Overdose Prevention and Management

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Overdose Prevention and Management

• TOPICS
• Overdose in EE/CA
• What are opiates? What are the causes of opiate
  overdose (and ways to prevent)?
• How to avoid an opiate overdose
• What is Narcan / naloxone
• How to respond to an opiate overdose
• How to design overdose prevention/intervention
  programs in a health services setting.

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Overdose prevalence in Central and Eastern Europe
and Central Asia

• 2001 Study
• 78 of drug user respondents reported being
  present at an overdose
• 90 had heard about one in the past year
• 85 of drug user respondents had overdosed (mean
  3 overdoses)
• Large proportion of reported overdoses involved
  mixing drugs, most notably benzodiazepines (45)

Coffin, Phillip and Agnese Strodaha. Preliminary
Overdose Survey of Central/Eastern Europe,
Former-Soviet States and Central Asia.
International Harm Reduction Development Program,
New York 2001.
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Overdose Response in CEE

• Rescue breathing, inducing pain, keeping awake
• Injecting boiling water, salt water, ammonia
  solution, giving vitamins
• Many reported that they did not call ambulance
  out of fear of police
• Police may question, register, or imprison those
  who overdose
• Ambulances can take 30-90 minutes to arrive

Coffin, Phillip and Agnese Strodaha. Preliminary
Overdose Survey of Central/Eastern Europe,
Former-Soviet States and Central Asia.
International Harm Reduction Development Program,
New York 2001.
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Regional Variations in CEE

• Russia and Central Asia
• least access to naloxone
• especially poor emergency care services
• highest frequency of overdose
• Users in Russian-speaking countries more likely
  to inject in groups, more reluctant to involve
  authorities

Coffin, Phillip and Agnese Strodaha. Preliminary
Overdose Survey of Central/Eastern Europe,
Former-Soviet States and Central Asia.
International Harm Reduction Development Program,
New York 2001.
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Russia Prevalence of overdose

• In a 2003 survey, respondents reported that
• 59 had overdosed
• 81 had seen others overdose
• 15 had witnessed a fatal overdose

Sergeev, Boris, A Karpets, A Sarang, M Tikhonov.
"Prevalence and Circumstances of Opiate Overdose
Among Injection Drug Users in the Russian
Federation." Journal of Urban Health v. 80, n.
2, June 2003, p. 212-219.
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Causes of Overdose in Russia

• 74 of ODs occur during heroin use
• In some smaller cities, overdoses from choyrnaya
  or hanka are more common
• Older users more likely to have overdosed
• 59 of overdoses involve combining opiates with
  other drugs
• alcohol (56), sedatives (23), antihistamine
  blockers (11)

Sergeev, Boris, A Karpets, A Sarang, M Tikhonov.
"Prevalence and Circumstances of Opiate Overdose
Among Injection Drug Users in the Russian
Federation." Journal of Urban Health v. 80, n.
2, June 2003, p. 212-219.
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Russia Overdose Responses

• Rescue breathing
• Calling an ambulance
• rare (13-16 of reported cases) because of fear
  of police, mistreatment by ambulance services
• Ambulance services sometimes came so late that
  the victim had already recovered or died
• Walking the victim, keeping them awake
• Dangerous responses include injecting salty,
  boiling, or ammonia water, and cold showers/bath

Sergeev, Boris, A Karpets, A Sarang, M Tikhonov.
"Prevalence and Circumstances of Opiate Overdose
Among Injection Drug Users in the Russian
Federation." Journal of Urban Health v. 80, n.
2, June 2003, p. 212-219.
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Responding to Opiate OverdoseWhat Are Opiates?

• Opiates are a type of drug that come from the
  opium poppy or are synthetically made by a drug
  company. All opiates act the same way in the
  brain. Opiates are depressants, which means that
  they slow down your central nervous system,
  including your breathing and heart rate.
  Examples of natural opiates are heroin, morphine
  and codeine. Examples of synthetic opiates are
  methadone, oxycontin, percodan, percocet, and
  vicodin.
• Opiates differ in both their strength and in the
  length of time they act on your body.
• DRUG Duration Potency
• METHADONE 24-32 hours
• HEROIN 6-8 hours
• OXYCONTIN 3-6 hours
• CODEINE 3-4 hours
• DEMEROL 2-4 hours
• MORPHINE 3-6 hours
• For example, Heroin is a strong opiate that
  produced effects for 6 8 hours. Methadone is a
  strong opiate too, but acts much longer in your
  body between 24 and 32 hours. Codeine is a
  weak opiate whose effects last for 3 4 hours.

