Healthy  Streets  Outreach  Program  

a  program  of  Northeast  Behavioral  Health    

 280  Union  Street  

Lynn,  ma    

781-­‐592-­‐0243    

First  things  first…slang  �  Jammed,  jambox,  jam  sandwich:  really  high  

�  Falling  out:  overdosing  

�  Fell  out:  overdosed  

�  Dope:  heroin  

�  Narcon  or  Narcain:  Narcan  pronounced  incorrectly  

�  Beaned  out:  on  a  lot  of  benzos  

Opioid  OD  Stats:  �  Two  people  die  from  opioid  overdoses  every  day  in  Massachusetts.  

�  More  people  are  killed  by  opioid  overdoses  in  Massachusetts  than  by  

car  accidents.  

�  In  2007,  there  were  over  6  times  more  deaths  due  to  opioid-­‐related  

overdoses  than  in  1990.  

�  For  every  death  due  to  an  opioid  overdose  in  2007,  there  were  47  

people  who  were  treated  for  an  overdose  and  lived.  �  *Sources:    “Opioids:  Trends  and  Current  Status  in  Massachusetts,”  Massachusetts  Department  of  Public  HealthBureau  of  Health  

Information,  Statistics,  Research,  and  Evaluation  and  the  Bureau  of  Substance  Abuse  Services,  2009  �  DAWN  data  “Massachusetts  Oxycontin  Commission:  Final  Report”  2009  

 

MDPH  Pilot  Details:  �  Standing  order  authorizes  Approved  Opioid  Overdose  Trainers  to  possess  

nasal  naloxone  and  to  distribute  it  to  Approved  Opioid  Overdose  

Responders.  

�  Trainers  and  Responders  are  authorized  to  administer  naloxone  to  person  

experiencing  a  drug  overdose.  

�  Approved  by  MDPH  Drug  Control  Program  and  the  Commissioner  of  

DPH,  overseen  by  medical  director  Dr.  Alexander  Walley.  

�  DPH  General  Counsel’s  Office  determined  the  legality  of  the  pilot  

programs.  Once  efficacy  of  the  pilots  has  been  established,  Public  Health  

Council  will  be  asked  to  pass  regulation  to  make  the  program  permanent.  

Expanded  Access  Currently  providing  OD  prevention  in  additional  venues:  

�  Detox  � Methadone  clinics  �  Suboxone  programs  �  Homeless  shelters  �  Other  HIV  P&E  programs    �  Parent  support  groups  �  Corrections  

Opportunity  for  Family  IntervenCon    

�  Majority  of  ODs  occur  in  the  presence  of  others    

�  ODs  can  be  reversed  by  rescue  breathing  and/or  Narcan  (Naloxone)  

administration  

�  Many  younger  drug  users  are  still  living  at  home  or  are  still  allowed  to  

visit  the  home.  

�  Treatment  options  can  be  discussed  at  the  hospital  with  family  

present  in  the  case  of  an  overdose.  

�  Realistic  and  useful  education  for  families.  

Narcan  Training  Components  �  20-­‐minute  session  (or  longer)  

�  Enrollment  form  (used  for  data  collection,  risk  

assessment,  risk  reduction)  

�  Review  of  overdose  risks,  prevention,  response,  calling  911,  

rescue  breathing,  refill  procedure  

�  Participant  repeats  information  back,  demonstrates  ability  

to  assemble  Narcan  

What  is  an  Opioid  Overdose?  

The brain has many, many receptors for opioids. Too much opioid fitting in too many receptors slow and stop the breathing.

Opioid fits exactly in receptor

Opioid receptor on brain

Narcan  reversing  an  OD  

Narcan has a stronger aff in i ty to the opioid receptors than the heroin, so it knocks the heroin off the receptors for a short time and lets the person breathe again.

Opioid receptor

Narcan

Heroin

Opioid  ODs,  conCnued  

�  ODs  are  rarely  instantaneous!      

�  ODs  happen  as  a  process-­‐  someone  slowly  stops  breathing    

�  They  usually  happen  1-­‐3  hours  after  the  drug  was  used  

�  Someone  “found  dead  with  a  needle  in  their  arm”  is  a  rare  event  that  

is  sensationalized  

What  are  the  Signs/Symptoms    of  an  OD?  

