Overdose Prevention and Response Train the Trainer

Overdose Prevention and Response Train the Trainer Eliza Wheeler Drug Overdose Prevention & Education (DOPE) Project Harm Reduction Coalition 510.444.6969 x 16 wheeler@harmreduction.org

Training overview: Review of major drugs involved with overdoses l Risk factors l Prevention Messages l Recognizing an OD l Responding to an OD l Practice l

Drug Overdose Trends Drug overdose death rates in the US have more than tripled since 1990 and have never been higher. l In 2008, more than 36,000 people died from drug overdoses, and most of these deaths were caused by prescription drugs. l Approximately 200 people die each year in San Francisco from unintentional drug overdoses. l

Opioids: Heroin and Rx painkillers

Opioids lď Źâ€Ż

Opiates and opioids are classes of depressant analgesics derived from or chemically similar to substances found in P. somniferum, the opium poppy. They include both naturally occurring and synthetic substances.

Effects of Opioids l l l l l

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Pain relief, euphoria Itchiness Dryness of the mouth Sedation Respiratory Depression Nausea/Vomiting Sweating Constipation

Opioids: Heroin l l

Schedule I Chemical Name: Diacetylmorphine

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History l

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Heroin was isolated from morphine in 1874 It was thought to be the cure for morphine addiction In 1914 the Harrison Narcotic Act banned the importation of Heroin into the United States

Opioids: Black Tar Heroin l

Blackish brown sticky tar

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Can be injected, snorted, smoked

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Black Tar Heroin is notorious for carrying harmful bacteria and virii. Staph infections and necrotizing fasciitis, abscesses, collapsed veins, sepsis/shock (from injecting plant material), scar tissue, etc are all much more common with BTH than powder.

Opioids: Heroin l

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Comes in the corners of sandwich baggies or fingers of gloves, condoms, etc.

Wholesale (Kilo): $10,000 Ounce (24 grams): $300$700 Gram: $40 Approx. ½ gram (.4 gram): $20 1&1 (coke and heroin): $20 (Prices are approximate, and change often)

Strong opioids l

Fentanyl*; hydromorphone** Actiq®, Fentora®, Onsolis®,Duragesic®; Dilaudid®, Palladone®

Moderate strength opioids l

Hydrocodone; oxycodone; oxymorphone, morphine; codeine; methadone* Vicodin®, Lortab®, Lorcet®; OxyContin®, Percocet®, Percodan®, Tylox®, Combunox®;Opana®; Embeda®, Kadian®, Avinza®, MS Contin®; Norco®, Tylenol-3®,

Weak opioids l

Tramadol; pentazocine; propoxyphene; buprenorphine; meperidine Ultram®, Ultracet®; Talwin®; Darvocet®, Darvon®; Subutex®, Suboxone®; Demerol® * synthetic ** semi-synthetic

Opioids: Fentanyl • 100 times more potent than morphine • Introduced in the 1960s as an IV anesthetic, Sublimaze.

Commonly used in surgeries.

• Duragesic: Fentanyl skin patch used to manage chronic pain.

• Actiq: Lollipop for pain • Overall biologic effects indistinguishable from heroin, except that Fentanyl has superior potency [from 80 to 100x

Opioids: Codeine l

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Most widely used naturally occurring narcotic in medical treatment worldwide Prescribed for mild pain relief, cough suppression [eg.

Wisdom teeth, back pain, etc].

Codeine is base material for both dihydrocodeine and hydrocodone (Vicodin) Promethazine-codeine or hydrocodone cough syrup (antihistamine+opioid) widely prescribed and used recreationally Purple drank, Purple Tonic, Sip-Sip, Lean, mixed with Sprite

Opioids: Hydrocodone l l

Semi-synthetic opioid Most prescribed drug in the US. 131 million prescriptions in 2010.

Opioids: Oxycodone l

Oxycodone Hydrochloride l

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Oxycodone/Acetaminophen l

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Percocet, Roxicet, Endocet, Tylox

Oxycodone/Aspirin l

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Oxycontin, Roxicodone, Endocodone, Oxyfast

Percodan, Roxiprin

Oxycodone/Ibuprofen l

Combunox

Oxycontin (oxycodone)

The NEW OxyContin

Opioids: Morphine, hyrdromorphone, oxymorphone l l l

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Kadian (morphine) Oramorph (morphine) MSContin (morphine sulfate) Dilaudid (hydromorphone)

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Opana (oxymorphone) Numorphan (oxymorphone)

Opioids: Methadone l

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Methadone (Symoron, Dolophine, Methadose, Heptadon, etc.) is a synthetic opioid, used medically to treat pain, or as an opioid replacement therapy.

Full agonist It was developed in Germany in 1937.