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What Are The Causes of Opiate Overdose

• An overdose is when your body has more drugs in
  its system than it can handle. People can
  overdose on lots of things, including alcohol,
  cocaine/crack, opiates or a mixture of drugs.
  Opiate overdoses happen when there is so much
  opiates and/or other CNS depressants in your body
  that your brain shuts down your breathing. If
  you cant breathe, then you cant get oxygen to
  your brain and after a little while your heart
  stops, which leads to death.
• There are a lot of things that can lead to
  overdosing on opiates
• Q Can you name any of them?

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TOLERANCE
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Be Aware of the Risks of Mixing Drugs

• Mixing heroin with other CNS depressants like
  alcohol, benzos, or prescription opiates can be
  especially dangerous. The drugs interact and can
  create a much more powerful effect than when they
  are used by themselves.
• If you are going to mix heroin with other
  downers, you may want to do the heroin first
  especially if you are injecting because this gets
  the drug into your system very fast.
• Alcohol and pills come on more slowly and you may
  not get the full effects for a while after
  ingesting them. Also, alcohol and pills can
  interfere with your judgment and may result in
  you doing more heroin than you intended or not
  being as safe when using.
• The important thing is to be aware of what youre
  taking and how different drugs can interact.
  Remember to pace yourself.

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Try Not to Use Alone

• If you are using alone and overdose, there is
  nobody there to call for help or to try and
  revive you. If you are going to use alone, it is
  especially important to follow the guidelines
  above so you minimize the risk of overdosing.

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Injection Technique

• Dont slam the shot, ESPECIALLY if it is from a
  source youre not used to or part of a new batch.
  Instead, after you register give several small
  pushes to taste the quality of the drug(s).
  Remember, once its in, you cant get it out.

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What Are The Signs of an Opiate Overdose?

• There are a number of signs that someone has
  overdosed on opiates.
• Q Can you name any of them?

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Signs of an Opiate Overdose

• Passing out unconscious
• Awake but unable to talk
• Slow breathing (less than 12 breaths per minute)
• Choking or gurgling sounds
• Limp Body

• Pale complexion
• Cold, clammy skin
• Turning blue (fingers and lips turn blue first)
• Vomiting
• Slow heartbeat/pulse

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Sometimes it may seem difficult to tell if
someone is overdosing or they are just really
high.
REALLY HIGH OVERDOSE
The most important things to consider are
responsiveness to stimuli and breathing.
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What is Narcan or Naloxone?

• Pure opioid antagonist that is safe and effective
  for use in reversing opiate overdose. Narcan has
  no other effects and cannot be used to get high.
  You cannot overdose on Naloxone.
• Narcan is active for about 30 90 minutes in the
  body.
• Because Narcan blocks opiates from binding with
  receptors in the body, it is possible that it can
  cause withdrawal symptoms in someone who has a
  habit. Therefore, after giving someone Narcan
  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 Narcan wears off.

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How to Respond to An Opiate Overdose

• What NOT to do
• Dont leave the person alone--they could stop
  breathing
• Dont put them in a bath--they could drown
• Dont induce vomiting--They could choke
• Dont give them something to drink--they could
  vomit
• Dont inject them with anything besides
  Narcan--it wont work any more than physical
  stimulation and can waste time or make things
  worse depending on what you inject.

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How to Respond to An Opiate Overdose

• Assess the signs
• Stimulation
• If the person is unconscious or out of it, try
  to wake them up. Call their name and shake them.
  If this doesnt work, try to wake them by
  causing mild pain like pinching them or rubbing
  your knuckles into their sternum (the place in
  the middle of your chest where your ribs meet.
  DEMONSTRATE and have them try it). If this
  causes them to wake up try to get them to focus.
  Can they speak to you? Try to get them to stand
  up and walk around, even if you have to support
  them. Check their breathing. If this is shallow
  or the person tells you have they have shortness
  of breath, or chest tightness call for medical
  help, if that is possible. Continue to monitor
  them, especially their breathing and their pulse
  and try to keep them awake and alert.
• Call for Help If the person DOES NOT respond to
  stimulation and remains unconscious or their
  condition appears to get worse.
• THIS IS OFTEN A SERIOUS PROBLEM THAT HELP, IF IT
  IS AVAILABLE, MAY LEAD TO INVOLVEMENT WITH THE
  POLICE.
• Is there an organization that has medical staff
  and a hotline available?

