Managing opioid overdose, including naloxone

mds275

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This thread is about recognizing and managing an overdose that involves opioids. These are some common opioids: opium, morphine (MS Contin), codeine (Tylenol #3), thebaine, heroin, hydromorphone, hydrocodone (Vicodin, Norco, Lorcet- all w/ Tylenol), oxycodone (Percocet & Roxicet w/Tylenol, OxyContin), oxymorphone (Opana), buprenorphine (Suboxone, Subutex, Butrans), fentanyl (Duragesic, Actiq, Abstral), methadone (Dolophine, Methadose), meperidine (Demerol), propoxyphene(Darvon, Darvocet)
Opioid overdose is rarely instantaneous; people slowly stop breathing minutes to hours after the drug was used. While sometimes people have been “found dead with a needle in their arm,” there is usually time to intervene between when an overdose starts and before a victim dies. With opioid overdoses, the difference between surviving or dying depends on breathing and oxygen. These are some signs of overdose:
• 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- this signal is often overlooked
• Breathing is very slow, irregular, or has stopped
• Awake, but unable to respond

These are steps to take if someone is having an opioid overdose:
Assess the signs
Is the person breathing? Is the person responsive? Can the person speak? What is the skin color (especially lips and fingertips)?

Stimulation
If the person is unconscious or “out of it,” try to wake them up. Call his or her name. If this does not work, try to stimulate him or her with mild pain by rubbing your knuckles into the sternum (the place in the middle of your chest where your ribs meet), rubbing your knuckles on their upper lip. If the person’s breathing is shallow or they tell you he or she has shortness of breath or a tightness in their chest call 911/999. If the person does not respond to stimulation and remains unconscious, or the condition appears to get worse, do not try a different or alternative form of stimulation.

Call for help
The bystander should call 911/999 in the case of an overdose because it is important to have trained medical professionals assess the condition of the overdose victim. Even though naloxone can reverse the overdose, there may be other health problems of which you may not be aware. In addition, people who survive any type of overdose are at risk of experiencing other health complications as a result of the overdose, such as pneumonia and heart problems.
What to say when calling 911/999 depends on the local emergency response to overdoses. In every community, it is important to report the victim’s breathing has slowed or stopped, he or she is unresponsive, and the exact location of the individual. If naloxone was given and it did not work, this is important information to tell the dispatcher. In many communities, the police respond along with the ambulance to all 911/999 calls. Often, when the police respond they do not arrest the bystander or victim at the scene of an overdose. There are always exceptions to this and thus the fear of arrest and police involvement is substantial. Overdose bystanders should try to learn what the real risk is by talking to people who have actually had an experience and not make assumptions based on hearsay.

Individuals who overdose can die because they choke on their own vomit (aspiration). This can be avoided by putting the individual in the recovery position. The Recovery Position is when you lay the person on their side, their body supported by a bent knee, with their face turned to the side. This position decreases the chances of the individual choking on their vomit. If you have to leave the person at all, even for a minute to phone 911/999, make sure you put them in the Recovery Position.

Rescue Breathing
For a person who is not breathing, rescue breathing is one of the most important steps in preventing an overdose death. When someone has stopped breathing and is unresponsive, rescue breathing should be done as soon as possible because it is the quickest way to get oxygen into the body. Steps for rescue breathing:
1. Place the person on his or her back.
2. Tilt chin up to open the airway. Check to see if there is anything in the mouth blocking the airway. If so, remove it.
3. Give 2 breaths.
4. Blow enough air into the lungs to make the chest rise.
5. Turn your head after each breath to ensure the chest is rising and falling. If it doesn’t work, tilt the head back more.
6. Breathe again every 5 seconds.

Administer naloxone
Nasal naloxone- formulation is 2mL of 1mg/1mL Assembly video here
1. Pop off two yellow caps and one red cap.
2. Hold nasal spray device and screw it onto the top of the plastic delivery device.
3. Screw medicine gently into delivery device
4. Spray half (1mL) of the medicine up one side of the nose and half up the other side.

