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Training Guide

Guide to Developing and Managing Overdose Prevention and Take Home Naloxone Projects

This section adapted from the work of Maya Doe-Simkins, Alex Walley and colleagues for their “Notes from the Field (temporary title)” Overdose Prevention Manual. 

This is a list of questions and responses that overdose education and naloxone distribution trainers have gathered.

Naloxone is that stuff that you stick through the heart, like in that movie Pulp Fiction, right? 

No. While naloxone does have an injectable form, it is never injected into the heart. The injectable form of naloxone is injected either intravenous or intramuscularly.

What role does your liver play in an overdose? 

The liver processes all drugs in a person’s body. If the liver is damaged or not functioning properly, it causes a backup of drugs in the body, which can contribute to overdose. A person whose liver isn’t functioning properly may overdose more frequently and overdose may last longer.

Hey, isn’t there naloxone in Suboxone®? What’s up with that? 

Buprenorphine (brand name Suboxone®) is used in opioid substitution therapy. Buprenorphine diminishes cravings for opioids such as heroin; naloxone is added to Suboxone® as a way to counter “potential abuse” (i.e. injection) of Suboxone®. If the Suboxone® is taken under the tongue as prescribed, the small amount of naloxone will get absorbed into the body  and does nothing. However, if Suboxone® is injected, the naloxone will beat the buprenorphine to the opioid receptors, delaying and lessening the high.

Will Suboxone® reverse an overdose? 

Using buprenorphine to reverse an overdose is not something that has been studied scientifically; however, there are anecdotal reports of this approach having worked. Buprenorphine has a stronger affinity or attraction to opioid receptors than heroin or other opioids and can therefore displace the opioids that are causing the overdose. However, it is unlikely that the naloxone is the reason that Suboxone® can reverse an overdose since it is such a small amount. Rather the buprenorphine displaces the opioids, which then causes the person to wake up. But remember: successful overdose response is all about time and oxygen. Preparing Suboxone® for injection takes precious time, and waiting for the pill to dissolve in the mouth can take even longer; these actions may also keep you from being able to perform consistent rescue breathing.

Will Naloxone work on an alcohol overdose? 

No. Naloxone will not work on an alcohol overdose, only opioid overdose. If the overdose is a result of using both alcohol and opioids, administering naloxone might help by addressing the opioid part of the overdose.

Can I give someone who is overdosing a shot of coke or speed OR does speed-balling balance you out? 

No. Speedballing does not cancel out overdose risk and in fact, it actually increases risk. Speedballing is any combination of a stimulant (upper) and a depressant (downer) taken together; common speedballs include a mixture of heroin and cocaine or heroin and methamphetamine injected into the bloodstream. Stimulants actually constrict blood vessels, which can deplete the body of much-needed oxygen and makes the overdose worse. The more different drugs someone’s body has to process, the harder it is on their body. Also, people who speedball usually use more frequently than people who only use heroin, which increases overdose risk.

Can I give someone naloxone for a crack/cocaine overdose? 

Naloxone will not work on a cocaine overdose, only opioid overdose. If it is a cocaine overdose that also involves opioids, naloxone might help by addressing the opioid part of the overdose. Cocaine overdose is dangerous because it is not dose-dependent and is a complicated medical emergency — call 911.

Clonidine: Is it an opioid or a benzo? 

Neither. (Do not confuse clonidine with Klonopin®, which is a benzo). Clonidine is traditionally a medication used to treat high blood pressure, however it can be used to relieve withdrawal symptoms from opioids, alcohol and nicotine. When combined with opioids it increases one’s high; it lowers blood pressure, heart rate, causes dizziness and drowsiness. There is a higher risk of overdose with a clonidine/opioid combo than with opioids alone, but less than with a benzodiazepine/ opioid combination. Clonidine is not as long lasting as benzos are and it doesn’t have amnesiac effects (short-term memory loss). Lowering the blood pressure also raises the risk of dizziness and falling down, which can result in injury. Stopping regular use of clonidine does result in mild physical withdrawal symptoms and in cases where it was being used to treat high blood pressure, stopping results in very high blood pressure.

What about Phenergan® (Finnegan, Promethazine)? 