�  Blue  skin  tinge-­‐  usually  lips  and  fingertips  

show  first  

�  Body  very  limp  

�  Face  very  pale  

�  Pulse  (heartbeat)  is  slow,  erratic,  or  not  

there  at  all  

�  Throwing  up  

�  Passing  out  

�  Choking  sounds  or  a  gurgling/snoring  

noise  

�  Breathing  is  very  slow,  irregular,  or  has  

stopped  

�  Awake,  but  unable  to  respond  

REALLY HIGH OVERDOSE Muscles become relaxed

Deep snoring or gurgling (death rattle)

Speech is slowed/slurred

Very infrequent or no breathing

Sleepy looking Pale, clammy skin

Nodding Heavy nod, not responsive to stimulation

Will respond to stimulation like yelling, sternal rub, pinching, etc.

Slow heart beat/pulse

Slow heart beat/pulse

What  puts  people  at  risk  for  ODs?  

�  Mixing  Drugs    

�  Variation  in  strength  and  content  of  ‘street’  drugs  (purity)  

�  Tolerance  changes  (coming  out  of  jail/TX)  

�  Using  alone  

�  Physical  Health  (liver  functioning,  weight  loss,  etc.)  

�  Transient  living  –  new  dealers/new  product  

�  Thinking  you  “know  everything”  

�  Switching  from  sniffing/eating  to  injection.  

How  can  you  avoid  an  opioid  overdose?  �  Know  your  tolerance  

�  Know  your  supply  

�  Control  Your  Own  High  

�  Be  Aware  of  the  Risks  of  Mixing  Drugs  

�  Try  not  to  use  alone  

� Make  a  plan  

�  Talk  with  other  users    

�  Stop  Using  

PrevenCon  Messages  for  Families  �  I  want  to  remind  you  that  (BECAUSE  OF)  your  tolerance  

is  very  low,  you  are  at  high  risk  for  an  overdose.    

�  Do  you  have  an  overdose  plan?  Do  you  and  your  friends  

know  about  Narcan?  

�  I    love  you  but  not  what  you  do  and  I  do  not  want  

anything  to  happen  to  you.  

�  If  you  relapse  please  do  not  do  it  alone.      

A  few  words  about  benzos:  �  They  are  long  acting  (at  least  a  day,  usually)  

�  They  impair  your  short-­‐term  memory.    So  you  can  actually  forget  how  many  benzos  or  how  much  heroin  you  have  used  in  the  last  24  hours-­‐  this  could  put  someone  in  danger  for  an  OD!!  

�  Very  common  and  easy  to  find  on  the  street  

�  Cheaper  than  heroin  

�  They  are  frequently  necessary  for  mental  health  reasons-­‐  there  is  a  high  comorbidity  between  substance  abuse  disorders  and  mental  illness  like  anxiety,  

depression,  and  post-­‐traumatic  stress  disorder  

�  Make  people  who  are  in  withdrawal  feel  better  

�  People  use  benzos  to  get  jammed-­‐  enhances  the  effects  of  heroin  (or  methadone,  etc)  

�  Drugs  could  be  cut  or  enhanced  with  benzos  without  the  user  knowing  

Responding  to  an  Overdose  �  “Are  you  alright?  You  ok?”  

�  No  response  try  a  STERNUM  RUB  

�  Call  9-­‐1-­‐1  

�  Give  the  person  AIR  using  rescue  breathing    

�  Give  2  or  3  breaths  and  set-­‐up  the  Narcan  

�  Spray  the  Narcan  

�  Continue  rescue  breathing  

�  Spray  second  dose  if  necessary  

�  Continue  rescue  breathing  

If  an  OD  happens…  Recovery Position

Overdose  PrevenCon  Using    Nasal  Narcan  

�  Simple  device,  medication  and  nasal  spray    

�  Narcan  is  a  pure  opiate  antagonist    

�  No  physiological  effect  other  than  blocking  opiates    

�  No  adverse  reactions    

�  No  potential  for  abuse  or  potential  for  OD  

Narcan  Kit  components  

What  are  barriers  to  calling  911  from  the  perspecCve  of  a  substance  user?  

�  Fear  of  legal  risk  (outstanding  warrants,  DSS  involvement,  loss  

of  public  housing)  

�  Fear  of  judgment  from  family/  community  

�  Personal  embarrassment/shame  

�  Other  punitive  measures  (students  loose  federal  financial  aid)  

�  Manslaughter  charges  if  someone  dies  on  the  scene  

 

What  about  families?    � Are  there  fears  about  calling  9-­‐1-­‐1  among  families?  

