Welcome to the Online Overdose Responder Training Program, sponsored by LI Medical Training and Consulting, a division of Have Dummy Will Travel, Inc. I’m Erik, the Chief Emergency Expert at Have Dummy Will Travel, and it is my pleasure and distinct honor to be your host throughout this program. Completion of this training class gives you the legal authority to carry naloxone, also known as Narcan, and administer it to a person whom you believe is experiencing an opiate associated life-threatening emergency.
This online training class and the naloxone emergency kit is completely free of charge. Upon completing all modules of this training, you will be asked to take a short test and register for the kit. You will then be able to pick the emergency kit up at our office, located in Miller Place, during normal business hours. If you prefer, the kit can be mailed to you for $9.95 to cover shipping and handling fees. This class is specific to New York State, and cannot be used for certification in another state. Likewise, the emergency kit cannot be shipped to an address outside of New York State.
This certification is good for two years.
Thank you for your willingness to respond to an emergency and possibly save a life.
The New York State Commissioner of Health has signed a non-specific patient prescription for Narcan, to be used by responders, like you. The law requires, however, that prior to administering Narcan, a person must go through a training program, similar to this one.
This program is compliant with Section 138 of Chapter 10 of the New York Code of Rules and Regulations Article 80 and Public Health Law Section 3309, and is given as a harm reduction strategy, intended to save one life at a time, until a victim can receive proper mental health care and counseling. This philosophy is similar to providing IV drug users with clean needles, to prevent the spread of HIV/AIDS and other diseases, or to providing middle school students with condoms. We know kids at that age are going to experiment with sex. The least we can do is prevent disease transmission and unwanted pregnancies.
It is important to note that this strategy is only one of several ways our community needs to manage the rampant opioid abuse problem.
Opiates are medications that are often prescribed for pain. At relatively high doses, an opiate can give the user a sense of euphoria, causing him or her to feel “high”. This opens the door to addiction and abuse. Opiate medications include Oxycodone (OxycotinTM), Hydrocodone (VicodinTM), Morphine, Codine, Percodan (PercocetTM), Fentanyl (DuragesicTM), Hydromorphone (DilaudidTM) and Methadone. Heroin, an illegal drug, is also a strong opiate, and is relatively inexpensive to obtain on the street. It is often self-administered by injection into the body or by snorting through the nose. Many of the opiate overdoses we see are from misuse of heroin or illegally obtained opiate pills.
Narcan does not work on non-opioid sedating drugs such as alcohol, benzodiazepines (ValiumTM, XanixTM, ClonopinTM), ClonidineTM, ElavilTM, γ-Hydroxybutyric acid (GHB), Ketamine or K2/Spice. Narcan also does not work on stimulates such as cocaine, amphetamines, methamphetamine, or Ecstasy, MDMA or Molly.
At the relatively higher doses that create the “high” abusers seek, opiates bind to special receptor sites on the brain that control normal breathing function. This causes breathing to slow and eventually stop. When breathing slows, oxygen levels in the blood decrease and carbon dioxide levels increase, causing the brain and heart to sustain damage. Eventually the heart stops altogether, leading to death. Overdose is not an instant phenomenon. Instead, it is a process that usually takes between one and two hours for death to occur.
For a rescuer, that means there is time to act, but no time to waste. With the right tools, most opiate overdose deaths can be prevented.
Overdose is more likely to happen to experienced users, especially when they had been clean for a while. Perhaps this clean period was during a detox or rehabilitation attempt, hospital stay, or incarceration. While using, an addict builds up a tolerance for opiates over time and often find themselves needing greater quantities at once in order to experience a “high”. The addict loses his / her tolerance for the drug while clean and during a relapse, may make the mistake of using the same amount he or she needed to get high prior to the clean period.
It is important to note that relapses are a part of the recovery process, and should be expected in anyone who is trying to recover from addiction.
Other risk factors for overdose include mixing opiates with other drugs. The Suffolk County medical examiner reports seeing six or more illicit substances in toxicological tests performed on suspected overdose deaths on a regular basis. It is also suggested that there may be several additional substances that degrade quickly in the body and so may not show up by the time a sample can be collected.
Slide #7 – (Video)
The video is a report from a local Lowell, Massachusetts news station. The content of the report highlights an issue we are seeing all over the nation, including in New York State.
Many drug dealers are cutting heroin with a synthetic opiate called Fentanyl. Fentanyl is 50 times stronger than heroin. Of course, there is no standardization amongst dealers, and different dealers will use different amounts of Fentanyl to design an “ultimate high” for their customers.
In addition, when the police arrest a dealer, addicts will find another source with a possibly more potent heroin-Fentanyl mix. Not having any way of knowing this, the addict may use much more than they need to in order to achieve a “high”.
Risk of overdose is also increased when a user has a serious underlying disease such as HIV/AIDS, liver disease, diabetes, or heart disease.
Since no one is there to call for help or administer naloxone, the risk of overdose increases when a user uses while alone.