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Methadone is eliminated from the body at a slower rate than many other opioids.

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Although chemically unlike morphine or heroin, methadone also acts on the opioid receptors and thus produces many of the same effects

Methadone continued l

A proper dose used in methadone maintenance therapy will block or greatly reduce cravings for illicit opioids, while not inducing any euphoric feelings or other sense of being high, and if dose is high enough, will actively prevent the patient from experiencing any high if they do use other opioids.

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In 2004, SAMHSA reported that the increase in methadone-deaths did not appear to stem from the liquid issued by methadone treatment center, but instead from an increase in solid tablets or diskettes used to treat pain

Rx Opioid costs Depends, pills can sell from around $.10 per milligram up to about $1 per milligram or more (OCs). l For example, a 80mg OC is currently selling for about $80-100, where you could get a 10/325 Norco (hydrocodone/aceteminophen) for $4, $.40 per milligram. l Access, demand, knowledge of quality l

Depressants, Sedatives and Hypnotics Non-opioid

Benzodiazipines l

Schedule 4

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The first benzodiazepine, chlordiazepoxide (Librium), was discovered accidentally

by Leo Sternbach in 1955, and made available in 1960

by Hoffmann–La Roche, which has also marketed diazepam (Valium) since 1963.

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Benzos have sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, muscle relaxant properties.

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These properties make benzodiazepines useful in treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol withdrawal.

The Benzo Family Most Commonly Used: l (Klonopin) Clonazepam l (Xanax) Alprazolam l (Valium) Diazepam l (Ativan) Lorazepam Less Commonly Used: l Oxazepam (Serax) l Prazpam (Centrax) l Halazepam (Paxipam) l Clorazepate (Azene, Tranxene) l Chlordiazepoxide (Librax, Librium) l Halcion (Triazolam) l

Sold for about $1-2 per milligram

Benzos

Risks l Cause heavy sedation, memory loss l Overdose, especially when mixed with opioids and/or alcohol l Aggression, impulsivity, irritability

Benefits: l Treat symptoms of anxiety, panic disorder l Enhance the effects of heroin, alcohol, and/or l Physical dependence, marijuana withdrawal that can be l Stimulant users often take benzos when over-amping on dangerous speed or coke, or after to come down. l Ease withdrawal from opiates l Benzos are easy to obtain & cheap

Muscle Relaxers & Sleep Aids l

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Somas and Flexeril are the most common and available muscle relaxers Ambien and Lunesta are common sleep aids All have sedative effects that are manageable when taken in correct dosage.

When mixed with other CNS depressants or alcohol, can be dangerous About $1-5 per pill

Stimulants

Stimulants l

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Class of drug that has historically been used to treat asthma and other respiratory problems, obesity, neurological disorders, and a variety of other ailments.

Prescribed for the treatment narcolepsy, ADHD, and depression that has not responded to other treatments.

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Stimulants increase alertness, attention, and energy, as well as elevate blood pressure, increase heart rate and respiration, constrict blood vessels, increase blood glucose, and open up the pathways of the respiratory system.

Benefits: l

Increased alertness and energy

Cocaine Risks:

Feelings of intense pleasure, well-being and euphoria

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Heart arrhythmia

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Nasal, throat or lung damage

Feelings of competence and superiority

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Depression and anxiety

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Self-confidence

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Sociability

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High blood pressure Constriction of blood vessels Elevated body temp

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Heightened sexual arousal

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Paranoid or violent behavior

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Hallucinations

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Loss of appetite

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Decreased sex drive

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Headaches

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Insomnia

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Heart Attack, Stroke, Seizure

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Powder Cocaine Typical Cuts: l

Levamisole (veterinary antiparasitic)

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Corn starch

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Vitamin C powder

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Sugar

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Talcum powder

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Baby milk powder

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Local anesthetic (Rocaine)

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Other amphetamines

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White to off white in color

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Powder, Flake, or Rock (not crack, but compressed powder)

Price/quantity l Bump (20-30 bumps to a gram) l Lines, about a 1/10 of a gram l Around $40-50 a gram (compared to $60-80 in NYC!) l Around $75-125 for a Teener (1.75g or 1/16th of an oz) l $120-180 for an 8-ball (1/8 of an ounce) compared to about $150-250 in NYC.

Crack l

Crack is usually made by mixing two parts of cocaine hydrochloride with one part baking soda in about 20ml of water.