 

� How  will  YOU  handle  this  discussion  if  it  comes  up  

without  judging  the  person  in  front  of  you?  

Street  Methods  now  have  safer  alternaCves  �  Don’t  leave  the  person  alone-­‐-­‐they  could  stop  breathing  

�  Don’t  put  them  in  a  bath-­‐-­‐they  could  drown  

�  Don’t  induce  vomiting-­‐-­‐they  could  choke  

�  Don’t  give  them  something  to  drink-­‐-­‐they  could  throw  up  

�  Don’t  put  ice  down  their  pants-­‐  it’ll  make  their  pants  wet!    Cooling  down  the  core  body  

temperature  of  someone  who  is  ODing  is  dangerous  because  it  will  slow  down  their  body  

function  even  more  than  just  the  OD.  

�  Don’t  try  to  stimulate  them  in  a  way  that  could  cause  harm-­‐  slapping  too  hard,  kicking  in  the  

testicles,  burning  the  bottom  of  the  feet,  etc.  can  cause  long-­‐term  damage  

�  Don’t  inject  them  with  anything  (saltwater,  cocaine,  milk)-­‐-­‐it  won’t  work  any  more  than  

physical  stimulation  and  can  waste  time  or  make  things  worse  depending  on  what  you  inject;  

a  salt  injection,  for  instance,  could  cause  someone  to  go  into  cardiac  arrest  if  they  already  

have  high  sodium  levels  in  their  system.    Also,  every  injection  brings  a  risk  of  bacterial  

infection,  abscesses,  endocarditis,  cellulitis,  etc.  

Does  Speedballing  balance  you  out?  �  “Speedballing”  refers  to  any  combination  of  a  stimulant  

(upper)  and  a  depressant  (downer)  taken  together,  esp.  a  

mixture  of  heroin  and  cocaine  or  heroin  and  

methamphetamine  injected  into  the  bloodstream.    

�  No-­‐  speedballing  does  not  cancel  out  OD  risk  

�  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  

Will  using  Narcan  help  someone  give  a  clean  urine?  � No  

� Narcan  knocks  opiates  off  the  opiate  receptors,  but  

the  drug  is  still  floating  around  in  the  body  (AND  

urine!)  

Can  you  use  Suboxone  to  reverse  an  OD?  �  Not  a  good  idea,  probably  not  enough  Naloxone  in  a  Suboxone  to  

reverse  and  overdose,  will  not  act  fast  enough  

�  Suboxone  is  a  drug  that  contains  both  Buprenorphine  (a  partial  

agonist)  and  Naloxone  (antagonists,  same  thing  as  Narcan)  

�  Suboxone  is  supposed  to  be  taken  sublingually,  and  if  taken  this  way,  

the  Naloxone  has  no  effect  

�  If  crushed  and  snorted,  or  injected,  the  Naloxone  is  “activated”  and  

acts  as  an  antagonist  

Enrollments  �  BLUE  or  BLACK  Pen  

�  Non-­‐users  do  not  get  asked  any  questions  below  the  lot  number.  

�  Must  fill  in  all  information  

�  If  you  do  not  have  an  answer  use  X’s  or  a  zero  

�  Use  leading  zeroes  

�  If  someone  is  not  sure  they  are  enrolled  please  fill  out  another  

enrollment  

�  DO  NOT  FORGET  THE  BSAS  CODE  

�  All  codes  are  on  the  back  of  the  enrollment  

 

Refills  � Never  give  a  kit  without  doing  the  refill  form.  

� Only  answer  all  the  questions  if  they  are  reporting  an  

overdose.    

� ALWAYS  write  comments,  especially  if  it  is  a  reversal.    

I  used  the  Narcan.  � Trauma  associated  with  witnessing  an  OD  may  not  

manifest  immediately.    

� Be  open  to  hearing  the  details  but  never  ask  for  the  

details.    

� Positively  reinforce  all  actions  performed  by  the  

responder.    

� Refill  Narcan  

Mary  Wheeler  Program  Director  –  Healthy  Streets  Outreach  Program    

a  program  of  Northeast  Behavioral  Health  781-­‐592-­‐0243  

mwheeler@nebhealth.org