opioids and are released from prison are given naloxone. Scotland has a national naloxone
program. Edmonton started the first program in Canada in 2005 and Toronto started in 2011. Ontario started
a provincial naloxone initiative in 2012. Naloxone has been used successfully to reverse opioid overdoses in
thousands of people around the world.
Who has access to naloxone now in BC?
Currently the BC Ambulance Service, hospitals, and some clinics use naloxone. The Portland Hotel Society,
including InSite, also use intranasal naloxone. A few doctors in BC prescribe naloxone to their patients but it
is not currently covered by PharmaCare, so the patient pays for it fully.
Why are opioid overdoses an important public health issue in BC?
There are approximately 275 overdose deaths per year related to illicit drugs, and 70+ overdose deaths per
year of people prescribed opioids in BC. Other long term effects occur in people who survive an overdose,
like brain injury caused by the lack of oxygen to the brain during an opioid overdose. Naloxone can reduce
these deaths and injuries.
Where can I find more information?
Visit the naloxone page on www.towardtheheart.com for up to date information and resources.
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TAKE HOME NALOXONE:
OVERDOSE PREVENTION
TRAINING AND KITS
People who use opioids, either prescribed or who
use them illegally are at risk of opioid overdose. In
2011, provisional data suggest over 275 deaths
were attributed to illicit drugs in BC. .An additional
70+ deaths occurred in individuals’ prescribed
opioid medication. Overdose events may not result
in death so are even more frequent; however the
lack of oxygen to the brain during an overdose can
result in lifelong effects.
Unintentional deaths and injury from opioid
overdose are preventable with overdose and
naloxone education. Naloxone, or Narcan®, quickly
reverses the respiratory depression caused by
opioids in an overdose. It is not a controlled
substance, cannot be abused, and in the absence
of narcotics has no pharmacologic activity.
Research has shown having naloxone available
does not increase risk taking behaviour.
Naloxone is a safe drug with minimal side effects
(even less than an epi-pen!). It may induce
withdrawal in those who are opioid dependant.
People at higher risk of overdose include those
who: are initiating or tapering opioid therapy, have
difficulty accessing primary care, have a period of
non-use. Providing education regarding overdose
prevention and response and increasing access to
naloxone will reduce harms and save lives in BC.
Participants who successfully complete community
overdose prevention and response training and use
opioids may be eligible to be prescribed naloxone.
In addition to the kit, the training increases
awareness about preventing overdose and
provides the capacity to respond appropriately even
if naloxone is not available in an overdose event.
Overdose education provides the knowledge and
skills to save a life while sending a clear message
to individuals that their lives matter. It is an
important intervention, within comprehensive
treatment and support, which can help reduce
harm, encourage connection to services, and
support people in improving their health.
Each Take Home Naloxone kit contains:
• 2 glass ampoules of 0.4mg/ml naloxone
wrapped in gauze inside a pill bottle for
protection. Label includes provincially
designated prescription information
• 2 retractable VanishPoint® safety syringes:
3cc – 25g x 1”
• 2 alcohol swabs
• 2 latex gloves
• One-way rescue breathing barrier mask
• THN Administration Information Form with
Kit Identifier Information
• Steps to respond to opioid overdose
2012/08/22 [1 of 1]
OVERDOSE PREVENTION AND
RESPONSE TRAINING: ATTENDANCE
Educator/Trainer(s):__________________________________________________
YYYY
MM
DD
Date: ________/_____/______
Affiliation/Agency: ___________________________________________________
Site: ___________________________________
Prescriber(s): ________________________________________________________________________________________________
Date
training
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Participant’s Full Name
Person (check all that apply)
uses opioids
eligible to
receive
naloxone kit
is
staff
is a
peer
is a
volunteer
cares about a
person who
uses opioids
Person (check one)
completed
training &
received
naloxone kit
completed
training
only
Staff to fill out form to ensure confidentiality.
Please FAX to the BC Harm Reduction Program at 604.707.2516 at end of session or when form completed
2012/08/29 [1 of 2]
didn’t
complete
training
Trainer’s notes and reflections to be filled out after training (things that went well, things to do differently, feedback):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________________
2012/08/29 [2 of 2]
PRE-TRAINING QUIZ
PRE-TRAINING QUIZ
1) What can increase your risk of having an
overdose? (choose best answer)
a) mixing drugs
b) mixing drugs and alcohol
c) using after a period of non-use
d) all of the above
a) mixing drugs
d) all of the above
2) Which of the following is not a sign of an opioid
overdose?
a) person unable to be woken up
b) not breathing at all or breathing very slowly
c) turning blue/purple around lips and fingertips
d) increased energy, wanting to exercise
overdose?