Injectable naloxone- formulation is 0.4mg/1mL in either 1mL or 10mL vials Example at 5:50 of this video
1. Use a long needle: 1 – 1 ½ inch (called an IM or intramuscular needle)- needle exchange programs and pharmacies have these needles.
2. Pop off the top of multi or single dose vials or snap off neck of single dose ampoule
3. Draw up 1cc of naloxone into the syringe 1cc=1mL=100u.
4. Inject into a muscle – thighs, side of the butt, or shoulder is best.
5. Inject straight in to make sure to hit the muscle,
6. If there isn’t a big needle, a smaller needle is OK and inject under the skin, but if possible it is better to inject into a muscle with a longer needle.

If there is no breathing or breathing continues to be shallow, continue to perform rescue breathing for them while waiting for the naloxone to take effect. If there is no change in 3-5 minutes, administer another dose of naloxone and continue to breathe for them. Continue to rescue breathe until the victim breaths on his or her own, while you wait for help to arrive.

Evaluation and Support
Naloxone only lasts between 30 – 90 minutes & the effects of the opioids may last much longer. A heroin overdose may last as long as 4 hours and a methadone overdose may last longer. It is possible that after the naloxone wears off the overdose could recur. It is very important that someone stay with the person and wait out the risk period just in case another dose of naloxone is necessary. Also, naloxone can cause uncomfortable withdrawal feelings since it blocks the action of opioids in the brain. Sometimes people want to use again immediately to stop the withdrawal feelings, which also could cause another overdose.
 
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mds275

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What is naloxone (Narcan)?
Naloxone is a medication that reverses overdose from heroin or other opioids. Naloxone is the generic name for Narcan and these names are often used interchangeably. Naloxone works by displacing or knocking off opioids from opioid receptors in the brain, which decreases and blocks the effect of the opioid, allowing the victim to breathe again and come out of the overdose. Naloxone has a stronger affinity or attraction to opioid receptors than opioids that stimulate the receptors. It is a pure opioid antagonist, which means that it has no other function than to block opioids and it cannot be abused. Naloxone may work immediately, but can take up to 8 minutes to have an effect.

Where to get naloxone
Naloxone access varies widely. In the USA, overdose education and naloxone distribution programs exist in several areas- to find out if there’s a program close to you, search here. Information on programs in other parts of the world can be found here.
A doctor can prescribe naloxone, too, though this is a little more complicated because most normal pharmacies don’t routinely stock it. It can be ordered, though.
Anyone else who has experience/success/failure in getting narcan, PLEASE POST!
 

mds275

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I've had a bit of experience with naloxone- used it, seen it used, trained people how to use it, and advocated for more availability of the stuff. In the past few years, here are some common questions that have come up from a variety of different people with different agendas:

Naloxone/Narcan 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/narcan is injected either intravenous or intramuscularly.

Isn’t there naloxone/narcan in Suboxone? What’s up with that?
• Suboxone contains both buprenorphine and naloxone. The naloxone in Suboxone is only active when tablets are crushed and injected or sniffed. The naloxone works to neutralize the activity of buprenorphine or any other opioid agonist in the body. Thus a person injecting or sniffing a Suboxone tablet will usually either feel no effect or may feel withdrawal symptoms until the naloxone wears off.

OK, so there IS naloxone/narcan in Suboxone…will Suboxone work for an overdose?
• 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- naloxone needs to be injected or nasally administered to be absorbed in the body and it does not get absorbed under the tongue (which is the way that Suboxone is supposed to be taken)

What’s what?!
• Narcan® = naloxone
• Suboxone® = buprenorphine + naloxone
• Subutex® = bueprenorphine
• naloxone is NOT naltrexone
• Naltrexone (Revia or Vivitrol) is a long acting opioid antagonist which can be used for treatment of alcohol or opioid dependence, but is not a good overdose antidote because it is long lasting and will cause withdrawal symptoms for long periods.

Will naloxone/narcan work on an alcohol overdose?
• Naloxone/narcan 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 overdose.

Doesn't speedballing balance you out?
• No- speedballing does not cancel out overdose risk- it actually increases risk compared to people who use heroin or cocaine alone
• Stimulants increase heart activity which uses up oxygen faster than the supply can be replenished because opioids slow down breathing.
• People who speedball often use more frequently than people who use only heroin- this increases overdose risk

What if it is a crack/coke overdose?
• Naloxone/narcan 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 overdose
• Cocaine overdoses are dangerous because they are not dose-dependent and they are a complicated medical emergency- call 911!