Phenergan® is used to combat nausea, as a sedative, as an allergy medication, to treat motion and morning sickness, and to increase the activity of opioids. For example, someone on high doses of opioid pain medication could take Phenergan® and lower their dose of pain medication to get the same effects. Similarly, the effects of heroin or methadone would also be increased when taken with take Phenergan®. There is a higher risk of overdose with a Phenergan®/opioid combo than with opioids alone, but less than with a benzodiazepine/opioid combination. Phenergan® is not considered to be habit-forming or cause withdrawal.

What’s the deal with fentanyl and overdose? 

Fentanyl is an extremely concentrated and potent opioid. Some people who sell heroin mix fentanyl powder with larger amounts of heroin in order to increase potency or compensate for low-quality heroin. If it is not well-mixed, a small bit of highly potent fentanyl could cause an overdose in a user that is expecting just heroin or whose tolerance isn’t high enough. Fentanyl patches can also be used by: putting them on the skin to get the time-released medication and using other drugs on top of that; placing the patch inside the cheek, which allows the medication to release quicker; or shooting or snorting the gel inside the patch (there is a process required to get fentanyl into injectable form, but it can be done). Fentanyl carries a lot of risk in terms of overdose because it is extremely potent and short acting and can flood the receptors in the brain very quickly. Fentanyl is designed to treat pain for people who are already dependent on opioids for pain management, so it is designed to be very strong to handle the pain someone experiences despite already taking sometimes high doses of opioids.

What about giving someone a salt shot when they overdose? 

A salt shot will cause pain — both because of the injection and because saltwater will sting/burn—so if the person can respond to pain, they will (i.e., if the overdose isn’t as serious and pain will rouse them). That said, fixing a salt shot wastes precious time that could be spent on calling 911, performing rescue breathing and giving naloxone. While salt shots may have appeared to work in some cases, salt shots do not address the need for oxygen and can also cause damage. Naloxone is a safer and more effective alternative.

Will hitting or slapping someone bring them out of an overdose?

You really do not want to kick, slap, punch, or drag anyone… you might hurt them. The sternal rub basically does the same thing as hitting — the point is to cause pain without causing harm. If someone doesn’t respond to a sternal rub, move on! Call 911, do rescue breathing and give naloxone.

What about ice or cold showers? 

Ice down the pants or a cold shower is not an appropriate response to overdose. While it might rouse someone who would also respond to pain stimulus, ice down the pants or cold showers can slow down the respiratory system and send someone into shock or hypothermia. A safer, quicker, more effective action is to call 911, do rescue breathing and give naloxone.

Will using naloxone help someone pass a urine test? 

No. Naloxone knocks opioids off the opioid receptors, but the drug is still floating around in the body (and urine!).

Are police, probation officers or program staff allowed to confiscate my naloxone rescue kit? 

Your naloxone rescue kit is yours like any other possession. It should not be confiscated. It is a prescription medication. If it does get confiscated, please tell someone at the naloxone distribution program where you got it. Some programs and shelters have policies about needing to check prescription medications — you can expect to have to follow individual program guidelines pertaining to prescription medications. Sometimes people like police or probation officers might assume that the only people who have naloxone rescue kits are people who might overdose themselves, they might assume that it is a flag for illegal activity.

Can someone get arrested for being present at an overdose? 

Unfortunately, there is no easy answer to this question, because it depends on the policies and culture of your local police department and community. For example, some departments have unwritten policies that people at the scene of an overdose will never be arrested after for calling for help. Other regions, cities and communities take a much more punitive stance, and the chance of getting searched and arrested at the scene of an overdose is higher. Some states have passed laws (or are trying to) that are called 911 Amnesty or Good Samaritan bills that make it extremely unlikely for police to arrest you or at least to charge and prosecute someone who called for help for an overdose. The following considerations may be important: Are you on probation? Do you have warrants/open cases? Could the incident impact your housing situation? For example, could you lose your housing because of drug use or drug possession? Do you live with your mom, whose landlord may evict her if there is an incident involving drugs? 

What if the police come after calling 911 and question use? 

It is important to plan as if police will respond in advance. Remove all drugs and paraphernalia from view to reduce the likelihood of search or arrest. The first priority for police is safety at the scene — the smoothest interactions will happen when it is calm and under control.

What’s with the intranasal naloxone, or Narcan, does it work? 

Yes. The intranasal naloxone device has a stronger concentration of naloxone (2mg/2ml versus the standard injectable naloxone concentration, .4mg/1ml) to compensate for the different mode of absorption into the body. EMS services across the country are now using intranasal naloxone, as well as some hospital emergency, police and fire departments. Nasal naloxone is also distributed at several overdose prevention programs, including The DOPE Project. There has been some formal research done on the effectiveness of intranasal naloxone in programs that currently distribute it. Intranasal naloxone is more expensive, but has the advantage of having no needle.