3) Is it essential that you call 911 for all overdoses?
a) Yes
b) No
a) Yes
b) No
4) Does naloxone work for a cocaine overdose?
a) Yes
b) No
a) Yes
b) No
5) How many doses of naloxone should you
administer for an opioid overdose?
a) 10 doses
b) 1 dose initially, possibly 2
c) 1 dose
a) 10 doses
c) 1 dose
6) Why must you stay and support the person that
overdosed? (choose best answer)
a) naloxone may wear off and overdose may return
b) may need to give a 2nd dose of naloxone
c) provide important information to EMS
d) a person’s health and other drugs can make OD’s
complicated
e) all of the above
complicated
e) all of the above
7) How many mL’s (1 mL= 1 ampoule) of naloxone
do you administer for each dose?
a) 5 mL
c) 10 mL
b) 1 mL
d) 0.5 mL
a) 5 mL
c) 10 mL
b) 1 mL
d) 0.5 mL
8) How long does it take for naloxone to start
working once given IM (intramuscularly)?
a) 10 min
b) 1-5 min
c) 20 min
a) 10 min
b) 1-5 min
c) 20 min
9) How long does the effect of naloxone last before
it starts to wear off?
a) 15 min
b) 30 min
c) 3 hours
a) 15 min
b) 30 min
c) 3 hours
2012/08/29 [1 of 2]
POST-TRAINING QUIZ
POST-TRAINING QUIZ
a) mixing drugs
d) all of the above
a) mixing drugs
d) all of the above
overdose?
overdose?
a) Yes
b) No
a) Yes
b) No
a) Yes
b) No
a) Yes
b) No
a) 10 doses
c) 1 dose
a) 10 doses
c) 1 dose
complicated
e) all of the above
complicated
e) all of the above
a) 5 mL
c) 10 mL
b) 1 mL
d) 0.5 mL
a) 5 mL
c) 10 mL
b) 1 mL
d) 0.5 mL
a) 10 min
b) 1-5 min
c) 20 min
a) 10 min
b) 1-5 min
c) 20 min
a) 15 min
b) 30 min
c) 3 hours
a) 15 min
b) 30 min
c) 3 hours
2012/08/29 [2 of 2]
TAKE HOME NALOXONE:
ADMINISTRATION
INFORMATION
After kit use, please return this form to your regular or nearest harm reduction supplies
distribution site as it will help us to improve the program. Completing this form with a staff
member may help you debrief after an overdose event.
Name:_________________________________________________
I am ☐ the person who overdosed ☐ the person who responded
1. When did the overdose occur? Date: ______/___/____
YYYY MM DD
YYYY MM DD
Date: ______/____/_____
2. Who administered the naloxone? (check all that apply)
☐ partner
☐ family member ☐ friend
☐ acquaintance
☐ stranger
☐ self
☐ health worker
☐ other:___________________________________
3. Where did the overdose occur?
☐ private residence
☐ shelter
☐ on the street
☐ hotel
☐ supportive housing ☐ other: ______________________________
4. What drugs were involved in the overdose? (check all that apply)
☐ heroin
☐ codeine
☐ morphine ☐ fentanyl
☐ oxycodone ☐ methadone ☐ alcohol
☐ meth
☐ GHB
☐ cocaine/crack
☐ benzodiazepines, ‘benzos’ (eg: valium)
☐ additional:____________________________
5. Why do you think the overdose occurred?
☐ reduced tolerance to opioids (eg: a break from using) ☐ change in purity
☐ polydrug use, specify:_________________________ ☐other:______________________________
6. Did the person who overdosed and received naloxone…
i) experience any symptoms of withdrawal? ☐ none ☐ mild ☐ severe
ii) display aggression because of these symptoms? ☐ yes ☐ no
7. How long did it take for naloxone to work?
Time (minutes):_________________________
☐ it didn’t work
8. Was the person who overdosed made aware…
(i) that the effects of naloxone wear off in 30-90 minutes? ☐yes ☐no
(ii) that overdose can return and to avoid using for a couple of hours? ☐ yes ☐ no
9. How many ampoules of naloxone were administered? ☐ 1 ☐ 2
10. Was 911 called? ☐ yes ☐ no
If no: what prevented a call to 911?
