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Narcan Training:

Preventing and Responding to Opioid Overdoses

Presented By:

Brooke Zwack-Tramski, RN, BSN

Personal Health Nurse Coordinator

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Goals

An understanding of opioids
How to properly identify and respond to an opioid overdose with Narcan

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Work in the brain to provide pain relief
Affects areas that control emotion
Can cause people to feel relaxed or “high”
Slow down the heart and breathing
Legal (prescription) or illegal
Natural or synthetic
Swallowed, snorted, smoked or injected
St. Clair County had 147,566 opioid prescriptions dispensed in 2020

Opioids

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Codeine
Fentanyl (Duragesic)
Hydromorphone
Methadone
Heroin
Hydrocodone (Vicodin)
Oxycodone (OxyContin, Percocet)
Oxymorphone (Opana)
Morphine

Commonly Use Opioids

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Opioid Strength

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Fentanyl

Synthetic opioid-man made
Treats severe pain
Most recent cases of harm, overdose, and death are linked to illegally made fentanyl
Sold through illegal drug markets for its heroin-like effect.
Often mixed with heroin and/or cocaine as a combination product to increase its euphoric effects

Fentanyl is a synthetic opioid that is about 50-100 times stronger than morphine and 50 times as potent as heroin. It has been around since 1968 for surgery and pain management. People use fentanyl because it is cheap to manufacture and a small amount goes a long way. Many individuals consume fentanyl without knowledge while others use it intentionally because of its potency. Fentanyl moving through the street market comes in a powder form and can be injected, smoked, or snorted. It has also been found in other drugs, like heroin, meth, cocaine, and pressed pills.

We offer fentanyl testing strips at our SSP program to help with overdose prevention.

Starting in 2012, there has been a spike in the number of overdose deaths related to synthetic opioids. Overdose deaths involving fentanyl have quadrupled in recent years.

I would like to talk about a fentanyl myth. You cannot overdose simply by touching fentanyl. It must be introduced into the bloodstream or a mucus membrane in order for someone to feel the effects. While there are fentanyl patches that can be placed on the skin for pain management, this is not the formulation that is used to cut into other substances.

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Opioid Side Effects

Tolerance—you need to take more for the same pain relief
Physical dependence—you have symptoms of withdrawal when the medication is stopped
Increased sensitivity to pain
Constipation
Sleepiness and dizziness
Confusion
Depression

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When a toxic amount of a drug, or combination of drugs, overwhelms the body
People can overdose on lots of things, including alcohol, Tylenol, opioids or a mixture of drugs

What Is An Overdose?

What is an overdose? An overdose is what happens when a toxic amount of a drug, or combination of drugs overwhelms the body. People can overdose on lots of things, including alcohol, Tylenol, opioids or a mixture of drugs.

Fatal overdose is the leading cause of death for people in the U.S. under 50 years old.

More than 800,000 people died from fatal overdoses in the U.S. from 1999-2018.

An opioid overdose happens because opioids fit into specific receptors that also affect the drive to breathe. If someone can not breathe or is not breathing enough, the oxygen levels in the blood decrease and the lips and fingers turn blue. This oxygen starvation eventually stops other vital organs like the heart, then the brain. This leads to unconsciousness, coma, and then death.

Within 3-5 minutes without oxygen, brain damage starts to occur, soon followed by death. With opioid overdoses, surviving or dying wholly depends on breathing and oxygen.

