What is Naloxone and How to Use it in an Emergency

• Why Naloxone is Important
• How to Use Narcan

• Is the Opioid Crisis Only an American Issue?
• Narcan: The Opiate Overdose Antidote
• High Opioid Prescription Rates Shadow Prescriptions for Naloxone & Overdose Reversal Drugs

Welcome to The Community Education series hosted by The Recovery Village and Advanced Recovery Systems. Hi guys, I see familiar faces. Hi, Scott. I’m accustomed to doing this in person, and this is my first attempt at doing this via Zoom. So, I’m gonna just be utterly transparent from the jump, and if it’s a little awkward, I apologize. I will try to smooth it out. I’m just going to dive right in. Can you guys all see the screen? Perfect. Thanks, Libby.

Alright, so kinda like Libby, I want to know your name, where you work and why you would like to carry naloxone — if you want to drop that in the chat. I think it’s super important to have a purpose behind why you want to carry this — not only to save lives, but if there’s anything personal in your life as to why you’re wanting to do this, or if you need it for work or sober living. So, drop those in the chat ‘cause I’m curious to see.

So, I always do working agreements in person. I kind of want to do the same here; while you may not be talking over each other, I’d like to save questions until the end. But still, this material can be very sensitive, and if you have any lived experience with overdose, you may find this training triggering at times. I want you to take a moment, walk away, come back if you need to, and if you missed anything or you feel like you missed something, don’t hesitate to reach out to me afterwards. I’d be happy to spend some time talking with you one-on-one. But a few of my ground rules would be — and this goes for chat, as well — is to be respectful of others and make yourself comfortable because this is heavy material. I kind of want us to get as comfortable as possible, like settle into your chair, take notes if you want and we’ll get rolling.

On today’s agenda, we’re going to learn what naloxone is, prevention in recognition of overdose, overdose, rescue and naloxone used, and then what to do after the naloxone has been administered. ‘Cause that can be the trickiest part. I’m going to have to move this chat, like the faces, around sometimes. Alright, what is naloxone? Naloxone is safe, highly effective. It’s the only antidote to opioid overdose. It’s going to bind to the receptors in the brain that receive heroin, and it quite literally kicks it out of the brain. Naloxone cannot get you high, so there’s literally no potential for abuse. So I always say — and I’ll say it multiple times throughout this training — when in doubt, administer naloxone. When in doubt, use the Narcan. Naloxone is not a scheduled drug and it’s safe to carry after you’ve had training on it. I know in the state of Colorado — you may be in different States — but I know in the state of Colorado, you can go into the pharmacy and pick it up

These are some tough statistics, but I like to find the positive in them because naloxone has reduced the number of opioid deaths by 11%. That’s a huge number. I wouldn’t be alive today without naloxone. I wouldn’t have the opportunity to be coming up on five years, clean and sober. I wouldn’t have the opportunity to be a mother to my children, a daughter to my parents, a sister to my sister without the use of naloxone. I overdosed November 3rd, 2015, and I’m alive today because of it. So I’m extremely passionate about the use of naloxone because it saves over 7,000 people per year.

We’re going to get into prevention and recognition of overdosing. I like to ask: What is an overdose? Some people may not know; not everybody works in this industry, and they may not know. So, an overdose happens when a toxic amount of substance or combination of substances overwhelms the body and causes it to, quite literally, shut down. With downers like heroin, alcohol, benzodiazepines, breathing slows and stops and then eventually, the heart stops. With stimulants, the heart is going to speed up, body temperature rises, a person goes into seizures and can have a heart attack or a stroke. Naloxone cannot work for stimulants. It can only be used for opiates. The fatal overdose happens when the opiates shut down the respiratory system and then the heart stops.

Today, you’ll learn how to save someone’s life. This is my favorite slide. If you see someone overdose, you’ll have two jobs: to administer naloxone and to breathe through them while the paramedics are on their way. Then again, in stimulant overdose cases, all you can do is call 911 and support them as best you can. If the person is having a seizure, simply protect their head. Naloxone will not work in stimulant overdoses. Don’t do anything like try to put a spoon in their mouth to stop them from biting down on their tongue. There’s a lot of misconception with stimulant overdose; I advise you to do some research. There’s still many things that people do in movies that doesn’t help anyone.

So, how does an overdose happen? How can it be prevented? There are many reasons a person can overdose, but we generally see a combination of the categories that you’re going to see on this slide, which is mixing substances — say they’re mixing opiates with benzodiazepines or opiates with alcohol. A tolerance issue: They might be coming fresh out of treatment, fresh out of prison, and their tolerance is just not the same as what it used to be. The quality: There is no quality control in illicit substances. It’s a huge factor in overdose deaths because people cut heroin with fentanyl and all kinds of other things. And then, using alone: The stigma associated especially with IV drug use is that people are going to use alone in restrooms or hiding places because of the shame associated with the act.

