Training of Trainers Maryland Overdose Response Program Behavioral Health Administration Maryland Department of Health and Mental Hygiene April 20, 2016 Part I INTRODUCTION 1
Housekeeping Today s schedule Restrooms Introductions Overview I. Introduction II. Core Curriculum III. Tailoring the Training IV. Practice Teach V. Maryland Overdose Response Program: Key Elements VI. Wrap up 2
Learning Objectives Participants will: Identify 5 signs and symptoms of opioid overdose List 5 key steps to respond to an opioid overdose Identify 5 ways to prevent opioid overdoses Identify ways to tailor overdose response trainings to your audience Explain the following key elements of the Maryland Overdose Response Program (ORP): How to issue ORP certificate How to dispense under standing order Context Overdose deaths in Maryland (and in the US) have risen every year since 2010 3
Harm Reduction Framework Goal: minimize the negative effects of drug use for people who use drugs, their families, and their communities Harm reduction approaches: Are rooted in a commitment to public health & human rights Combat stigma Empower people who use drugs to keep themselves as safe as possible Meet people where they are Aim to attain any positive change (Harm Reduction Coalition, Harm Reduction International) Context: Overdose Education & Naloxone Distribution Overdose education and naloxone distribution (OEND) has been part of the harm reduction landscape for decades Originally provided to those at risk for overdose through syringe exchange programs OEND provided crucial education on overdose risk Naloxone is an empowerment tool for individual and community 4
Evidence Base for OEND Evidence OEND is feasible in many settings. Walley et al. JSAT 2013; 44:241 7 Bennett et al. J Urban Health. 2011: 88; 1020 30 Enteen et al. J Urban Health 2010:87: 931 41 Doe Simkins et al. Am J Public Health 2009: 99: 788 791 Piper et al. Subst Use Misuse 2008: 43; 858 70 Participants demonstrate knowledge and skills after training. Naloxone does not lead to an increase in risky use, but does lead to an increase in drug treatment. Wagner et al. Int J Drug Policy 2010: 21: 186 93 Tobin et al. Int J Drug Policy 2009: 20; 131 6 Green et al. Addiction 2008: 103;979 89 Seal et al. J Urban Health 2005:82:303 11 Wagner et al. Int J Drug Policy 2010: 21: 186 93 Galea et al. Add Beh 2006: 31: 907 912 OEND contributes to reduction in overdose in communities. Maxwell et al. J Addict Dis 2006:25; 89 96 Evans et al. Am J Epidemiol 2012; 174: 302 8 Walley et al. BMJ 2013; 346: f174 Trauma Informed Approach A trauma informed approach recognizes that the impact of trauma is widespread and strives to avoid re traumatizing people. Why might the material in this training be difficult for some participants? As a trainer, how can you be sensitive to overdose related trauma? 5
Language Research demonstrates that the language we use about drug use can affect our attitudes toward people who use drugs. Our attitudes, in turn, impact our actions and our policies. As a trainer, part of your role is to model how to use non stigmatizing language. More at http://www.facesandvoicesofrecovery.org/sites/default/files/resources/2016%20kelly%20e t%20al.%20 %20Language%20SUDs%20and%20Policy%20%2800000002%29.pdf Model Respectful Language Avoid Substance abuser Addict Junkie Dirty Clean Substance abuse Use this instead: Person with a substance use disorder Person who uses drugs Positive urinalysis Negative urinalysis Substance free Substance use Substance misuse Non medical use Risky use 6
Applying Adult Learning Principles Rather than assuming participants don t know anything about the subject matter, find out what they know & build on it. Give people a chance to practice assembling and using naloxone devices. Ask people to teach you. Part II CORE CURRICULUM 7
Core Curriculum Overview A. What is an Opioid? B. Recognizing an Opioid Overdose C. Responding to an Opioid Overdose D. Information for Certificate Holders E. Tips for Preventing Opioid Overdose (optional) F. Suggested Resources for Family & Friends (optional) Core Curriculum: Section A WHAT IS AN OPIOID? 8
Opioids An opioid is any drug that contains opium (or its derivative). Opioids can be: Natural or synthetic Prescription medications or illegal drugs Pills, capsules, powder or liquid Swallowed, smoked, snorted or injected About Opioids Opioids: Manage pain, suppress coughs and treat opioid use disorders (addictions) Cause feelings of euphoria, contentment and/or detachment Have effects lasting from 3 to 24 hours In excessive amounts, opioids can suppress a person s urge to breathe. 9