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United States in 2020:

91,799 Overdose Deaths

Michigan:

3,096 Overdose Deaths in 2021
30,920 Non-Fatal Overdose ED Visits 2021
2,350 Overdose Deaths Jan 2022 to Feb 11, 2023
15,573 EMS naloxone administrations Jan 2022 –Feb 12, 2023

St. Clair County:

37 Overdose Deaths 2020

Overdose Data

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Decreased tolerance (jail, prison, rehab, recovery, etc.)
3-5 days abstinent = tolerance ↓ 50%
2 weeks abstinent = no tolerance
Mixing substances
Quality/Purity
Unfamiliar medications
Prior Overdoses -29x more likely to overdose
Multiple Prescribers

Overdose Risk Factors

The risk of an overdose increases for someone who has recently stopped using opioids. Tolerance to opioids significantly decreases in just a few days of non-use. For example, someone who has been in jail for 3-5 days, their tolerance decreases by 50%. Someone that is not using for 2 weeks will have zero tolerance. If that person goes back to using the same amount of opioids as they did prior to jail, they are at a much higher risk of overdosing.

Most overdose deaths involve use of more than one type of drug. Mixing substances is dangerous because different drugs act on our bodies in different ways. For example, mixing heroin and cocaine results in a high risk of overdosing because the cocaine causes the body to use more oxygen while heroin reduces the breathing rate.

The quality and purity of drugs can also put someone at risk of an overdose. Illegally obtained drugs are not regulated and so you don’t know exactly what is in them or how potent. A user may be told the product contains one substance, while in reality it could contains something else. The drug may be in combination with other drugs such as heroin or fentanyl.

People with a history of prior overdoses are also at a higher risk of a fatal overdose. Those with a history of past overdoses are 29 times more likely to overdose again within 30 days.

Patients with multiple doctors and/or pharmacies are also at risk of an overdose. Nearly 1 in 3 patients who received opioids within the last 3 years reported that they did not know they were taking opioids. There is a drug prescription system called MAPS, Michigan Automated Prescription System, that is being used to track controlled substances. It allows pharmacists, nurses, doctors to see what medications you have been prescribed. It helps with making sure that a person isn’t taking too many, catch potential interactions, and help with drug diversion.

The picture there is how much fentanyl it takes for a person to overdose.

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Overdose Signs and Symptoms

Signs of an overdose may include:

Unresponsive/loss of consciousness
No breathing or shallow breathing
Low heart rate/pulse
Limp muscles
Pale skin
Blue lips and/or fingernails
Gurgling or snoring noises
Foaming at the mouth or nose

Sometimes it can be difficult to tell if a person is just high, or experiencing an overdose.

Signs of an overdose may include:

Unresponsive

Breathing is very slow and shallow, erratic, or has stopped

Pulse (heartbeat) is slow, erratic, or not there at all

Muscles are limp

For lighter skinned people, the skin tone turns a bluish-purple. You can see this around the lips, or fingernails

for darker skinned people, it turns grayish or ashen.

gurgling or snoring noises, choking sounds

foaming at the mouth or nose.

They might “nod out”

Speech may be slurred

Awake, but unable to talk

Vomiting

it is important that if you come across someone like this, you don’t leave them alone. If the person is still conscious, walk them around, keep them awake, and monitor their breathing.

If someone is making unfamiliar sounds while “sleeping” it is worth trying to wake them up. Sometimes people will think a person was just snoring, when in fact the person was overdosing.

Not all of these symptoms may be present. If there is any indication of a possible overdose, you should respond to the situation as if it is an overdose

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Naloxone Hydrochloride = Narcan

Commonly known as Narcan®
FDA approved in 1971
Only works on opioid overdoses
Safe to administer even if opioid use is unknown
Has no effect if opioids are not present
Non-addictive and causes sudden withdrawal – unpleasant (vomiting, diarrhea, sweating)
Routinely used by EMS but usually in larger doses

Naloxone Hydrochloride, commonly known as Narcan, is in a class of medications called opioid antagonists. It reverses the opioid effects of sedation and respiratory depression by knocking the opioids off the receptors in the brain. Narcan only works on opioid overdoses but is safe to give even if you are unsure if opioids were used. Narcan will have no effect if opioids are not present. Narcan is not addictive but can cause sudden unpleasant withdrawal symptoms, like vomiting, diarrhea and sweating. Narcan was FDA approved in 1971 and is routinely used by emergency medical services.

Only side effect is withdrawal.