What if someone injects intranasal naloxone? 

The intranasal naloxone device has a stronger concentration of naloxone (2mg/2ml versus the standard injectable naloxone concentration, .4mg/1ml) to compensate for the different mode of absorption into the body. If this dose were to be injected, it may be a higher dose than therapeutically necessary and the person may experience more severe withdrawal symptoms. Injecting about one quarter of the naloxone in the vial is a good amount to start. That said, injecting intranasal naloxone would work to reverse an overdose.

What happens if the MAD nasal adapter gets lost for the nasal naloxone?

Two things have been done successfully (but should only be done in an emergency): Either inject the naloxone from the vial or squirt it up the person’s nose anyway without the nasal adapter. If you squirt it without the adapter it will be more of a stream than a spray—make sure the head is tilted way back so it doesn’t all run out the nose! When making a decision about which to do, remember time and oxygen! Try to keep the nasal spray piece attached to the naloxone box with a rubber band or attach it ahead of time so it’s ready to go.

What if I lose the muscle syringe for my injectable naloxone and only have a regular syringe?

Regular insulin syringes have shorter points than muscle syringes, so you’re not getting the naloxone all the way into the muscle, but they are better than nothing! Some studies have shown that subcutaneous injections (under the skin, but not all the way into the muscle) are just as effective as shooting it into the muscle. But make sure to pay attention to the measurements—you want to inject 1cc of naloxone to start, which will be a FULL syringe if you are using a 1cc syringe, and it will be TWO full syringes if you are using a ½ cc syringe.

What is the risk period for an overdose to reoccur after giving naloxone? 

The risk that someone will overdose again, after giving naloxone, depends on several factors: the person’s metabolism (how quickly the body processes things); how much drug they used in the first place; the half-life of the drug they used (i.e. methadone has a much longer half-life than heroin); how well the liver is working; and if they use again.

Naloxone is active for about 30—90 minutes in the body. So if you give someone naloxone to reverse an opioid overdose, the naloxone may wear off before the opioids wear off and the person could go into overdose mode again. Because naloxone blocks opioids from acting in the brain, it can cause withdrawal symptoms in someone that has a habit. After giving someone naloxone, they may feel sick and want to use again right away. It is very important that they do not use again for a couple of hours because they could overdose again once the naloxone wears off. Ideally people should receive medical attention but if they are able to speak clearly and walk after the naloxone they will probably be ok; if not, they must get medical attention.

Why do the new CPR guidelines for lay people suggest hands-only CPR instead of rescue breathing and chest compressions, when we still advocate for rescue breathing for overdose? 

The new guidelines are aimed primarily at response to cardiac arrest, not respiratory arrest. In cardiac arrest, respirations are not as important as compressions — particularly in the first few minutes. In respiratory arrests (like overdose), respirations are the key. If the respiratory arrest progresses to a full cardiac arrest the patient should get both chest compressions and rescue breathing. Opioid overdose, where the primary problem is lack of oxygen because of decreased breathing, affects the body differently than a heart attack. The newest AHA guidelines for trained Basic Life Support do actually include instructions to do rescue breathing for opioid toxicity prior to cardiac arrest, but this has not been publicized as widely as the new recommendations for cardiac arrest.

What if the person is not even overdosing and I give them naloxone? Will it hurt them?

Naloxone has no effect on someone who has no opioids in their system. It will not hurt or help anyone who is not experiencing an overdose. For someone who is opioid dependent, naloxone will likely cause uncomfortable withdrawal symptoms.

Can someone overdose on naloxone or what if I give too much naloxone?

It is not possible to give too much naloxone in the sense that it is dangerous. If a person is dependent on opioids or has a habit (including people on chronic pain medication), the more naloxone they get, the more uncomfortable they will be because of withdrawal symptoms. Vomiting is a possibility — be sure they don’t aspirate (inhale) the vomit — that is very dangerous. If the person gets too much naloxone, try to explain to them that the withdrawals will fade in a half hour or so.

Can you develop immunity to naloxone?

No, people do not develop immunity to naloxone — it can be used as effectively on the first overdose as on the 8th overdose, for example. However, someone who overdoses a lot might want to explore why they are overdosing repeatedly. A good trainer can help brainstorm some of the reasons.