Examples of Prescription Opioids Generic Name Brand Name Oxycodone Oxycontin, Percocet, Roxicodone Oxymorphone Opana Hydrocodone Vicodin, Lorcet, Zohydro, Zortab Hydromorphone Dilaudid Morphine Meperidene Demerol Codeine Tylenol 3 & 4 Buprenorphine Suboxone, Subutex, Zubsolv Methadone Fentanyl Duragesic Examples of Illicit Opioids Heroin Non pharmaceutical fentanyl Illicitly produced, synthetic drug Pill form packaged to look like prescription medications Powder form looks similar to heroin Fentanyl + heroin can be a deadly combination. Fentanyl may be hundreds of times more potent than heroin. 10
Core Curriculum: Section B RECOGNIZING AN OPIOID OVERDOSE What is an Opioid Overdose? Opioid overdose happens when a toxic amount of an opioid alone or mixed with other opioid(s), drugs and/or substances overwhelms the body s ability to handle it. Many opioid related overdoses result from mixing prescription painkillers or heroin with benzodiazepines (benzos), cocaine and/or alcohol. 11
What Leads to Overdose Death? Respiratory failure Lack of oxygen in the blood Vital organs like heart and brain start to fail Unconsciousness, coma, death Signs & Symptoms of Opioid Overdose Loud snoring or gurgling noises Body very limp Unresponsive Skin pale/gray, clammy Lips/fingertips turn blue(ish) Pulse slow or erratic Breathing very slow, shallow, or not at all Unconscious 12
Core Curriculum: Section C RESPONDING TO AN OPIOID OVERDOSE Responding to an Opioid Overdose 1. Rouse & Stimulate 2. Call 911 3. Give Naloxone 4. Further Resuscitation 5. Care for the Person 13
Step 1: Rouse & Stimulate Noise Shake person s shoulders and yell: [Name!] Are you all right? Wake up! Pain If no answer, do a sternum rub: Make a fist & rub your knuckles firmly up and down the breastbone. Sternum Rub 14
Step 2: Call 911 Get emergency medical help for someone experiencing an overdose! Why? Naloxone is only temporary. Person may: have complications or other health problems need more naloxone May be a non opioid overdose situation. Tell 911 operator: Call 911: What to Say Where you are What you observe (e.g., person is turning blue, won t wake up, making gurgling noises) Tell emergency responder onsite: Drugs/substances the person used Naloxone administered how much & when 15
Step 3: Give Naloxone What is Naloxone? Naloxone is a medicine that reverses opioid overdose by restoring breathing. About naloxone: Wears off in 30 90 minutes Safe for children and pregnant women Delivery: intramuscular, intranasal or intravenous No potential for misuse or getting high No effect on someone who hasn t taken opioids Side effects are minimal and rare Naloxone is only effective in reversing opioid overdoses. 16
How Does Naloxone Work? The brain has many receptors for opioids. When too much of an opioid fits on too many receptors, an overdose occurs. Naloxone knocks opioids off opioid receptors and binds to receptors for a short time. This blocks the opioids effects, quickly restoring breathing. Naloxone Storage & Disposal Storage Do not attach naloxone to delivery device until ready to use Store in original package at room temperature Avoid exposure to light Keep in a safe place away from children & pets, but easy to access in case of emergency Disposal Naloxone devices with syringes: dispose as medical sharps (in a rigid container) Other devices: dispose in household trash 17
Intranasal Naloxone Amphastar NARCAN Instructions: Amphastar Nasal Naloxone 18
Instructions: Amphastar Nasal Naloxone 1 Remove caps from needle less syringe. 2 Screw nasal atomizer into top of syringe. 3 Remove cap from vial of naloxone. 4 Gently twist naloxone vial into syringe until you feel it catch. Instructions: Amphastar Nasal Naloxone 5 Tilt the head back (so the naloxone will not run out of the nose). 5 Spray one half (1 cc) of the naloxone up each nostril. 19
Instructions: Amphastar Nasal Naloxone 7 Allow 1 to 3 minutes for the naloxone to work. Continue resuscitation as necessary. 8 If breathing is not restored after 2 or 3 minutes, give another dose of naloxone. Continue resuscitation as necessary. 9 Stay with the person & provide care as directed until medical help arrives. Instructions: NARCAN Nasal Spray 20