For recognizing signs of an overdose, what does it look like when someone’s high on heroin? If you don’t know, pupils are going to be really, really penned, so very small. They often get grayish in color. Nail beds will start to turn blue when it’s more intense than like a heavy nod; their lips start to turn blue because they’re running out of oxygen. What would be a warning sign to you that someone is overdosing? The most familiar to me is when you can hear their breathing is labored. It’s almost like a slight gurgling and their breathing becomes erratic, and it’s really difficult not to notice it. And then, I have an ear who hears them in an overdose, ‘cause most people in person like to volunteer that information. I personally lost a loved one — my significant other — to overdose. It’s something that, if naloxone had been around, I could have saved his life. This was a long time ago, and it wasn’t readily available like this. It’s amazing that we get to do free trainings like this today to show people how to do this.

So, opiates such as heroin directly affect the region of the brain that regulates breathing. Quite literally, it regulates our breathing. Heroin overdose often happens slowly over the course of several hours. A lot of people don’t know that the calming part of that is that it’s very peaceful. Respiratory depression is the most alarming symptom as it’s the last to occur before unconsciousness — where they absolutely cannot help themselves after that point. Breathing becomes erratic and then very shallow, and if the person’s condition is not addressed, breathing does stop altogether.

We’re going to dive into the good stuff of rescue and naloxone use and life-saving tactics. If you see someone that is exhibiting the symptoms that we just talked about, you can simply walk up to them and check for responsiveness. Ask them questions. Some people may not answer, even though they can hear you, because they’re really high. I didn’t want to answer someone either. But a quick sternum rub — you make a fist like this and your knuckles are up and you briskly rub on their chest bone right here. I promise you, if they can feel you and they can hear you, they will say something because it is extremely uncomfortable and they don’t want you to administer Narcan if they’re just very heavily nodded out. Trust me, it’s not a fun experience.

After the sternum rub, if you get no response after that, you’re going to check for their breathing. All of these assessments slides — there’s three total — this entire assessment takes no longer than 30 seconds. You’re going to spend 10 seconds on each slide. A lot of you are probably CPR-certified. If you’re not, I advise doing that as well because you’ll learn every bit of this too. You’re going to check the airway; this is difficult to do via Zoom, but I hope you can tell from the pictures how to do a look, listen, feel. You quite literally head tilt and chin lift, and you place your ear to their mouth and look down their chest and you look, listen, feel for 10 seconds. Can you feel them breathing on your ear? Can you see their chest raising? Check for pulse, two fingers. You should have 10 to 12 heartbeats within 10 seconds.

While I go get my phone, I like to put someone in this recovery position. It doesn’t matter if they’re on the left or right side, unless it is a pregnant female — she then has to be laid on her left side in this recovery position. At this point, call for help. While you’re getting your stuff to administer your Narcan or naloxone — we have the luxury of cell phones and putting them on speaker and geo-targeting with 911 — you can call 911 while you’re getting your stuff together. You can say, “My friend is unresponsive and not breathing.” The reason you say unresponsive and not breathing is because if you say, “My friend’s overdosed,” you go further down 911’s response list.

I know that that is terrifying and almost disgusting, but it’s true. So the code words of unresponsive and not breathing move you to the top of the list. It’s crucial that paramedics get there directly after naloxone is administered because your one dose may not be enough if that heroin was cut with fentanyl. So, you tell them that, “We can be found here.” When paramedics arrive, then you tell them immediately this is a heroin overdose. “I believe that they were taking benzodiazepines,” or, “They may have been drinking alcohol with this.” Like, whatever: Give them all the details because they’re the ones that truly want to save that life. Tell the paramedics everything that they need to know.

This is always interesting for me to ask because — how long do you think it takes the brain to start to die without oxygen? It’s five to six minutes, which seems like not that much time. How long does it take for an ambulance to arrive in most neighborhoods? Up to 10 minutes, sometimes more if you live in Denver. I live right by downtown, and one of my neighbors was overdosing. I got over there administered Narcan. It took the paramedics 22 minutes to arrive. 22 minutes. So I was called an “on-scene” and had administered Narcan before paramedics even arrived, and Denver Health is about a mile from us, so there’s paramedics everywhere. I don’t want that to be like a startling statistic, but maybe it should be — that if we don’t keep these things on hand and we don’t know how to do this ourselves, that young man would have lost his life that night.

Something must be done in order to prevent brain damage, like naloxone or Narcan use and rescue breathing. Naloxone needs the blood to be circulating; the slower their circulation, the longer it takes the naloxone to travel through the bloodstream. You can perform rescue breathing until paramedics arrive. The rescue breathing alone sometimes is enough to save their life, even if you don’t have Narcan, even if you don’t have naloxone on hand. So, kit assembly: I normally pass out kits when I do these trainings so that people go home right after training with Narcan or naloxone, the syringes involved for the naloxone, the naloxone injection gloves, alcohol pads, the disposable CPR face shields and an instruction cheat-sheet card with my contact info on there as well. You can make one of these for yourselves. You can go to the pharmacy, pick these things up. I keep one in my gym bag. I keep one in my car. I have one in my kitchen. I keep them everywhere.

