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Training Guide

Opioid Overdose Basics

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. However, the dramatic difference between the character overdosing and the character after receiving the medicine that is depicted in the film is a possible scenario with naloxone.

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 could cause a back-up of drugs in the body, causing an OD. A person whose liver isn’t functioning properly could have a longer overdose in addition to more frequent overdoses.

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

Buprenorphine (brand name Suboxone) diminishes cravings for opioids such as heroin, while naloxone (naloxone) counters “potential abuse” (meaning: injecting) of Suboxone. If the Suboxone is taken under the tongue, naloxone will not get absorbed into the body. If Suboxone is injected, the naloxone will beat the buprenorphine to the opioid receptors, delaying and lessening the high.

OK, so there IS naloxone in Suboxone…will Suboxone work for an OD?

Using buprenorphine to reverse an overdose is not something that has been scientifically studied. However, there are reports of this working. This is probably because the buprenorphine has a stronger affinity or attraction to the opioid receptors than heroin or other opioids, so it displaces the opioids. The reason Suboxone may reverse an overdose is probably not because of the naloxone in it—it is a very small amount—and it is most likely the buprenorphine that causes the person to wake up. Remember: during an overdose it is all about time and oxygen. Anything that is done to reverse an overdose should not sacrifice time or oxygen. Preparing a Suboxone to inject takes precious time, and waiting for the pill to dissolve in the mouth takes even longer.

Will naloxone work on an alcohol OD?

Naloxone will not work on an alcohol overdose, only opioid overdoses. If it is an alcohol overdose that also involves opioids, it might help by dealing with the opioid part of the OD

Can I give them a shot of coke or speed OR does Speedballing balance you out?

No- speedballing does not cancel out OD risk- it actually increases risk, especially cocaine which can also numb the urge to breathe. Speedballing is any combination of a stimulant (upper) and a depressant (downer) taken together, especially a mixture of heroin and cocaine or heroin and methamphetamine injected into the bloodstream.  Stimulants actually constrict blood vessels, and cause the heart to beat faster, which can depletes the body of much-needed oxygen, which makes the overdose worse. The more different drugs someone’s body has to process, the harder it is on their body. People who speedball usually use much more frequently that people who use only heroin- this increases OD risk

What if it is a crack/coke OD?

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

Clonidine: Is it an Opioid? A Benzo?

Neither (do not confuse with Klonopin, which is a benzo). It can be used to relieve withdrawal symptoms from opioids, alcohol & nicotine. When combined with opioids recreationally it increases the high. It lowers blood pressure, heart rate, causes dizziness & drowsiness. Lowering the blood pressure raises the risk of falls. There is a higher risk of overdose with a clonidine/opioid combo than with opioids alone, but less than with a benzodiazepine/opioid combination. It is not as long lasting as benzos, no amnesiac effects (short-term memory loss). Stopping regular use does cause mild physical withdrawal symptoms and in people using it for high blood pressure it can cause very high blood pressure.

What about Phenergan (Finnegan, Promethazine)?

It’s used to combat nausea, as a sedative, allergy medication, for motion & morning sickness, and to increase the activity of opioids. For example, someone on high doses of opioid pain medication could lower dose of pain med and take Phenergan to get same effect…similarly, the effects of heroin would be increased. There is a higher risk of overdose with a phenergan/opioid combo than with opiods alone, but less than with a benzodiazepine/opioid combination. It is not considered to be habit-forming or cause withdrawal

What’s the deal with Fentanyl and ODs?

Fentanyl is an extremely concentrated/potent opioid. Some heroin dealers 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 OD in a user that is expecting just heroin. Fentanyl patches can also be used by either slapping them on the skin to get the time released medication, and then using other drugs on top of that, or by placing the patch inside the cheek, which allows the medication to release quicker, or by shooting or snorting the gel inside the patch (a bit of a process to get it into injectable form, but it can be done!). Very risky in terms of overdose, Fentanyl 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 salt shots?

The salt shot causes pain (1. the injection & 2. saltwater will sting/burn) so if the person CAN respond to pain, they WILL. Fixing a salt shot wastes precious time that could be spent on calling 911, rescue breathing & giving naloxone.  While salt shots may have appeared to have worked sometimes, they could also cause damage. Naloxone is a safer alternative.

Will hitting someone bring them out of an OD?

You really do not want to kick, slap, punch, drag anyone…you might hurt them. The sternal rub basically does the same thing as hitting, but we want to cause pain but 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 might work and it might not. Ice down the pants or cold showers can slow down the respiratory system and can send someone into shock or hypothermia.

A safer, quicker, more likely to work action is: Call 911, do rescue breathing and give naloxone.

Will using naloxone help someone give a clean urine?

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

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

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

Can someone get arrested for being at an OD?