Instructions: NARCAN Nasal Spray 1 Remove NARCAN nasal spray from box. Peel back tab with circle to open. 1 Hold NARCAN nasal spray with your thumb on the bottom of the plunger and your first & middle fingers on either side of the nozzle. Instructions: NARCAN Nasal Spray 3 Tilt head back & support person under neck. Gently insert tip of nozzle into nostril, until your fingers on either side of the nozzle are against the bottom of the nose. 4 Press plunger firmly to administer. 21
Instructions: NARCAN Nasal Spray 7 Allow 1 to 3 minutes for the naloxone to work. Continue resuscitation as necessary. 8 If breathing is not restored after 2 or 3 minutes, give another dose of naloxone. Continue resuscitation as necessary. 9 Stay with the person & provide care as directed until medical help arrives. Intramuscular (Injectable) Naloxone 22
Instructions: Injectable Naloxone 1 2 3 4 Pop off the flip top from naloxone vial. Insert needle into vial & draw up 1 cc of naloxone into syringe. Use alcohol wipe to clean injection site: shoulder, thigh, or buttocks. Inject needle straight into muscle (through clothes, if necessary), then push in plunger. Do not inject naloxone into the person s heart, chest, or back. Instructions: Injectable Naloxone Where to inject naloxone: Shoulder Thigh Buttocks (upper, outer quadrant) 23
Instructions: Injectable Naloxone 5 Allow 1 to 3 minutes for the naloxone to work. Continue resuscitation as necessary. 6 If breathing is not restored after 2 or 3 minutes, give another dose of naloxone. Continue resuscitation as necessary. 7 Stay with the person and provide care as directed until medical help arrives. Evzio 24
Instructions: Evzio 1 Pull off the red safety guard. Note: the red safety guard is made to fit tightly. Pull firmly to remove. Instructions: Evzio 2 Place the black end of Evzio against the outer thigh. (Over clothing, if needed.) Press firmly & hold in place for 5 seconds. Evzio makes a distinct sound (click & hiss) when pressed against the thigh. This is normal & means that it is working correctly. Keep Evzio firmly pressed on the thigh for 5 seconds after you hear the click & hiss sound. The needle will inject & then retract. The needle is not visible after use. 25
Instructions: Evzio 3 Allow 1 to 3 minutes for the naloxone to work. Continue resuscitation as necessary. 3 If breathing is not restored after 2 or 3 minutes, give another dose of naloxone. Continue resuscitation as necessary. 5 Stay with the person & provide care as directed until medical help arrives. Note: individual Evzio device cannot be reused. Practice: Naloxone Devices Practice using naloxone devices now. When you train people to use naloxone, it s important to give them a chance to practice using the device (especially if it requires assembly). Tips: Injectable naloxone: practice injecting into an orange. Amphastar nasal spray: refill the glass vial with water. Use expired naloxone for practice kits. Dispose of the naloxone liquid & refill with water. Evzio: every package of Evzio includes a training device and two doses of naloxone. Point out which is the trainer & which is the naloxone. 26
Step 4: Further Resuscitation Assess breathing. If the person is not breathing, or breath is shallow or short: Give rescue breaths OR Follow the 911 dispatcher s instructions OR Give CPR (chest compressions + rescue breaths) if you are trained in it Assess Breathing Look, listen & feel for breath. If shallow or short breaths, or not breathing start rescue breathing right away 27
About Rescue Breathing Rescue breathing is: the quickest way to get oxygen into the body one of the most important things you can do to prevent someone from dying from an opioid overdose Rescue Breathing Instructions 1 Lay the person faceup on a flat surface. 1 Tilt the chin to open the airway. 1 Remove anything blocking the airway. 28
Rescue Breathing Instructions 4 Pinch the person s nose closed. 5 Cover the person s mouth with your mouth. Blow 2 regular breaths (about 1 second each). Rescue Breathing Instructions 6 Continue breathing. Give 1 breath every 5 seconds. 29
Rescue Breathing Demonstration At least one volunteer should demonstrate rescue breathing now with a mannequin. Note: Seeing & doing things helps people remember them. When you do a classroom training, it helps to have a rescue breathing demonstration and practice on a CPR mannequin. Step 5: Care for the Person Stay with the person until medical help arrives. If person cannot sit up, put him/her in recovery position. Keep person calm. Encourage person not to take more opioids. If overdose happens again, give another dose of naloxone. 30