You cannot be allergic to this.

This does not interact with any other medications.

If it is not an overdose and this medication is given, it will do nothing.

It is generally available in two formulations, a nasal spray and IM injection. The nasal spray is more popular since it is easier to use.

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Responding To An Overdose

Step 1: Stimulate
Step 2: Administer Narcan
Step 3: Call 911
Step 4: Provide Rescue Breathing
Step 5: Recovery Position

We have talked about risk factors, and preventing an overdose. But what should you do if you discover that someone is overdosing? As a person begins to overdose, their breathing slows and may stop. The key to saving the life of a person who is overdosing is to get them breathing again as quickly as possible.

First thing you want to do is:

Step1: Stimulate- shout or yell at the person, use your knuckles to rub on their sternum (sternal rub). Tap their shoulders. If there is no response, you're going to give the Narcan.

Step 2: Peel back the package down to remove device. Place the tip of the nozzle in either nostril until your fingers touch the bottom of the persons nose, then press the plunger firmly to release the dose into their nose. Do not prime or test the device. Narcan takes three to five minutes to work. In the meantime, you need to:

STEP 3. Call 911. Explain someone is not responsive and not breathing. Tell the dispatcher exactly where you and the overdosing person are. Give them as much information as possible so that they can find you (i.e. 3rd floor, or in the bathroom).

STEP 4. Provide rescue breathing. Get the person on their back, tip their head back to straighten the airway, pinch their nose, put your mouth over theirs to form a seal, and give them one breath every five seconds. As youre doing this, evaluate. If the person is still not breathing or responding, continue rescue breaths. If after two minutes they are not breathing on their own, give the other dose of Narcan. Can be given into either nostril.

STEP 5. When the person starts to breathe regularly on their own, roll them into a recovery position. Lay the person slightly on their side, bend their knee, and turn their face to the side. This will help to keep their airway clear and prevent them from choking on their own vomit if they begin to throw-up. Wait for EMS.

It is important to point out that narcan is not a substitute for medical attention. The effects of naloxone will only last 30-90 minutes, the effects of opioids can last much longer and an overdose can return.

If you are unsure if the person is overdosing, there are some things you can look for:

Is the person breathing?

Is the person responsive?

Do they answer when you ‘shake and shout’ their name?

Can the person speak?

How is their skin color (especially lips and fingertips)?

IMPORTANT! If a person is not responsive to stimulation, not breathing, and has no pulse after receiving naloxone and rescue breathing, then the person needs CPR via a trained bystander and the emergency medical system. Call 911!

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Narcan

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Narcan And Michigan Laws

An individual, who in good faith, believes that another individual is suffering an opioid-related overdose and administers naloxone is not liable to a civil action for damages resulting from the administration.
People who are seeking emergency medical assistance for themselves or another person as a result of a drug overdose are protected from criminal charges in certain circumstances.

A quick response can save a life during a drug overdose. Michigan has prioritized saving lives by passing several laws that help facilitate life saving measures for someone experiencing an overdose.

Under Michigan Law, a pharmacist may dispense narcan without an individual prescription and without identifying a specific patient. Family, friends, and/or others can obtain narcan to use in an emergency without a prescription.

Michigan’s Good Samaritan Law also covers the person who administers the Narcan and prevents drug possession charges against those that seek medical assistance for an overdose in certain circumstances.

If someone calls 911 for a person overdosing, they will not be charged if also using drugs. Ie at a party or something like that. However, the exception to that is if they have a warrant out for their arrest.

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SCCHD Narcan Rescue Kits

Two does of Narcan®
One way valve breathing mask
Gloves
Recovery resources
Store Narcan at room temperature 68°-77° and protect from light.

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Replacement

To receive a replacement due to:

Use
Lost/Stolen
Expired
Prolonged exposure to light or heat

Contact:

Brooke Zwack-Tramski, RN, BSN

St. Clair County Health Department

(810) 987-5300 ext. 1501