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Recovery Position

• If you have to leave the person at all, even for
  a minute to phone 911, make sure you put them in
  the Recovery Position ?

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Rescue Breathing

• Clear the Airway/Perform Rescue Breathing
• Rescue breathing is one of the most important
  steps in preventing an overdose death. If you
  are performing rescue breathing, you are getting
  much needed air into someones body who will die
  without it.
• Its important that the persons airway is clear
  so air can get into their lungs. Place the
  person on their back, place your hand under their
  neck and tilt their chin up. Check to see if
  there is anything in their mouth blocking their
  airway, such as gum. If so, stick your fingers
  in their mouth and remove it.

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Rescue Breathing

• Use the head-tilt-chin-lift method to open the
  airway
• Tilt the head back with nearest hand by applying
  backward pressure to the forehead.
• Place other hand under chin bone and lift
• tilt head back without closing mouth and check
  for breathing (ear to mouth).
• pinch the nose to prevent air coming out of nose
• Take a deep breath and put your mouth over theirs
• Establish a tight mouth-to-mouth seal
• Give 2 slow breaths.
• Blow enough air into their lungs to make their
  chest rise.
• Turn your head after each breath to ensure the
  chest is rising and falling. If it doesnt work,
  tilt the head back more.
• Breathe again. Count one-one thousand, two-one
  thousand, three one thousand, four one thousand.
• Breathe again.

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Evaluate The Situation

• Has the persons begun to breath again on their
  own?
• Are they conscious now?
• Can they communicate with you?
• Continue to assess them and monitor their
  breathing.
• If they are still unconscious and not breathing.

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Administering Naloxone

• Prepare the naloxone be prepared to do this
  quickly different forms can be easier or more
  difficult.
• 1-2 cc / 1-2 mg intramuscular injection in any
  big muscle (upper arm, thigh, butt). Dont waste
  time trying to inject in a vein.
• Naloxone is effective in 1-3 minutes. Continue
  rescue breathing and monitoring until the drug
  acts.
• If no response after 3 minutes, OK to administer
  more naloxone.

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• Continue this pattern until
• the person starts to breathe on their own
• an ambulance comes
• someone else can take over for you.
• You are too exhausted to continue.

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Calling For an Ambulance?

• Tips Discussion

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Finally Plan Ahead

• Talk to your using partners and those people who
  are around you when you use and develop a plan
  for how to respond if you overdose.

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Starting an Overdose Program

• What is useful to know?
• Local OD situation among a programs participants
  (est. incidence, causes, drug scene issues,
  trends in incidence and mortality, clustering,
  etc)
• Local/national statistics, if any
• Current professional/non-professional response
  practices
• Is naloxone available? (form, regulations, price)
• Any constraints in a particular program
  environment? (harm reduction organization vs.
  hospital vs. drug treatment clinic etc.)
• See handout on Preliminary Questions for
  Developing Overdose Prevention and Intervention
  Programs in your conference packet for more
  detail.

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NYC as an example

• From 2005, NYC has adopted a city-wide overdose
  program involving all 11 harm reduction centers.
• How did we get there?

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2003
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New York City

• Pilot program initiated in areas with high OD
  rates with private foundation funding in Spring
  2004 LESHRC, CitiWide, Streetwork.
• First data analysis published late-2004 in
  collaboration with NYAM researchers
• IDUHA (NYC harm reduction services coalition)
  adds OD to city lobbying agenda wins NY City
  Council funding beginning early 2005, with Pilot
  adopted as the model intervention
• NYAM and JHSPH involved in program evaluation.

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Outcomes

• By October 2006 1,800 naloxone prescriptions
  filled (c. 3,600 doses)
• As of September 2006, reversal rate by
  participants is 9.4 (increased from 6 in early
  evaluation)
• 2005 data from city coroners office shows modest
  decline in mortality, but community district data
  not yet available.
• Comparatively, Cook County (Chicago) gt30 decline
  in mortality since program began in 2001.
• NY Governor signed law eliminating liability for
  naloxone providers, went into effect April 2006.

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Next Steps Lessons

• Pilot programs starting in Rikers Island (city
  jail) and adult homeless shelter system
  questions around IM syringes.
• Need to promote intervention in medical and drug
  treatment settings, and to work more closely with
  NYPD.
• Program shows effect of close collaboration
  between community, researchers, academia and
  government in addressing a major issue in drug
  user health.

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• For more info on NYCs
• overdose programs, visit
• http//harmreduction.org/OVERDOSE/