Care for the Person After receiving naloxone, a person may: Feel physically ill or vomit Feel withdrawal symptoms (unpleasant but not life threatening) Become agitated and upset Have a seizure (this is rare) Recovery Position If you have to leave the person (even briefly) put him/her into the recovery position. This keeps the airway clear and prevents choking or aspiration if vomiting occurs. 31
Recovery Position Face and body turned to one side Hand supports head Bent knee supports body If You Administer Naloxone Call the Poison Center within 2 hours: 1 800 222 1222 Or contact the training entity that issued your certificate 32
Core Curriculum: Section D INFORMATION FOR CERTIFICATE HOLDERS Good Samaritan Laws in Maryland These laws are meant to encourage people to: call 911 for help when someone overdoses administer naloxone 33
Good Samaritan Laws in Maryland A person who helps someone who is overdosing cannot be arrested, charged, or prosecuted for: Possession of a controlled dangerous substance Possession or use of drug paraphernalia Providing alcohol to minors Calling 911 in an overdose situation will not affect your parole or probation status. You cannot be held liable for a good faith attempt to help someone by administering naloxone. See: Code of Maryland, Criminal Procedure Article, 1 210, and Health General 13 3110 How to Get Naloxone By successfully completing a Maryland Overdose Response Program training, you are entitled to receive a certificate. How to get naloxone: Show your certificate to a physician or advanced practice nurse to get a prescription for naloxone. OR Take your certificate to a participating pharmacy to get naloxone through a standing order. You may also be able to get naloxone directly from a training entity. For a list of pharmacies that stock naloxone, go to www.bha.dhmh.maryland.gov/naloxone 34
Certificate Holder Responsibilities Administer naloxone in accordance with training procedures. Make a good faith effort to get emergency medical help for the person experiencing an opioid overdose. Contact the Poison Center or training entity after administering naloxone. Note: Certificates are valid for 2 years. An entity may charge you a reasonable fee to replace a lost certificate. Suspending or Revoking Certificate DHMH may suspend or revoke a certificate if: A certificate holder improperly uses or administers naloxone. OR DHMH determines it s necessary in order to protect public health or safety. The training entity does not meet DHMH requirements. OR The training entity issues someone an invalid certificate. What can you do? File an appeal. OR Write to DHMH requesting reinstatement of your certificate once you ve corrected the problem. Apply for a valid certificate after completing training at an authorized entity. (Ask DHMH for a list of approved entities.) 35
Core Curriculum: Section E TIPS FOR PREVENTING OPIOID OVERDOSE Activity Brainstorming Prevention Tips 36
Opioid Overdose Prevention Tips For everyone: Keep medicine in a safe place, like a locked cabinet. (Naloxone should be kept readily available.) Properly dispose of expired or unwanted medications. Only take medicine prescribed for you. Take medicine only as directed. Never share prescription drugs with others. If you have breathing problems (like asthma or sleep apnea), check with your doctor before taking opioids. Never mix pain medication with alcohol, benzos, sleeping pills, muscle relaxants, anti nausea drugs, other opioids, or illegal drugs. Opioid Overdose Prevention Tips If you use drugs: Do not use alone. Make an overdose prevention plan. Share it with someone you trust to give you naloxone if needed. If you have not used opioids in a few days, your tolerance will be lower and your risk for overdose greater. Use less opioids than you normally would. You are at greater risk for overdose if you have overdosed before. Always keep naloxone on hand. Tell others where it is. Get treatment for drug dependence or addiction. Seek professional help if you are depressed. Call a crisis hotline (phone #) or 911. 37
How NOT to Respond to an Overdose Anecdotal Remedy Use ice to cool down body Put person in bath or shower Hit, slap, or burn fingers or feet Give drink or induce vomiting Inject person with cocaine, salt water, milk, or epinephrine Possible Consequences Slowed heart rate, arrythmia Drowning Bruising, broken bones, infection, amputation Choking High blood pressure, infection While well intentioned, these methods waste valuable time that would be better spent on rescue breathing, administering naloxone, and calling 911. Optional Part III TAILORING THE TRAINING 38
