Opioid Overdose Toolkit: Five Essential Steps for First Responders

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1 S A M H S A Opioid Overdose TOOLKIT: Five Essential Steps for First Responders

2 TABLE OF CONTENTS FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS STEP 1: CALL FOR HELP (DIAL 911) 3 3 STEP 2: CHECk FOR SIgNS OF OPIOID OVERDOSE THINg STEP 3: SuPPORT THE PERSON'S BREA 4 4 STEP 4: ADmINISTER NALOxONE STEP 5: mONITOR THE PERSON'S RESPONSE 5 SummARy: DO'S AND DON'TS IN RESPONDINg TO OPIOID OVERDOSE 5 7 ACkNOWLEDgmENTS, ETC. n Acknowledgments Disclaimer n n Public Domain Notice Publication of Copies n Electronic Access and n Recommended Citation Originating Office n Also see the other components of this Toolkit: Facts Community . for Members . Prescribers for Information . & Safety Advice for Patients Members Family . Recovering from Opioid Overdose: Resources for Overdose Survivors & Family Members 

3 FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS is verdose among common STEP 1: CALL FOR HELP (DIAL 911) illicit persons who use opioids such AN OPIOID OVERDOSE NEEDS ImmEDIATE mEDICAL ATTENTION. who those among and heroin as O to get someone with medical expertise to see the An essential step is misuse medications pain, prescribed for as as personnel trained other or EMS patient no possible, so if soon and hydrocodone, oxycodone, as such are on is: say to have you All immediately. 911 dial scene, the morphine. incidence The of opioid overdose a clear address and/or “Someone is not breathing.” Be sure to give is between example, For nationwide. rising description of your location. poisoning of number the 2010, and 2001 States doubled, nearly United the in deaths largely involving overdoses of because STEP 2: CHECk FOR SIgNS OF analgesics This [1]. opioid prescription coincided increase fourfold nearly a with OPIOID OVERDOSE prescribed use opioids of the in increase OVERDOSE , which often Signs results in death if of not treated, of for the treatment pain [2]. include [3]: the problem, emergency To address professionals, personnel, health care medical is touch the Face to clammy and/or extremely pale n are being trained and patients increasingly Body is limp n of the use in the opioid antagonist nalox - (­ hydrochloride one Narcan), or naloxone n Fingernails cast purple or blue a have lips or the choice is which reverse to treatment of is vomiting or making gurgling The patient noises n potentially fatal the depression respiratory (­Note by caused that opioid overdose. is or n sleep from awakened be cannot she or unable He speak to non-opioid on no has naloxone effect n Breathing is very slow or stopped as those involving cocaine, overdoses, such [3].) alcohol benzodiazepines, or n very is Heartbeat slow or stopped scientific evidence urrent c on Based and extensive experience, the steps out - overdose, OVERmEDICATION , to which may progress of Signs lined below ar to recommended e reduce include [3]: number from opioid resulting deaths of the n drowsiness or sleepiness Unusual overdoses [4-9]. n behavior intoxicated speech, slurred confusion, Mental n shallow Slow or breathing n pupils Pinpoint n low heartbeat, pressure Slow blood n sleep Difficulty the waking person from breathing, and function respiratory ess opioids depr Because “death the is one telltale sign of a person in a critical medical state “death a with breath exhaled an — rattle” rattle.” If a person emits a emergency — very distinct, labored coming from the throat sound resuscitation will be necessary immediately, as it almost always is a is sign that the individual near death [8]. 