Is clonidine an opioid or benzo?
• Neither (do not confuse with Klonopin, which is a benzo)
• Clonidine can be used to relieve withdrawal symptoms from opioids, alcohol & nicotine
• Clonidine lowers blood pressure, heart rate, causes dizziness & drowsiness
• There is a higher risk of overdose with a clonidine/opioid combo than with opioids alone, but depending on the amount taken, probably less than with a benzodiazepine/opioid combination
• Clonidine is not as long lasting as benzos, and has no amnesiac effects (short-term memory loss)

What about Phenergan (“Finnigans”, promethazine)?
• Phenergan is prescribed to combat nausea, as a sedative, allergy medication, for motion & morning sickness.
• There is a higher risk of overdose with a Phenergan/opiate combo than with opioids alone.
• Phenergan is not considered to be habit-forming or cause withdrawal and is available over-the-counter in some countries (not the USA)

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. The salt itself does nothing to reverse an overdose. Another form of sitmulation, such as a sternal rub, is just as likely to wake up the victim and less likely to lead to a needlestick.
• Fixing a salt shot wastes precious time that could be spent on calling 911, rescue breathing & giving naloxone/narcan
• Naloxone/narcan is safer and more reliable.

Will hitting someone bring them out of an overdose?
• You really do not want to kick, slap, punch, drag anyone…you might hurt them
• If someone doesn’t respond to a sternal rub, move on! Call 911, do rescue breathing and give naloxone/narcan

What about ice or cold showers?
• Ice down the pants, cold showers or baths can slow down the respiratory system and can send someone into shock or hypothermia.
• An overdose victim can drown in a tub or shower.
• The actions that are safer, quicker, and more likely to work are: Call 911, do rescue breathing and give naloxone/narcan.

Will using naloxone/narcan help someone give a clean urine?
• No
• Naloxone/narcan knocks opioids off the opiate receptors, but the drug is still floating around in the body (AND urine!)

What if someone injects the nasal naloxone/narcan?
• It would work to reverse an overdose.
• However, injecting the whole amount would give the person a higher dose of naloxone/narcan than therapeutically necessary and the person would probably experience more severe withdrawal symptoms. Injecting about one quarter of the naloxone/narcan in the vial is a good amount to start.

What happens if the MAD nasal adapter gets lost?
• Try to keep the nasal spray piece attached to the naloxone box with a rubber band
• Two things have been done successfully (but should only be done in an emergency):
o Inject the naloxone/narcan in the vial
o Squirt it up the person’s nose anyway without the nasal adapter
• When making a decision about which to do, remember time and oxygen!

What is the risk period for an overdose to reoccur after giving naloxone/narcan?
• Naloxone/narcan is active for about 30 – 90 minutes in the body. So if you give someone naloxone/narcan to reverse an opiate overdose, the naloxone/narcan may wear off before the opiates wear off and the person could go into overdose mode again.
• It depends on:
o the person’s metabolism (how quickly the body processes things);
o how much drug they used in the first place;
o how well the liver is working; and
o if they use again.
• Because naloxone/narcan blocks opiates from acting in the brain, it can cause withdrawal symptoms in someone that has a habit. After giving someone naloxone/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 naloxone/narcan wears off.

Why are the new Hands Only CPR guidelines for lay people with no rescue breathing different than the response to an overdose that advises mouth-to-mouth/rescue breathing?
• The new CPR 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, 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. With any signs of life, such as gasping breaths or a pulse with inadequate breathing, then ventilation (rescue breathing) should be enough.
• The newest American Heart Association (AHA) guidelines for trained Basic Life Support includes rescue breathing in section 12.7 for opioid toxicity prior to cardiac arrest.