So, this is what your Narcan nasal spray is going to look like. If you’ve never seen it before, it’s really easy to administer. You literally pull it out of the packaging. After you’ve done those assessments for 30 seconds, you hold one side of the nose and spray it up the other. It’s real quick — spray, spray. Then as far as the injection goes, I walk you through it here in person. I do it with you. Like, we’re going to take oranges, we’re going to administer injections and we’re going to know exactly how to do this. I can talk you through it here and kind of show you a little on my own shoulder. You’re gonna pick the injection site and you’re going to wipe with an alcohol prep. I always tell people, if you’re doing a naloxone injection, do it in the shot in the shoulder muscle because it doesn’t matter the size of the person with an intramuscular needle — it will go in properly.

Take a deep breath. That’s a reminder for you to pause, take a deep breath and open your syringe packaging. They’re normally Luer lock syringes. I tell you to tighten, remove the cap from your syringe, set it to the side. You’re going to hold on to that cap; it’s extremely important to. You’re going to flip off the vial of your cap with your thumb — real simple. You pull a milliliter of air back into your syringe, push that milliliter of air into the vial of naloxone. The naloxone vials are about this big — they’re super tiny, just enough room to hold that milliliter of solution. When you flip it back, it’ll self administer into your syringe. Exactly one milliliter of solution because you’ve pushed one milliliter of air in there. You’re going to draw the skin tight with your thumb and forefinger on the shoulder; in a dart-like motion of 90-degree angle, you’re going to push the syringe into the shoulder and administer. It’s very simple, but I advise people to practice just to get comfortable with what you’re doing with those intramuscular syringes. I mean, overdoses don’t happen in the calmest of situations. So it’s good to have these tools memorized.

My mother, who’s a physician and has worked in prisons her entire life — she’s an amazing woman. She told me, she’s like, “You have to have an entire slide on recapping your syringe.” She helped me make this the best presentation, and it wouldn’t pass without this because we are dealing with a lot of communicable diseases and it’s extremely important to recap the syringe here to give to the EMT for proper disposal. This is called just a scoop-and-tap motion with your syringe, and it lays it out perfectly in the images. You’re literally going to scoop the syringe needle into the cap and then tap it down with your thumb and pointer finger. Pull it down; you don’t want to press on the top of it. Then, you’ll set it aside and give that to the EMT. They have sharps containers on their buses.

After you’ve administered, you’re going to perform rescue breathing. You’ll give one breath every five seconds for a minute, and then you’re going to perform those assessments again. Like I said, I would advise you to do CPR certification if you haven’t. It’s extremely handy in this situation. So you’re going to recheck breathing, recheck pulse. Let’s practice. It can be fun. Wow, we’re really rolling through this material. That’s okay, we’ll have time for questions. After naloxone, oftentimes, people are gonna wake up really agitated because you’re immediately withdrawing because the naloxone forces out all of the opiates that were in those receptors where the heroin was just hanging out. Naloxone went in and just booted it out, so people wake up really upset with you. You need to stay with them until paramedics arrive so they will not attempt to outshoot the naloxone to feel better.

It’s a common practice to try and to try and, like, soothe the withdrawal symptoms. You can explain to them — mind you, if they’re extremely aggravated and you feel that you’re in a dangerous situation, get out. Like, leave. But if you can stay with them until the paramedics arrive, please do. And just explain to them, “Look, you were overdosing and I gave you naloxone to save your life. If you’re feeling withdrawal symptoms now, you’ll start to feel better in two to four hours.” The naloxone does begin to wear off within 30 minutes — as early as 30 minutes — and the effects will be completely gone after four hours. After the naloxone wears off, their chances of overdosing are significantly and significantly higher, and they do need to go with EMTs to be assisted. I’ve never given someone an option — like it’s, “You’re going with these paramedics.” Like, they’re a little confused and I’m like, “Here you go. You’re going with these EMTs.” I don’t really give them an option.

And then I’ve included the laws on naloxone in Colorado. So in order to turn the tables on an opioid crisis in Colorado, officials have issued a standing order for naloxone. Those who intervene to assist a person who is overdosing will be protected from liability by a Good Samaritan law. In Colorado, Good Samaritan law limits liability for people who contact emergency services to report a person experiencing an overdose, administering naloxone or otherwise assist in saving the life of someone who is overdosing. By increasing access to naloxone, officials in Colorado hope to ensure the potentially life-saving naloxone is distributed to as many at-risk individuals as possible. In particular, it’s recommended that naloxone be kept on hand if you’re a member of a harm-reduction organization. Just being a woman in recovery, I carry naloxone. But especially working in the industry that I work in, I keep it everywhere. It’s in my desk, it’s in my car. This is a little about the program I worked for.

Thank you for watching this video. We hope you enjoyed the presentation.