4 FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS of DuRATION OF EFFECT . The duration STEP 3: SuPPORT THE effect of naloxone is 30 to 90 minutes, and PERSON’S BREATHINg be observed after this time patients should of overdose symptoms return for frame the are experiencing opioid overdose should Ideally, individuals who naloxone be [7-9]. The goal of should therapy is naloxone before oxygen 100% with ventilated be administered spontaneous adequate restore to breathing, so as to reduce the situations In [5,7]. injury lung acute risk of [7]. complete but not necessarily arousal where 100% oxygen is not available, rescue breathing can be very than More dose one may naloxone of be involves breathing Rescue [5]. respiration supporting in effective who overdosing. is needed someone to revive steps: following the have Patients who longer-acting taken (­check clear nothing the is inside that Be sure the person's airway n intravenous further may opioids require mouth blocking the airway). is person’s or throat doses infusion bolus naloxone an [7]. of or the Comfort being treated, person as P n and pinch lace one hand on the person's chin, tilt the head back triggered by naloxone can withdrawal feel the nose closed. a result, some As unpleasant. persons n P mouth to make a seal and lace your mouth over the person's this when combative or agitated become breaths. 2 give slow to remain help need calm. happens and n T stomach). he person's chest should rise (­but not the safety profile SAFETy OF NALOxONE. The naloxone is remarkably high, especially of n seconds. with up ollow one breath every 5 F to titrated and doses low in used when effect to are who individuals given When [5-8]. or opioid-intoxicated not opioid-dependent, STEP 4: ADmINISTER NALOxONE clinical effects, even produces naloxone no any be (­Narcan) Naloxone administered to should person who Moreover, doses. high at opioid while rapid or when overdose is shows [7]. suspected signs of opioid overdose, may be withdrawal tolerant patients in by been has approved and Naloxone used FDA is the injection for life-threatening. is it unpleasant, not to reverse decades (­EMS) by emergency medical services personnel safely manage be to used an Naloxone c opioid overdose and resuscitate individuals who have overdosed The women. pregnant opioid in overdose on opioids. maintain spontaneous to dose lowest given injection be an by intramuscular or intravenous Naloxone c used to avoid drive respiratory should be The [7-9]. minutes 3 to 2 every rapid most of action onset achieved is acute opioid withdrawal, which triggering recommended in emergency administration, which is intravenous by fetal distress may cause [7]. [8]. situations be titrated to the should effective smallest dose The drive. dose that maintains respiratory spontaneous normal to up mg 2 of atients may be given starting doses p Opioid-naive withdrawal for triggering without 9]. [5-7, symptoms concern route tramuscular in The suitable more be may administration of for a history of opioid dependence because it provides a patients with prolonged duration of effect, which may onset slower of action and a minimize rapid onset of withdrawal symptoms [5-7]. 

5 FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS SummARy: STEP 5: mONITOR THE PERSON’S RESPONSE Do’s and Don’ts in Responding to Opioid Overdose for signs of recurrence monitored be should and All patients symptoms of opioid toxicity for at dose last the from least hours 4 person’s DO suppor t the breathing by n who naloxone or discontinuation of the naloxone infusion. Patients of or oxygen performing administering should opioids long-acting on overdosed have prolonged more have breathing. rescue [5-7]. monitoring naloxone. ter adminis DO n with breathing, spontaneous atients respond by returning to p Most withdrawal The response symptoms generally occurs minimal [7]. put DO person the in the “recovery n to 5 minutes of naloxone 3 administration. (­Rescue breathing within or he if side, their on position” is she continue should [5-7]) effect. take to naloxone the for waiting while breathing independently. after but minutes, continue that 90 to 30 for work to will Naloxone essential Therefore, [8,9]. return may symptoms it overdose time, is the tay with person and keep him/ DO s n person to an emergency department or to get other source of the warm. her she as care the medical if even possible, after as quickly he revives or slap DON'T try stimulate forcefully or to n dose better. feel to seems initial naloxone and of cause only it — person the will further are you If wake injury. unable the to SIgNS OF OPIOID WITHDRAWAL. signs and symptoms of The person knuckles your by rubbing shouting, dependent on opioid withdrawal in an individual who is physically or chest the on rib of (­center sternum the to, the following: body aches, opioids may include, but are not limited be may she or cage), he pinching, light or tachycardia, fever, runny nose, sneezing, piloerection, diarrhea, unconscious. sweating, yawning, nausea or vomiting, nervousness, restlessness or shivering or trembling, abdominal cramps, weakness, and irritability, person a the or bath cold into DON'T put n withdrawal may also neonate, opioid pressure. the In blood increased of falling, shower. This increases the risk include: convulsions, excessive crying, and hyperactive reflexes [8]. into shock. going or drowning with person the any sub- DON'T inject n a patient does not NALOxONE-RESISTANT PATIENTS. If respond to “speed,” stance heroin, milk, water, salt (­ for an the naloxone, clinical symptoms should alternative explanation - appropriate only safe and treat etc.). The person is not be the considered. The most likely explanation is that ment is naloxone. on other some rather but an overdosing substance or may opioid possible A emergency. medical non-overdose a experiencing be even DON'T try person the make vomit to n to overdosed has individual the whether is consider explanation may she or drugs that he swallowed. have buprenorphine, Because on a long-acting opioid partial agonist. inhaling vomit into the lungs Choking or receptors opioid the than do buprenorphine has a higher affinity for can a injury. cause fatal effects the reversing at effective be not may naloxone opioids, other date, expiration an have products NOTE: All naloxone buprenorphine-induced opioid overdose [9.] In all cases, support of check it is important to so the expiration date and sufficient pressure blood be should and oxygenation, ventilation, of naloxone replacement obtain needed. as to prevent the complications of opioid overdose and should be given to if the response priority naloxone is not prompt. 

