- NALOXONE/NARCAN. This training is designed to teach you about one action you can take in case of an overdose of opiates.

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1 OVERDOSE MANAGEMENT PROTOCOL - NALOXONE/NARCAN TRAINING This training is designed to teach you about one action you can take in case of an overdose of opiates. This training program will not make you a doctor, or capable of acting like one. There is much more to keeping people alive than is covered here, but you will leave with an understanding of the more common life-saving actions helpful to keeping someone alive who has overdosed in the hope your ability to act quickly and correctly can save a life. Are all opiates created equal? In some ways all opiates are the same, and in other ways they are different. All opiates are the same in that they... (... come from the opium poppy or are chemically created to be like a drug which comes from the opium poppy; (... have their effect on the same part of the brain; & (... cause overdose in the same ways if too much is used -- this overdose comes in the form of stopped breathing. Opiates are different in that they (... have different concentrations or strengths (... have varying durations of action, such as Drug How long it works Drug How long it works methadone 24 hours codeine 3-4 hours heroin 6-8 hours Demerol 2-4 hours Dilaudid 4-6 hours Fentanyl 1-2 hours (... produce different speed, length and intensity of withdrawal. IMPORTANT NOTE: Combining opiates with other drugs, especially alcohol and other downers, is much more likely to lead to an overdose. This training describes opiate overdose management and not overdose with other drugs. While

2 this training may help you keep a friend alive who overdosed on heroin, it may not work if your friend has also used other drugs. OD PREVENTION Some things you can do to prevent OD: - know your stuff - testing small amount - purification - purity testing - inject with OD prevention technique (tourniquet off after hit, several slow pushes to taste...) What actually causes a severe overdose? cardiac arrest... when someone's heart stops apnea... when someone can no longer breath circulatory collapse... when there is no circulation of blood Taking too much... Recognizing an OD vs. a Good High: Some signs of a serious overdose with opiates, which may lead to death, are: ( respiratory depression... very slow and ultimately no breathing ( cyanosis... turning blue on the lips and fingertips first ( extreme somnolence... hard to awaken sleepiness ( progressing to stupor or coma... falling out ( skeletal muscle flaccidity... loose muscles ( cold or clammy skin ( bradycardia... slow heartbeat & hypotension... low blood pressure

3 TREATMENT OF OPIATE OVERDOSE... once you have determined someone has taken too much... First Call 911! Whatever is going on with them -- the more help the better. CPR is hard to keep up for long! There are many reasons why many people choose not to call the cops, the neighbors, an official record of an overdose. This training on how to administer naloxone should be considered as both an additional step you can take after you call 911, but also as an alternative if you've chosen (after discussing this with your friends...) not to call for help. You should also check around where you live to see if the police respond to a 911 call along with the ambulance and EMTs. Then BREATHING IS THE THING Make sure they are breathing. If they are not breathing, breathing for them will keep them alive....in medical terms: "Primary attention should be given to the re-establishment of adequate respiratory exchange through provision of a patent airway and the institution of assisted or controlled ventilation." Maintain the person's airways. Put them in a position so that they can breathe CPR Training and Certification here -----

4 ---- The Recovery position: DEMO here ---- Consider using naloxone for opiate overdoses only. Why? If used correctly, naloxone can reverse the overdose and save the person's life. Why not? If you get so tied up with the naloxone you don't keep up the breathing the person will die. How do you use Naloxone? Dose: 1 ml/100 units ideally with a prepared syringe Repeat the dose as needed every 2-3 minutes If someone doesn't come to after 10 doses, its probably not an opiate overdose - just do CPR until help arrives. Method: Intravenously.Can you get a vein? If you can get a vein, naloxone will work more quickly. Consider using veins under the person s tongue. If you can't get a vein--- Rectally... squirting naloxone into someone s rectum may be a quicker alternative than the methods below. Of course, take the needle off first.

5 Into the muscle?., the shot might take 3-15 minutes to work. Also: Can you continue to breathe for them? Do you have the right syringe (1-1 1/2 inch needle)? Under the skin? With this method, it might take 30 minutes to work. Can you continue to breathe for them for that long?

6 If the naloxone works... SUPPORT THE PERSON While the naloxone may have started them breathing again it may also start withdrawal symptoms. Using again will likely make the OD worse when it returns in an hour or so. If you can support the person in dealing with the discomfort, if any, for an hour the naloxone should wear off and the withdrawal will fade. WATCH FOR THE RETURN OF THE OVERDOSE Naloxone will quit working after 30 to 90 minutes. If the person still has too much opiate in their system the overdose will return and you'll be faced with the same situation. BE PREPARED... IT MAY NOT BE OVER YET Call for help again, go to the emergency room, prepare another shot of naloxone... Keep up the CPR if the person is not breathing!

7 TAKING IT TO THE STREETS Developing a plan with your injection partner(s)... Now that you have had a chance to learn about opiate OD, CPR, and naloxone you need to consider a critical part of OD management -- TALKING WITH YOUR PARTNERS TO WORK OUT A PLAN. Obviously, the time to talk about what you want your partner(s) to do to you in case of an OD or you to do to them if when you all can talk. Among the questions to consider for yourself and know for your partner(s) are: - When do you want someone to take action? (How slow breathing? What is turning blue?) - What do you prefer regarding use of CPR, naloxone (where/how injected, how much - 1cc or less, multiple doses) and about calling What do you want to do after you start breathing again? What kind of support do you want after you are breathing again? What plan do you have when the naloxone wears off? Use of the ER, etc. see handout at back...

8 Roleplay with Your Partner - Use Completed OD Checklists for Guidance Take turns OD'ing. Doing what your partner said they want in case of their OD. -- Come on -- this is your chance to act it out -- pretend. Call time and ask questions if you need to. Any changes you want to make? Satisfied? Next Steps...

9 Just so you know about naloxone (Narcan)... The narcotic antagonist naloxone is a specific antidote against respiratory depression which may result from overdosage or unusual sensitivity to narcotics, including heroin, morphine, and other opiates. Therefore, an appropriate dose of naloxone (usual initial adult dose: 0.4 mg -- generic naloxone or brand name Narcan both contain 0.4mg of naloxone per 1ml (100 units)) should be administered, preferably by the intravenous route and simultaneously with efforts at respiratory resuscitation. Since the duration of action of the opiate used (heroin, morphine, methadone, etc.) may exceed that of the naloxone, the patient should be kept under continued surveillance and repeated doses of the antagonist should be administered as needed to maintain adequate respiration. An antagonist should not be administered in the absence of clinically significant respiratory or cardiovascular depression. Oxygen, intravenous fluids, vasopressors and other supportive measures should be employed as indicated. Gastric emptying may be useful in removing unabsorbed drug. Knowing how to do CPR is one of the best things you can do to keep someone alive no matter why they are not breathing and so training to do CPR well is a important part of being a good overdose manager.

10 OD Prevention/Management Checklist Ο Ο Ο Knows OD prevention techniques Ο Ο Ο Knows when to act for you - color/# breaths in 10 seconds Ο Ο Ο Knows when you want them to call 911 Ο Ο Ο Knows if and when you want rescue breathing or CPR Ο Ο Ο Knows if and when you want naloxone Ο Ο Ο Knows how and where you want naloxone given and how much Ο Ο Ο Knows if and when you want to go to the hospital ER Ο Ο Ο Has agreed to stay with you to support while naloxone wears off (about an hour after it is given) Ο Ο Ο Notes your commitment to not use again while you wait for the naloxone to wear off OTHER COMMITMENTS:

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