Don’t Be Afraid to Call 9-1-1. New York’s new “911 Good Samaritan Law” encourages people to seek help and avoid leaving overdose victims to die in their beds or in remote areas, away from law enforcement, for fear of getting in trouble. To this end, the Good Samaritan Law in New York provides protections, for the victim and those who seek help during an overdose, from charge and prosecution for:
· Drug possession of up to 8oz of narcotics, what would constitute an A2 felony offense;
· Alcohol possession by underage drinkers
· Possessing any amount of marijuana, or
· Sharing drugs, which normally constitutes a sales offense in New York.
The Good Samaritan Law does NOT provide protection for parole violations, outstanding warrants, other crimes on the scene such as weapons or stolen goods, and Child Protective Services and housing issues.
If you encounter a person who is unconscious, you should suspect that he / she is suffering from an opiate overdose if you see the following signs:
· The person has a heavy head nod or is not responsive to stimulation
· The person has slowed or shallow breathing
· The person’s lips and / or nail beds are turning blue.
· The person has extremely small pupils in both eyes
Let’s look at each of these signs in a little bit more detail and see how they all fit together.
A person who is unconscious with his or her chin down or who appears too sleepy to keep their head up is in a dangerous position. This can lead to a partial or complete airway obstruction, reducing the volume of air moving into the lungs. If you find an unconscious person, roll him or her on to his or her back and do a head tilt, chin lift to open up the airway. Tap his/her shoulders while shouting their name or shout “Are you ok? Are you ok?”. If there is no response, rub the person’s sternum or roll the barrel of a pen down his/her nailbeds while pushing.
If there is still no response, check for breathing by looking for rise and fall of his or her chest.
If the victim is not breathing at all, immediate intervention is needed. If breathing is present, but at a rate that is less than 10 times per minute, or once every six seconds, there is strong evidence for opiate overdose, check the person’s lips and / or nail beds.
Bluish skin is a sign of a lack of oxygen in the blood. This is especially likely in people who have not been breathing adequately for an extended period of time. If you see bluish lips and / or nailbeds in an unresponsive person, this is even stronger evidence for opiate overdose. Look at the person’s pupils.
Normal pupils may be small in sunlight, as is shown in the top picture. However, opiates cause pupils to look extremely small, perhaps the size of a pin-point, as can be seen here, in the bottom picture. Check that both pupils are about equal in size and significantly smaller than usual. Unequal pupils may be a sign of a head injury. It is important to note that pupil constriction may not occur if opiates were taken with a stimulant, such as cocaine.
The strongest evidence for a victim of overdose is slow, shallow breathing with bluish lips and / or nail beds and pin point, but equal, pupils in a person who is unresponsive to painful stimuli.
Naloxone, or Narcan, is an opiate reversal agent that has proven itself to be very safe and effective over the past few decades. Only relatively small doses of naloxone are needed to reverse an overdose, although we are seeing that more and more is needed as additional opiates, such as Fentanyl, are being mixed in.
Narcan works by stripping the opiates off of the receptors on the brain and taking their place. This reduces the effects of the opiates on respiration and terminates the “high” feeling, usually in about 5 minutes. Since this is the only action of Narcan, accidental administration to a person not experiencing an overdose cannot cause any harm. The only side effect of Narcan is withdrawal from the opiate. These symptoms usually subside after about an hour from the time of administration.
Traditional administration of Narcan has been through an IV or a shot in the arm or leg. With the invention of the Mucosal Atomization Device (MAD), naloxone is now atomized into a fine mist and may be injected into a victim’s nostrils. This route is painless and absorption through this route is quick enough to be effective in reversing opiate overdoses. Removing a needle from the delivery system allows injections to be done safely, by everyday people who have little or no medical training. Since everyone’s nose is easily accessible, there is no need to worry about exposing skin on an arm or leg to find an injection site, especially in the winter time.
While Narcan is a life-saving tool, it may not always be enough. In addition, it is possible that you may not have enough narcan in your kit to reverse an overdose. Therefore, your first priority must be to call 9-1-1 for help. In addition, it may also be necessary to administer CPR to an overdose victim who has completely stopped breathing. Without CPR, the naloxone may not circulate throughout the body, including to the brain where it is needed. Therefore you are strongly encouraged to learn Hands-only CPR at minimum and urged to attend a class that will lead toward certification. A link to our CPR class schedule is available at the end of this presentation.
The overdose prevention rescue kit consists of:
· A barrier mask for rescue breathing;
· Two pre-filled syringes of naloxone (NarcanTM) without needles;
· Two mucosal atomization devices;
· One pair of non-latex gloves;
· Two New York State Department of Health Reporting Forms;
· Two Alcohol Prep Pads; and
· One certificate of completion card, legalizing your possession of a prescribed medication.
Like any medication, naloxone (NarcanTM) has an expiration date. You can find this date on the side of the box the medication is packaged in. Also note, Narcan should be stored away from temperature extremes and light.