There is no easy answer to this question, because it depends. It depends on the policies and culture of your local police department and community. For example some departments have unwritten policies to never arrest people at the scene of an overdose just 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 impossible for police to arrest you or at least  to charge and prosecute at an overdose if you called for help. HOWEVER, consider: Are you on probation? Do you have warrants/open cases? What is the housing situation where you are at?

What if the police still come and question us?

PLAN in advance- remove all paraphernalia from view- if no reason for a search is obvious, it might not happen. Police’s first priority is the safety of the scene. The smoothest interactions will happen when it is calm and under control

What’s with the nasal naloxone, does it work?

EMS services across the country are now using nasal naloxone (Boston and San Francisco, for example) and some hospital emergency departments. In addition to ambulances and hospitals, in some places the police and fire departments use nasal naloxone. Nasal naloxone is also distributed at several overdose prevention programs, including the DOPE Project in San Francisco, Project Lazarus in North Carolina, at naloxone distribution programs in New York City, and statewide in Massachusetts and New Mexico. The nasal 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. There has been some research done already on the effectiveness of nasal naloxone. 1000s of lives have been saved using nasal naloxone in the 5 programs that are currently distributing it. Intranasal has the advantage of having no needle but it is more expensive.

What if someone injects the nasal naloxone?

It is probably a higher dose of naloxone than therapeutically necessary and the person would probably experience more severe withdrawal symptoms. Injecting about one quarter of the naloxone in the vial is a good amount to start. However, it would work to reverse an OD.

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

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. Two things have been done successfully (but should only be done in an emergency): Inject the naloxone in the vial; or squirt it up the person’s nose anyway without the nasal adapter, it will be more of a stream than a spray, so 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!

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

This is not ideal, because muscle syringes have longer points, which are better for getting the naloxone into the muscle. Regular insulin syringes have shorter points, 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 OD to reoccur after giving naloxone?

It depends on: 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 dope 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 ODs?

The new guidelines are aimed primarily at cardiac arrest, not respiratory arrest. In cardiac arrest, respirations are not as important as compressions -particularly in first few minutes. In respiratory arrests (like overdoses), respirations are the key. If the respiratory arrest progresses to a full cardiac arrest the patient should get both chest compressions and rescue breathing. The situation with an opioid overdose where the primary problem is lack of oxygen because of decreased breathing is different than a heart attack. With any signs of life, such as gasping breaths or a pulse with inadequate breathing, then ventilation (rescue breathing) should be enough. 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. Read Harm Reduction Coalition’s alert on the guidelines here.

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 help anyone who is not in an OD, but it will not hurt them either, unless it means wasting time or delaying getting access to emergency medical services.

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

It is not possible to give so much naloxone so as to harm a person. However, if a person is dependent on opioids (including people without substance use disorders, but on chronic pain medication) or has a habit, 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 or dopesickness will fade in a half hour or so.

Can you develop immunity to naloxone?

No, people will 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 start to wonder what is going on with their body if they rarely overdosed before and now seem to be overdosing all the time. A good trainer can brainstorm some of the reasons why this might be happening. Some examples of reasons that have been discovered are:

• 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
• Suicidality

What if my kids (or small children in area where naloxone rescue kit is kept) find and use the naloxone can it hurt them?

Naloxone acts as an opioid antagonist and has no adverse effects – it simply kicks opioids off brain receptors temporarily to reverse an overdose. While the medication itself does not pose a real risk to small children, its important to keep in mind the risks associated with the 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 old kit, that’s great because the program can use it as a demonstrator. If you forget, it is not a big deal.

My naloxone expired- can I still use it?

If it is the only thing you have, use it. Like most other medication, 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 can not hurt, so use it and continue to perform rescue breathing.

Our clinic/program policy is not to even give people over the counter medication- how is it possible that we are now allowed to give people naloxone?It depends. OD trainers should ask this question specifically of 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 overdoses or to give out Naloxone for program participant use. In this case, focus on helping the program create a policy for on-site overdoses 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, and then refer them outside to obtain Naloxone. In some cities and states, there are regulations or laws that have passed to allow “3rd party administrators” of Naloxone which provides protections for staff persons to have and use Naloxone at their programs. Learn what you local regulations are concerning this before the training.

Naloxone makes people violent, right?Naloxone itself does not evoke ‘violent’ reactions in folks – rather, having too much Naloxone administered to them (if you 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 dopesick, 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…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/or disoriented is certainly a combination that could cause someone to act like a jerk, even if you or another bystander may have just saved their 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 angry at the time, some may return later to thank you. The OD reverser may feel better later by venting to a staff person at a naloxone program.

Shouldn’t people just go into 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; Financial; Waiting lists/availability; Stigma; Untreated underlying mental health or trauma issues; Acceptability of treatment models, hours of operation, staff, requirements. 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 overdoses, 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 IV-TR) 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.