CUMC OVERDOSE PREVENTION
PROGRAM
Approved
by NYS DOH on March 6, 2007
BACKGROUND:
Drug overdose is the number two cause of accidental death among U.S. adults.
About 900 NYC residents die of illicit drug overdose each year, 3/4 involving opiates,
with an incidence of 5-9 deaths /100,000 residents in Washington Heights. Based
on the results of epidemiologic research, an increasing number of health
departments and NGOs around the world and within the United States have
distributed naloxone for lay administration in case of an overdose. New York
State opted to encourage such programs with a law establishing “Overdose
Prevention Programs” to distribute naloxone and by protecting program
participants from liability for administering naloxone to individuals suspected
of opiate overdose. The NYC DOH has made overdose prevention through naloxone
distribution a priority.
HOW
IT WORKS:
-
Any patient with opioid users in their social network should be offered
training in overdose prevention and management and a prescription for naloxone.
-
The patient should be trained in the risk factors for overdose, how to
recognize overdose, and how to manage overdose including naloxone
administration (see Provider Fact Sheet for more
information)
-
A “kit” can then be obtained from a SUPPLY SITE listed
below and given to the patient along with a prescription for the naloxone.
-
We recommend using a sample naloxone syringe to demonstrate how it is used.
-
A record of the training as well as copies of patient and provider information
sheets are kept in the supply boxes.
HOW
TO PARTICIPATE: Any CUMC MD, NP, or PA may register as an affiliated prescriber by attending a training
or by otherwise demonstrating their knowledge of the Program procedures, then
providing their name and license number to the Program Director.
PROJECT
DIRECTOR AND CONTACT PERSON: Phillip Coffin, MD, poc2@columbia.edu
CLINICAL
DIRECTOR: Erik Gunderson, MD, Assistant Professor, Department of Internal
Medicine
Allen
Pavilion – IM Chief’s office
AIM
Clinic – VC 205, bottom drawer directly in front of Dr. Chang’s door labeled in
white “Overdose Prevention”
AIM
East – Supply closet
More
information about the New York State program http://www.health.state.ny.us/diseases/aids/harm_reduction/opioidprevention/index.htm
Consumer
fact sheet
Provider Overdose Information
Introduction
Overdose is
a preventable cause of death in the majority of cases because it usually:
happens to
experienced users.
happens
over 1-2 hours, not instantly.
is witnessed
by other users or others in the users social network.
can be
treated effectively with naloxone (Narcan).
Opioids and overdose –
what are opioids?
Opioids
include:
·
heroin,
morphine, codeine, methadone, oxycodone (Oxycontin, Percodan, Percocet), hydrocodone (Vicodin) fentanyl (Duragesic), and hydromorphone (Dilaudid)
Naloxone
does not work for-
·
Non-opioid
sedatives: Valium, Xanax, Clonopin,
Clonidine, Elavil, alcohol
·
Stimulants:
cocaine, amphetamines
What are
risk factors for overdose?
Major risks
·
Loss of Tolerance: Regular
use of opioids leads to tolerance- more is needed to achieve the same effect
(same high). Overdoses occur when people
start to use again, following a period of abstinence such as incarceration, detox or “drug free” drug treatment.
·
Mixing Drugs: Mixing opioids with other drugs, especially depressants such as
benzodiazepines (Xanax, Clonopin)
or alcohol. They are “synergistic”- the
effect of taking mixed drugs is greater than the effect one would expect if
taking the drugs separately or together.
Cocaine is a stimulant but in high doses it can also depress the urge to
breath.
·
Using alone: When using drugs alone there is no one present to see signs of overdose.
As noted above, users are at greater risk of overdosing if recently abstinent or mixing drugs and should try to avoid doing that
when alone.
·
Variation in strength of ‘street’ drugs Street drugs may vary in strength and
effect based on the purity of the heroin (or other opioid) and the amount of other
ingredients used to cut the drug. Users can use small amounts of new batches or
inject slowly enough to get a feel of the quality.
·
Serious illness including: AIDS,
liver disease, diabetes and heart disease.
What does
an overdose look like?
Users can
check in with each other for responsiveness. Overdose is more likely 1-2 hours
after using rather than just after injection
Signs:
·
Deep,
slow snoring or gurgling
·
Heavy nod, not responsive to stimulation – teach sternal
rub (rub breastbone hard with knuckles)
·
Slowed
breathing
·
Cyanotic-
bluish lips and nail beds
Understanding
naloxone
Naloxone (Narcan) reverses an opioid overdose by blocking opioid
receptors in the brain. It wakes a person who is overdosing in 3-5 minutes and
is active for about 30 – 90 minutes at which point the effect of opioids can
return. This 30-90 window is usually enough to prevent death even if the overdoser does not get medical services. Naloxone has no other effects and cannot be
used to get high; it will cause no harm if the person is not having an
overdose.
Responding
to an Opioid Overdose
·
Stimulation
·
Call
their name and shake
·
Sternal rub
·
Call for Help
·
Call
911 say: “I can’t wake my friend up” or “My friend isn’t breathing”.
·
If
leaving the person alone, place them in the Recovery Position –
positioned on the side. This will help to keep the airway clear and prevent
them from choking on vomit.
What is
next? If the overdoser is not breathing start with a
few breaths and then administer naloxone. If still breathing but unresponsive
then the responder should administer naloxone first.
3) Administer Naloxone
·
Inject
1cc of naloxone into a large muscle such as the upper arm or thigh
·
Repeat
in 3-5 minutes with a new needle and vial if no response If 911 has not
yet been called, it is vital to do so now.
·
Continue
rescue breathing as needed.
4) If not breathing Perform Rescue
Breathing
·
Tip
the head back with one hand under the neck, the other holding the nose
·
Make
a seal over the mouth with your mouth and give 2 quick breaths then one every
five seconds.
·
Keep
it up until the person breaths on his/her own.
5) Evaluation and Support
·
Monitor
the overdose survivor reassuring them that the drug withdrawal will decrease in
about one hour, and more drugs should not be used now.
·
Inform
EMS of what happened and how much naloxone was given.
·
Encourage
survivor to go to the hospital.
Common questions:
What about salt or milk shots? Many users believe that injecting salt
water or milk will revive an overdose victim. There is no medical reason why
this works and it can be dangerous as it wastes time. Some people are certain
that they work, explain that naloxone is definitely effective so salt shots are
unnecessary.
What about walking someone around? If the overdoser
can walk this is good and they don't need naloxone. Dragging someone around
doesn't help.
What about ice? Like the sternal
rub, ice can wake someone in a heavy nod. The sternal
rub is easier.
How bad does getting naloxone feel? Naloxone puts an opioid dependent
person into withdrawal. This program recommends starting with 0.4mg. Emergency
Medical Services often give 1.2-1.6mg and precipitate much more severe
withdrawal.
Can one take naloxone and give a clean urine? No, the naloxone only blocks the opioid for a little while;
it is still in the body.
What if I hit a vein instead of the
muscle? Naloxone is
effective intramuscularly (in the muscle), intravenously (in the vein) and
subcutaneously (skin popping). Intramuscularly is the quickest and easiest way.
What if someone is pregnant or taking
medications- is it dangerous to administer naloxone? Remember naloxone is only to be given
if you think someone is dying.