To administer Nacan follow these steps. First, assemble the syringe by removing the caps from the shooter and syringe. Twist the mucosal atomization device to the right, onto the top of the shooter, about ½ to ¾ turn, or until you feel it is tight. Insert the glass syringe into the back of the shooter and twist to the right gently one full turn or until you feel some resistance. Be careful not to allow any of the medication to squirt out of the syringe. The following video shows how to assemble the Narcan syringe.
Slide #22 (Video) – Assembly
This video demonstrates how to assemble the Narcan syringe.
Next, position the victim on his or her back and tilt his or her head back. This opens the airway to help breathing and positions their nasal cavity to receive the naloxone. Push the tip of the nose upward, toward the forehead and insert the mucosal atomization device into one nostril. If the glass syringe will not push forward, try twisting the glass syringe a bit more to the right while it is still inserted into the nostril. Push the syringe forward, watching the measurement gradations on the glass syringe until 1 mg or 1 mL has been administered. Administer the balance of what is in the syringe into the other nostril.
If after two to five minutes, the victim is not breathing and awake, administer the second dose of naloxone (NarcanTM) in the same manner as the first.
If administering naloxone to a child, administer only ½ mg or ¼ of the syringe in each nostril, wait 30 seconds and repeat. This will allow time for absorption in the smaller nasal cavity of the child.
This flow chart will help you determine how to respond to an emergency where there is a potential for an opiate overdose.
If you come upon a person you suspect is a victim of opiate overdose:
1. Ensure that the area is safe for you to be in. As you look around, look for blue lips and / or fingertips.
2. Tap his or her shoulders and shout his or her name or shout, “Are you ok?. Are you ok?”. Rub his or her sternum or roll the barrel of a pen down the fingernails while pushing. Look for pinpoint pupils, remembering that this is not always a reliable sign.
3. If still no response, call or send someone to call 911. Ideally, you will be able to call from your cell phone and place the phone in speaker mode.
4. Look to see if the victim is breathing. If the victim is breathing greater than 10 times per minute, roll him or he onto the side and stay with the victim until help arrives. If breathing less than 10 times per minute, administer narcan. If not breathing or just gasping, begin CPR and administer narcan. If you are alone, perform CPR for about two minutes before administering Narcan.
5. If the victim is not breathing and awake in two to five minutes, administer a second dose of naloxone (NarcanTM).
6. If you must leave the victim alone, place him or her into the recovery position.
7. Upon their arrival, inform the police and emergency medical technicians of what happened and what was done.
To place a person into the recovery position, simply bend the person’s leg closest to you. Raise the opposite arm above the head. While supporting the victims head and neck, push forward on the bent knee. Once the victim is on his or her side, place the free hand beneath the victim’s chin and open his or her mouth.
Once the victim is awake and breathing, he or she will likely begin feeling symptoms of withdrawal such as nausea and vomiting and restlessness. These feelings are likely to subside within an hour or so. It is also likely that the victim will try to get high again as soon as possible. Addicts can be extremely manipulative and will say anything they need to in order to get you to leave them alone. It is extremely important that you do everything you can to stay with him or her and prevent him or her from getting more opiates. Encourage him or her to go to the hospital for observation. As the naloxone (NarcanTM) wares off, the potential to relapse increases. If for some reason the victim is not brought to the hospital by EMS or law enforcement, stay with him or her for at least three hours, until the naloxone fully wears off, watching for signs of relapse. Call 911 immediately if signs of overdose return.
Addicts often resort to hurtful speech and empty threats. Very rarely will their behavior become violent, especially when withdrawal symptoms are present. That said, if you feel that you are in danger at any time, you should leave the area immediately.
Once the event is over, you will need to fill out the New York State Department of Health Reporting form and contact us to replenish your emergency kit. This form consists mainly of demographic information and is completely anonymous. The Department of Health uses this information to help determine where and to whom to push resources most effectively. If your naloxone is nearing expiration, please contact our office as well. You will be able to find a copy of this form in your naloxone kit or contact our office for a new form.
Many folks have questions about legal liability. Rest assured, you are protected from civil liability and criminal prosecution for administering overdose treatment, provided it is done in good faith and you believe the person is experiencing a drug overdose.
If a pregnant woman is experiencing an overdose, you may give her naloxone. There are no known harmful effects to a fetus. If the pregnant victim dies, her fetus will also.
Thank you again for taking the time to learn how to save a life. There are just a few steps remaining to obtain your naloxone rescue kit. Please click on the button below this video to begin your test. You must score 85% or greater in order to qualify for a naloxone kit. You may retake the test as many times as necessary.
Once you have passed the test, please fill in the form at the bottom of this page. If you desire more hands-on practice assembling the naloxone syringe, you can do so when you pick the kit up in our office. If you prefer, we can also send a practice syringe to you and set up a face-to-face appointment on Skype. Please note that a separate shipping and handling fee applies to send and return the practice syringe.
If you have any questions or need any additional information, please feel free to contact our office at 631-849-4978, or email email@example.com.
Click here to take the test.
Click here for our upcoming CPR certification class schedule.