What if the person is not even overdosing and I give them naloxone/narcan? Will it hurt them?
• Naloxone/narcan has no effect on someone who has no opioids in their system. It will not help anyone who is not in an overdose, 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/narcan or what if I give too much naloxone/narcan?
• It is not possible to give so much naloxone/narcan 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/narcan they get, the more uncomfortable they will be because of withdrawal symptoms and pain if they have chronic pain. If the person gets too much naloxone/narcan, try to explain to them that the withdrawals or “dopesickness” will fade in a half hour or so.

Can you develop immunity to naloxone/narcan?
• No, people will not develop immunity to naloxone/narcan- 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. Brainstorm some of the reasons why this might be happening- some examples of reasons that have been discovered are:
o Untreated asthma
o Seasonal allergies
o Changes in medications for depression, anxiety, sleep, HIV
o Disassociation because of trauma= not remembering amount of drugs used
o New environment, new friends, new practices

What if my kids find and use the naloxone/narcan- can it hurt them?
• Naloxone/narcan acts as an opiate antagonist and has no adverse effects – it simply kicks opiates off brain receptors temporarily to reverse an overdose. While the medication itself does not pose a real risk to small children, it’s 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/narcan expired- can I still use it?
• If it is the only thing you have, use it. Like most other medication, naloxone/narcan 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.

Naloxone/narcan makes people violent, right? / Why are people such jerks when they get Narcaned?
• In a person who has a tolerance to opioids, naloxone/narcan may cause a withdrawal reaction which can make the person feel physically ill, agitated and frustrated. Typically, intranasal naloxone/narcan and not giving too much naloxone (start w/ suggested dose) do not result in a violent withdrawal reaction.

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:
o 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
• Of course, not everyone who uses drugs/is at risk for an OD is addicted
 

ferryman

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Also naltrexone is now produced under the registered tradename "Nalorex" This is NOT Naloxone, and is not effective in treating overdose.
 

Tommyboy

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Great posts. I'm glad you found the time to write them up. The information is extremely helpful and informative.
 

effie

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I agree - added to BDD threads of note and soon to be added to OD directory. Thank you very much! :)
 

mds275

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Thanks Tommyboy & effie for your help & direction.

I hope that members post places where one can get naloxone in addition to the two websites with program listings...I know where to get where I am, but whenever I travel to smaller cities, people are always asking where to get some. It seems like people need a connect to orgs/people who are giving it out but not publicizing it.
 

mischievous_angel

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Say we don't have any of that stuff, but we've called 911 and are waiting for the ambulance to get to location. Would a cold (not freezing, but tolerable) shower, as well as while one person is giving CPR and another person administering a shot of saline solution be beneficial? It has to be better than absolutely nothing, right? Rather than just calling 911 and sitting there watching them die...
 

mds275

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Say we don't have any of that stuff, but we've called 911 and are waiting for the ambulance to get to location. Would a cold (not freezing, but tolerable) shower, as well as while one person is giving CPR and another person administering a shot of saline solution be beneficial? It has to be better than absolutely nothing, right? Rather than just calling 911 and sitting there watching them die...
Without naloxone, the best thing to do is to give rescue breathing/mouth-to-mouth (steps in original post) while you wait for the ambulance. Someone having an opioid OD can probably be kept alive for a long time with sufficient oxygen.

Cold showers/ice in the pants/etc are bad news because they cool down a person's body temperature which slows down their breathing. Sometimes people think it works because there can be an initial reaction due to being shocked by the cold, but in the long run it's a better idea to stimulate/shock the person by a sternal rub (chest noogie).

Salt shots are not recommended for two reasons- 1)physiologically speaking, there is no benefit and messing with someone's sodium levels has potentially dangerous outcomes and 2) every injection carries a risk of injury or bacterial/viral infection and maybe more so during an OD freak out. Sometimes people think salt shots work for the same reason of an initial response to the pain caused, but a safer way to try to stimulate the person is a sternal rub.

Agreed- don't do absolutely nothing, do rescue breathing! Be aware that rescue breathing is not likely to bring the person out of an OD- you need narcan for that- but it will probably keep them alive until the narcan arrives.
 

LiddellLady

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Does anyone have information on using suboxone to get off opiates? I dont know if i posted in the correct area this is my first post. If so will you send me a message. It'd be greatly appreciated.
 