Some potential reasons include:

• Untreated asthma
• Seasonal allergies
• Changes in medications for depression, anxiety, sleep, HIV
• Disassociation because of trauma = not remembering amount of drugs used
• New environment, new friends, new practices
• Infrequent use (which can lead to low/inconsistent tolerance)
• Suicidality

What if my kids (or any small children) find and use the naloxone — can it hurt them? 

No. Naloxone acts as an opioid antagonist and has no adverse effects in persons that do not have opioids in their system. Its only effect is to kick opioids off brain receptors temporarily to reverse an overdose. However, there are certain risks associated with the naloxone applicator itself — the small parts may pose a choking hazard, the vial is made of very thin glass which can be easily broken, and there is a sharp needle inside the plastic tubing of the applicator. It is a good idea to keep this and other medicines out of reach of children.

My naloxone expired — what should I do? 

Get a new kit! Simply go to the place where you got the first one and get one that is unexpired. If you bring in the expired kit, the program can use it as a sample for demonstrations. If you forget, it is not a big deal. If you witness an overdose emergency and all you have is your expired naloxone, it is better than nothing and may work. See the next question for more details.

My naloxone expired — can I still use it? 

If all you have is an expired naloxone kit — yes — use it. Like most other medications, naloxone will start to lose its effectiveness after its expiration date. However, it may be strong enough to reverse an overdose if that is the only kit that is available. It is not toxic, so use it and continue to perform rescue breathing.

Our clinic/program policy doesn’t even allow us to give people over the counter medication — how is it possible that we are now allowed to give people naloxone? 

This will vary from one program to another. It is important for overdose prevention trainers to ask these specific types of questions to programs (example: detox, shelter) before doing group trainings. Some programs are simply unable to get around this internal policy and are not allowed to have naloxone on-site to respond to overdose or to give out naloxone for program participant use. In cases like this, focus on helping the program create a policy for on-site overdose that includes identifying the overdose, calling 911, rescue breathing and recovery position and to help them think of ways they can still train program participants about overdose prevention and response while providing referrals to obtain naloxone. In some cities and states, there are regulations or laws that have passed to allow “3rd party administrators” of naloxone, thus providing protection for staff persons to have and use naloxone at their programs. Learn about your local regulations before the training.

Naloxone makes people violent, right? 

No. Naloxone itself does not evoke “violent” reactions in folks — rather, having too much naloxone administered to them (if you are opioid dependent, or have a habit, the more naloxone that is given, the sicker you will feel), or their environment at the time of them “coming to” may be a vitriolic one… Imagine waking up, feeling sick, not knowing what happened, maybe you are in a strange place or en route to a hospital, and people are yelling at you to wake up, or perhaps you are restrained. This can be a scary experience. Also, people may be angry to have their high ruined or taken away or be in withdrawals especially if they do not know that they were overdosing (which happens sometimes). Being uncomfortable and disoriented is certainly a combination that could cause someone to act like a jerk, even if you or another bystander may have just saved his or her life. The person may feel better if they are told that the naloxone will only last about a half hour and then they will go back to feeling how they did before. Even if they are angry at the time, some may return later to thank you. The overdose reverser may feel better later by venting to a staff person at a naloxone program.

Shouldn’t people just go into drug treatment? 

There are multiple barriers to people going into treatment for substance use: Sometimes people are not interested, willing, ready or able to go to treatment; there can be financial barriers; there are often waiting lists/ availability barriers; fear and stigma; untreated underlying mental health or trauma issues; acceptability of treatment models; hours of operation; staff; requirements (such as proper ID, etc.).

Overdose response and naloxone trainings are a practical strategy that focus on what is, as opposed to what should be. If this question is raised in a group setting, one successful strategy is to turn this question around to the group. Usually group members elucidate the reasons why treatment is only sometimes a viable option for some substance users.

If we help people avoid overdose, how will they ever learn how dangerous drug use is/hit “rock bottom”/get a “wake up call”? 

The death of a peer or a near death experience does not “teach” drug users a “lesson.” Increased psychological distress or trauma can actually increase substance use. The actual definition of addiction (called “dependence” or “abuse” by the American Psychological Association’s DSM V) includes one important criteria that relates to this issue: Use continues despite knowledge of adverse consequences (e.g., failure to fulfill role obligation, use when physically hazardous). This means that someone who is addicted by definition may not modify behaviors based on bad outcomes such as overdose.