☐ worried that police would become involved
☐ other:_______________________________
If yes: did the police attend? ☐ yes ☐ no
☐ thought person would recover on own
11. Did the person survive the overdose? ☐ yes ☐ no ☐ I don’t know
2012/08/29 [1 of 2]
COMPLETE PAGES 1 and 2 AND FAX TO 604.707.2516
12. If the person survived, in your opinion, did the naloxone prevent the person dying from an
overdose? ☐ yes ☐ no
13. Were the naloxone kit contents easy to access and use?
☐ yes ☐ no
14. What actions were taken during the overdose on this occasion? (check all that apply)
☐ checked breathing
☐ stayed with person until they come round
☐ gave stimulants (eg: coffee)
☐ walked the person around the room
☐ slapped or shook the person
☐ injected saline
☐ shocked the person with cold water
☐ placed the person in the recovery position
☐ performed mouth-to-mouth resuscitation
☐ stayed with the person until the ambulance
☐ taken to the hospital (by: ☐ EMS ☐ other)
arrived
☐ checked pulse
☐ checked airways for obstruction
☐ other:_______________________________
☐ gave chest compressions
15. If you were in a similar situation again, do you think giving naloxone would be a good thing
to do? ☐ yes ☐ no ☐ unsure
If no/unsure, why? _________________________________________________________________
16. Did you feel that you had enough training to give naloxone? ☐ yes ☐ no
If no, what could be done to better prepare you? _______________________________________
_________________________________________________________________________________
17. How did you know that an overdose was happening?
Person who administered naloxone:
Person who received naloxone (describe):
______________________________________
☐ person turned blue
______________________________________
☐ person wouldn’t wake up
______________________________________
☐ person stopped breathing
______________________________________
☐ no response to sternal rub & shout (stimuli)
☐ other:_______________________________
______________________________________
18. Where do you keep your naloxone kit?
________________________________________________________________________________
19. Do you experience any barriers carrying your naloxone kit? (eg: being ID’d as a drug user,
awkward to carry, etc) ☐ no ☐ yes, specify:_____________________________________________
20. Do you have a tip that you’d like to share about using naloxone kits? (eg: telling your family
where you keep your kit) _____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
21. Where did you get your naloxone kit? _____________________________________________
22. Where did you return this form? __________________________________________________
eg: health unit, harm reduction service provider
TAKE HOME NALOXONE KIT
The owner of this kit has been trained in overdose
prevention and response and has been provided
these harm reduction supplies by the BC Harm
Reduction Strategies and Services Committee.
TO FIND HARM REDUCTION DISTRIBUTION
SITES & MORE INFORMATION ABOUT
NALOXONE, VISIT: www.towardtheheart.com
OR CONTACT
Ph: 604.707.2400
Fax: 604.707.2516
E-mail: [email protected]
website: www.towardtheheart.com
Return this form to your regular or nearest
harm reduction supplies distribution site
for replacement details
KIT ID:
2012/08/29 [2 of 2]
COMPLETE PAGES 1 and 2 AND FAX TO 604.707.2516
CERTIFICATE
OF
COMPLETION
This certificate is awarded to
__________________________________________
In recognition of Overdose and Naloxone Education training
to Save A Life
BC Harm Reduction Program
YYYY / MM / DD
Educator’s Signature
Organizati
on
Educator’s Name (Print)
___________________________________________________
Organization
Date
TAKE HOME NALOXONE:
PARTICIPANT KNOWLEDGE
CHECKLIST
This checklist provides a guideline to assess the knowledge of the participant following the
training session. As the Educator you should be confident that each knowledge objective was
covered in the training and that the participant understands each of the objectives.