6 FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS REFERENCES for Center National (­CDC), Prevention and Control Disease or f Centers 1. CDC Health Statistics. WONDER Online Database, 2012. 2. Opioid addiction; drug in growth fuel Harvard Medic al School. Painkillers heroin. or Harvard Ment cocaine than overdoses now kill more people 2011;27(­7):4–5. . Hlth Let LE, Limbird E, Hardman Goodman and Gilman’s the Pharmacologic 3. eds. . McGraw-Hill, NY: pp. Basis of Therapeutics, 11th ed New York, 2006, 576–578. or f Centers 4. Community-based (­CDC). Prevention and Control Disease prevention opioid overdose programs providing naloxone — United MMWR Morb Mortal Wkly Rep 2012;61(­6):101–105. States, . 2010. Walley 5. Beletsky L, Rich JD, AY. Prevention of fatal opioid overdose. JAMA. 2012 Nov 14;308(­18):1863–1864. PO naloxone distributing Cost-effectiveness SD. Sullivan , of to 6. Coffin lay heroin users for overdose reversal. Ann Int Med. 2013;158:1–9. Centre. naloxone. with 7. BMJ E vidence Treatment of opioid overdose 2012. British Medical Journal . Updated October 23, [Accessed March 24, 2013, at www.bmj.com ] 8. Rx Lis t [Accessed March 24, 2013, at www.rxlist.com ] 9. Drugs.com [ Accessed March 24, 2013, at www.drugs.com ] 

7 Acknowledgments and Services Health Mental Abuse Substance the for prepared was publication This Association Officials, Health Territorial and State of the by (­SAMHSA) Administration number contract under in cooperation with Public Health Research Solutions, 10-233-00100 with SAMHSA, U.S. Department of Health and Human Services (­HHS). as the Government Project Officer. Brandon Johnson, M.B.A., served LCDR Disclaimer of those are publication this and opinions, views, The content do and authors the of not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. Public Domain Notice from directly taken those except volume this in appearing materials All copyrighted without copied sources are in the public domain and may be reproduced or permission from SAMHSA or the authors. Citation of the source is appreciated. a for distributed or reproduced be not may publication without fee However, this SAMHSA, authorization written , specific the HHS. Communications, of Office the of Electronic Access and Copies of Publication from at page Web Ordering Publications SAMHSA’s This publication may be ordered . 1-877-SAMHSA-7 at SAMHSA call www.store.samhsa.gov O r, please (­1-877-726-4727) (­English Español). and Recommended Citation Opioid SAMHSA Administration. Services Health Mental and Abuse Substance Overdose Prevention Toolkit: Five Essential Steps for First Responders. HHS Publication Substance Services Health Mental No. (­SMA) 13-4742. Rockville, MD: Abuse and Administration, 20 13. Originating Office of Division Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

8 HHS Publication No. (­SMA) 13-4742 Printed 2013

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