Artificial Emotion

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Can you theoretically get done for assault for shooting up an unconscious person that's OD'd on heroin with naloxone? Or if not that, practising medicine without a license or some other bullshit charge? This is in the UK specifically that I'm talking about.
 

mds275

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^Good point.

Theoretically, either situation is a possibility, though more likely (still not very likely) would be practicing medicine without a license, because an assault charge would be filed/initiated by the person whose life you saved and the practicing medicine without a license charge could be filed by a prosecutor independent of the lucky person who is alive because of your actions.

In practice, this isn't a major concern. Indeed, there are legal researchers in the UK and the US who have been on the lookout for a solid instance of this for case reporting/precedent setting for years. If any members have this experience, it would be useful to hear more about it!

One good way to be even more careful about these kinds of legal concerns would be to contact your local naloxone distribution organization so that you can get trained/enrolled/registered according to local public health statute. Here is a list of programs in the UK. This is a way to find local programs in the US.

Anyone else have other thoughts on this?
 
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jonesanderson

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Without naloxone, the best thing to do is to give rescue breathing/mouth-to-mouth (steps in original post) while you wait for the ambulance. Someone having an opioid OD can probably be kept alive for a long time with sufficient oxygen.

Cold showers/ice in the pants/etc are bad news because they cool down a person's body temperature which slows down their breathing. Sometimes people think it works because there can be an initial reaction due to being shocked by the cold, but in the long run it's a better idea to stimulate/shock the person by a sternal rub (chest noogie).

Salt shots are not recommended for two reasons- 1)physiologically speaking, there is no benefit and messing with someone's sodium levels has potentially dangerous outcomes and 2) every injection carries a risk of injury or bacterial/viral infection and maybe more so during an OD freak out. Sometimes people think salt shots work for the same reason of an initial response to the pain caused, but a safer way to try to stimulate the person is a sternal rub.

Agreed- don't do absolutely nothing, do rescue breathing! Be aware that rescue breathing is not likely to bring the person out of an OD- you need narcan for that- but it will probably keep them alive until the narcan arrives.
wow!!! thank you for this post. This is very informative and useful.
 

mds275

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Can you theoretically get done for assault for shooting up an unconscious person that's OD'd on heroin with naloxone? Or if not that, practising medicine without a license or some other bullshit charge? This is in the UK specifically that I'm talking about.
I just found out that the UK Advisory Council on the Misuse of Drugs just released a report calling for expanded availability of naloxone- it includes a section about regulations prescribing and using naloxone. The complete report can be found here. It essentially says that the prescription can only go to and be held by a person at risk of OD, but that naloxone is on the list of exempted drugs that can be administered by injection by anyone to save a person's life.

Here's the technical text:
4. Current regulatory framework for prescribing naloxone
4.1. Under the Medicines Act (1968 ), no-one, except individual patients with a prescription and appropriate medical practitioners (or those acting under medical instructions, including nurses), is allowed to administer parenteral (injectable) prescription-only medicines
4.2. There is a limited list of exceptions to the restrictions of Section 7 of the Medicines Act. These include a number of injectable medicines that can be given by injection by anyone for the purpose of saving life in an emergency. The list includes adrenaline, atropine, glucagon, glucose and snake-venom antiserum.
4.3. In June 2005, in the Medicines for Human Use (Prescribing) (Miscellaneous Amendments) Order, the United Kingdom added naloxone to that limited list of medicines. This means that currently:
i. naloxone is an injectable, and therefore prescription-only, medicine that may be used by anyone for the purpose of saving life in an emergency;
ii. naloxone can be prescribed directly to a patient, or supplied via a Patient Group Direction (PGD) or Patient Specific Direction (PSD);
iii. prescribers should only prescribe and supply naloxone to a known patient with a medical condition that requires the medication, and with the patient’s informed consent; and,
iv. naloxone cannot currently be prescribed (or supplied using a PGD/PSD) to a carer, peer, or member of staff on behalf of a drug user, and cannot be given to anyone without the drug user’s informed consent.
4.4. These conditions mean that naloxone is restricted under prescription-only supply, and that supplies are not able to be held for general use on people in settings such as homeless hostels, or carried by outreach workers, for example.
 
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