Participant’s Name: __________________________________________
Date: ______/_____/_____
YYYY MM DD
Educator’s Name (Print):______________________________________
Initials Knowledge Objective
• Demonstrates clear knowledge of causes, contributing factors, and
Overdose
prevention strategies to overdoses
Prevention
•Demonstrates understanding of stimulant overdose – there is no antidote
•Knows the application of myths in responding to overdose can be harmful
Signs of Opioid
Overdose
• Understands the signs of an opioid overdose:
breathing is very slow/ erratic or not there at all, fingernails/lips blue or
purple, unresponsive to stimulation/sternal rub, deep snoring/gurgling sound,
body is limp, unconscious
• Understands that naloxone does not work for non-opioid overdoses
Recovery
Position and
Calling 911
• Can demonstrate the recovery position and knows to put the person in this
position if they have to leave them alone to keep airway clear
• Understands the importance of calling 911, knows what to say to the 911
operator and knows to debrief EMS when they arrive
Stimulation &
Application of
Breaths
• Demonstrates understanding of how to provide stimulation: Sternal
Rub/Say the person’s name/Tell them to breathe
• Demonstrates understanding of how to provide breaths and use 1-way face
mask
Naloxone
Administration
• Demonstrates understanding, including: 1 mL into muscle of upper
shoulder, upper thigh, or upper-outer quadrant of buttocks. If no change in
condition within 3-5 minutes – should give another dose of naloxone
Evaluation &
Aftercare
• Demonstrates knowledge that the effect of naloxone only lasts 30-90
minutes and the overdose can return
• Knows to stay with person to communicate to that person: what happened,
not to let person take more drugs; sickness will go away, more opioids will
have no effect while naloxone is active, and more drugs will make OD more
likely to return when effect of naloxone wears off
• Knows to watch for OD symptoms returning
Care of
Naloxone
Vial, Program
Evaluation,
Refill
• Demonstrates knowledge how to store naloxone at room temp and away
from light
• Watch expiry date on ampoules
• Keep naloxone in a regular place and let others know where it is in case of
an emergency
• Knows how to get a repeat prescription, and if need more information to go
to www.towardtheheart.com
• Knows the importance of completing and returning the Administration
Information form
2012/08/22
OVERDOSE
SURVIVAL GUIDE
PREVENTION
THE RECOVERY POSITION
OVERDOSE IS MOST COMMON WHEN:
KEEP THE AIRWAY CLEAR
• Your tolerance is lower: you took a break, were in
detox/treatment or jail, or you are new to use
• You have been sick, tired, run down, dehydrated or
have liver issues
TIPS TO
SAVE A LIFE
• You mix drugs: prescribed or not, legal or illegal
• The drugs are stronger than you are used to: changes
in supply, dealer, or town
TO PREVENT OVERDOSE:
Hand supports head
• Know your health status and your tolerance
• Do not mix drugs and alcohol. If you do mix, choose
to use drugs before alcohol
Knee stops body from
rolling onto stomach
• Be aware: using drugs while on prescribed medications
can increase overdose risk
• Don’t use alone. Leave door unlocked. Tell someone
to check on you
• Do testers to check strength. Use less. Pace yourself
• Talk to an experienced person or a trusted healthcare
provider about reducing risk
• Know CPR and get trained on giving naloxone
• Choose a safer route of taking drugs
Stay with person. If you must leave them alone at any point,
or if they are unconscious, put them in this position to keep
airway clear and prevent choking. 'EPPJSVLIPT.
CHOOSE A SAFER ROUTE
SAFER
/ NO USE
Overdose Prevention and Response
SWALLOWED
SNORTED / SMOKED
/ INSERTED
INJECTED
MORE LIKELY
TO OVERDOSE
OVERDOSE?
TAKE CHARGE.
TAKE CARE.
OPIOIDS / DEPRESSANTS (e.g., opiods: morphine, dilaudid, heroin / depressants: alcohol, GHB, benzodiazepines)
• Stay with person. Use their name. Tell them to breathe
• Person cannot stay awake
IN CASE OF OPIOID OVERDOSE:
FEELS AND LOOKS LIKE:
• Can’t talk or walk
• Slow or no pulse
• Slow or no breathing, gurgling
• Skin looks pale or blue, feels cold
• Pupils are pinned or eyes rolled back
• Vomiting
• Body is limp
• No response to noise or knuckles
being rubbed hard on the breast bone
• Call 911 and tell them person is not breathing. When
paramedics arrive tell them as much as you can about
drugs and dose
• Use naloxone if available. Naloxone only works on
opioid overdose
• After naloxone a person might feel withdrawal. Do not
take more drugs. Sick feeling will go away when naloxone
wears off (30 – 75 minutes). Be aware: overdose
can return
SAVE ME
S
stimulation
A airway
evaluate
E
ventilate
V
Can you wake them up?
If not, call 911
Make sure there’s nothing in their
mouth that stops them from breathing.
Breathe for them. (Plug nose, tilt head
back, and give 1 breath every 5 secs).
Are they any better?
Are you trained to give naloxone?
M muscular injection Inject 1cc of naloxone
into a muscle.