Overview: Tailoring the Training A. What content is required by law? B. Training structure 1. Quick trainings (10 minutes) 2. Classroom style training (1 hour) C. Audience 1. General public 2. People who use drugs 3. Family & friends 4. Patients of opioid treatment programs 5. Others What Content is Required by Law or Regulations? This content is required to certify someone as an overdose responder under the Maryland Overdose Response Program: 1. Signs & symptoms of opioid overdose 2. How to respond to an overdose, including: a. How to administer naloxone b. Proper rescue breathing technique c. The importance of contacting emergency medical services (911) d. How to care for someone after administering naloxone 3. How to get & fill a prescription for naloxone DHMH may change this list. 39
Quick Trainings 10 minutes Suggested materials One page handout with key info Practice kits Teaching tips Start with what people know: ask questions and add or correct info as needed (e.g., What are some signs of an opioid overdose? ) Let people practice assembling and using the naloxone device Ask people to teach you When? Where? Classroom Style Trainings About 60 minutes Suggested materials Mannequin to demonstrate rescue breathing Practice kits One page handout with key info ORP applications & certificates Teaching tips Aim to engage participants (ask questions and have them participate) Don t assume that the information is new to people Logistics Helpful to have a 2 nd person to help with paperwork 40
Tailoring to the Audience When planning, consider your audience. What do they likely know already? What will likely be new to them? What will their concerns likely be? Make educated guesses, but remember that you may be wrong! Tailoring to the Audience Consider space in pharmacy: Can people overhear the training? Will the person feel comfortable? How much time is needed? How much time can you give? 41
All Audiences Remember that the training may bring up painful memories or difficult emotions. Be sensitive to that and respectful of participants. Model respectful language. Prepare based on educated guesses, but don t make assumptions about individuals. Part IV PRACTICE TEACH 42
Activity: Practice Teach Optional Part V MARYLAND OVERDOSE RESPONSE PROGRAM: KEY ELEMENTS 43
ORP Law and Regulations ORP = Maryland Overdose Response Program Law: Article Health General, Title 13, Subtitle 31, Annotated Code Maryland, 13 3101 3109 Regulations: COMAR 10.47.08.01.11 (3/3/14) Becoming an entity Entity application form Identify supervisor Supervisory agreement Dispensing protocols Data collection and reporting 44
Key Elements: ORP Certification Trainee Application Form completed by trainee, kept on file by entities Certificate awarded to trainees who successfully complete the training Certificate holder can show it to any authorized prescriber for a naloxone prescription Certificate holder can show it to obtain naloxone at any pharmacy in Maryland without a prescription Certificate log maintained by authorized training entity Naloxone Dispensing Store and dispense naloxone according to existing protocols Using the standing order: Keep copy of standing order on file Place copy with patient records Reference standing order guidance document 45
Pharmacy Barriers Reimbursement for training Reimbursement for naloxone and atomizer Time and space for training Liability concerns Others? Part VI WRAP UP 46
Learning Objectives Can you do the following? Identify 5 signs and symptoms of opioid overdose List 5 key steps to respond to an opioid overdose Identify 5 ways to prevent opioid overdoses Explain the following key elements of the Maryland Overdose Response Program (ORP): How to issue certificates How to dispense under the statewide standing order Explain Good Samaritan protections Identify 3 ways to tailor overdose response training Additional Resources Guide to Developing & Managing Overdose Prevention & Take Home Naloxone Projects (Harm Reduction Coalition) http://harmreduction.org/issues/overdose prevention/tools bestpractices/manuals best practice/ Naloxone Access: A Practical Guideline for Pharmacists https://cpnp.org/_docs/guideline/naloxone/naloxone access.pdf SAMHSA sponsored CE training for pharmacists: http://www.powerpak.com/course/preamble/112666 Prescribetoprevent.org 47
ORP website http://bha.dhmh.maryland.gov/naloxone Erin E. Haas, MPH Local Programs Manager, Overdose Prevention Maryland DHMH/ Behavioral Health Administration Office: 410 402 8574 erin.haas@maryland.gov 48