E evaluate & support Is the person breathing on their own?
If they’re not awake in 5min, another
1cc dose is needed. Tell the person
not to use any more drugs right now –
wait at least 2 hours.
This is proven to work. Other remedies can actually be harmful.
STIMULANTS (e.g., cocaine, methamphetamine, ecstasy)
ASSESSMENT: ARE THEY EXPERIENCING A OR B?
FEELS AND LOOKS LIKE:
• Cannot talk
or walk
• Confusion, hallucinations, unconscious
• Vomiting
• Body is hot/sweaty, or hot/dry
• Seizures
• Short of breath
• Chest pain
• Fast pulse or no pulse
• Clenched jaw
B: PHYSICAL DISTRESS/ACUTE STIMULANT TOXICITY
A: MENTAL DISTRESS/OVERAMP
Associated with: sleep deprivation, crashing, anxiety,
paranoia. If a person is conscious, and you are sure this
is not medical in nature, they may just need support and
rest. Call Poison Control to help assess.
Medical attention is required immediately if person has:
• Jerking or rigid limbs
• Rapidly escalating body temperature and pulse
• In and out of consciousness
WHAT TO DO:
• Shaky
There are NO medications to safely reverse a stimulant
overdose.
0!-0(,%4).&/2-!4)/."#(EVQ2IHYGXMSR4VSKVEQ
Tel: 604.707.2400 e-mail: [email protected]
OVERDOSE INFORMATION: Poison Control Centre (24 hrs)
Tel: 1-800-567-8911
• Severe: headache, sweating, agitation
• Keep calm. Stay with person. Use their name
• Chest pains
• Give water or fluid with electrolytes. Do not overhydrate
WHAT TO DO:
• Place cool, wet cloths under: armpits, back of neck, and head
• Keep person: conscious, hydrated, calm
• If aggressive/ paranoid suggest they close their eyes, give
person space
• Stay with person
• Get them comfortable. Move away from activity
• Call 911
• Open a window for fresh air
• Encourage person not to take any other substances
• Doctor may treat agitation and paranoia with a benzodiazepine
If you’re not comfortable with the situation, call 911.
EMERGENCY RESPONSE: Tel 9-1-1
• If heart has stopped do ‘hands-only’ CPR
• Tell medical professionals as much as possible
so they can give the right treatment to prevent
organ damage and death
Dr. O.D. Prevention, MD,
General Practitioner
The Best Practice Clinic
456 Everywhere Avenue
Ollover, BC B4U 0D9
Tel: 555.555.5911
Kit ID/Rx #:
Fax: 555.555.5911
Date:
YYYY / MM / DD
Patient details:
Last Name: _________________________ First Name:__________________________
Date of Birth:_______________________ PHN:_______________________________
Address:________________________________________________________________
Rx
Naloxone 0.4mg (=1mL) IM q 5 minutes prn x 2 doses
Indication: For reversal of opioid overdose
No repeats.
________________________________
Dr. O.D. Prevention (MSP 55555)
2012/08/29
TAKE HOME NALOXONE:
DISPENSING RECORD
Upon receipt of the naloxone prescription, complete the following form and store with the hard copies of
the prescriptions. Once full (or at your discretion), fax this form and the associated prescriptions to the
BC Harm Reduction Program at 604.707.2516
DATE
(YYYY/MM/DD)
PARTICIPANT’S FULL NAME
DISPENSER’S NAME
KIT ID NUMBER
Please complete this section to help us evaluate the program
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
st
1 Kit
Replacement Kit
Reason:  Used  Expired
st
1 Kit
Replacement Kit
st
1 Kit
Replacement Kit
st
1 Kit
Replacement Kit
st
1 Kit
Replacement Kit
st
1 Kit
Replacement Kit
st
1 Kit
Replacement Kit
st
1 Kit
Replacement Kit
st
1 Kit
Replacement Kit
st
1 Kit
Replacement Kit
 Lost  Stolen 
Confiscated
Confiscated
Confiscated
Confiscated
Confiscated
Confiscated
Confiscated
Confiscated
Confiscated
Confiscated
WHEN FULL, FAX THIS FORM WITH ALL LISTED PRESCRIPTIONS TO THE BC HARM REDUCTION PROGRAM AT 604.707.2516
2012/08/29 [1 of 1]

TRAINING MANUAL: OVERDOSE PREVENTION AND RESPONSE

Transcription

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