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White to tan in color Rock-like substance Waxy appearance

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Small rock $5-10 $10 to $20 per 1/4 gram Medium size block ($50) Sugar cookie ($900)

Crack

Amphetamines l l

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Schedule 2 Amphetamines Synthesized in 1887 in Germany as synthetic form of ephedrine Methamphetamine synthesized in 1893 in Japan 1930s - 1950s l Primary ingredient in the Benzedrine inhaler l Treatment for narcolepsy l Used to keep soldiers alert during combat l Widely used as diet pills By 1970, 10 billion amphetamine pills were produced in the US per year in 1954 methylphenidate (Ritalin) was synthesized

Ritalin (Methylphenidate) and Adderall (Amphetamine) l

Ritalin and Adderall are central nervous system (CNS) stimulants.

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Researches speculate that Ritalin and Adderall amplify the release of dopamine thereby improving attention and focus in individuals who have dopamine signals that are weak such as people with ADHD.

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Ritalin 10 mg

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Adderall 10 mg

Ritalin/Adderall Benefits: l Wakefulness l Increased focus/attentiveness l Euphoria l Appetite suppression Risks: l Increased blood pressure, heart rate l Crashing: extreme fatigue, insomnia, irritability, and depression l Psychosis l Heart attack, seizure, stroke

Methamphetamine: Crystal Meth, Speed, Tina, Crank l

Schedule 2

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Can be produced in small meth labs, using a variety of recipes, for example Red, White and Blue: red phosphorus, pseudoephedrine or ephedrine (white), and iodine (which is technically a purple color in elemental form

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Can look like clear shards of glass, or off whitish powder

Crystal Meth/Speed Benefits: l Increased alertness and energy l

Feelings of intense pleasure, well-being and euphoria

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Feelings of competence and superiority

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Self-confidence

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Sociability

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Heightened sexual arousal

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Intense focus

Risks: l Insomnia, restlessness l Paranoid psychosis l Hallucinations l Violent & aggressive behavior l Weight loss, reduced appetite l Increased heart rate l Increased blood pressure l Fatal overdose is possible, but not common

Crystal Meth/Speed l

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Causes rapid heart rate, although not usually accompanied by arrhythmia (irregular heartbeat).

Compared with cocaine use, speed causes fewer heart, pulmonary, and circulatory problems.

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Drug-induced psychoses in speed users are likely to last longer than those of cocaine users Speed users are more likely to appear in the ER as a result of trauma from fighting, firearm or motor vehicle accidents than for physical complaints.

Miscellaneous Drugs

Phenergan (Promethazine) l l

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Promethazine is used to relieve the symptoms of allergic reactions Promethazine is used with other medications to treat anaphylaxis (sudden, severe allergic reactions) and the symptoms of the common cold Promethazine is also used to relax and sedate patients before and after surgery, during labor, and at other times.

Promethazine is also used to prevent and control nausea and vomiting that may occur after surgery, and with other medications to help relieve pain after surgery.

Prescribed off-label for its sedating properties.

Neurontin (Gabapentin) l

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Gabapentin is used to help control certain types of seizures in patients who have epilepsy.

Gabapentin is also used to relieve the pain of postherpetic neuralgia (the burning, stabbing pain or aches that may last for months or years after an attack of shingles).

Gabapentin is in a class of medications called anticonvulsants.

Gabapentin treats seizures by decreasing abnormal excitement in the brain.

Symptoms of overdose may include: double vision slurred speech drowsiness Diarrhea Caution use of antacids, alcohol, hydrocodones, morphine and naproxen when taking Gabapentin because these drugs may decrease the effectiveness of Gabapentin, increasing the risk for a seizure.

Seroquel (Quetiapine) l

Quetiapine is indicated for the treatment of schizophrenia, depressive episodes associated with bipolar disorder, acute manic episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder.

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The most common side effect of quetiapine is drowsiness. Other common side effects include: sluggishness, fatigue, dry mouth, sore throat, dizziness.

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Frequently prescribed off-label for other purposes, including insomnia and the treatment of anxiety disorders.

Clonidine (Catapres) l

Has been prescribed historically as an antihypertensive drug.

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It has found new uses, including treatment of some types of neuropathic pain, opioid detoxification, anesthetic use, and off-label, to counter the side effects of stimulant medications such as methylphenidate or amphetamine.

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It is becoming a more accepted treatment for insomnia, as well as for relief of menopausal symptoms.

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Clonidine has mild sedative properties, but when mixed with other CNS depressants, alcohol or pain relievers can have dangerous effects, including overdose.

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Caution use of MAOIs, beta blockers, acetaminophen/opiate combos, methadone, opiates.

Use of some meds with Clonidine may make Clonidine ineffective and increase risk for high blood pressure, and possible breathing problems.

Overdose Prevention, Recognition, and Response Training

Components of a Training 1.

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What is an overdose?

What causes an overdose?

Prevention messages Recognition Response Aftercare Follow-up and refills

What puts people at risk for ODs? Mixing Drugs l Variation in strength and content of street drugs (purity) l Tolerance changes l Using alone l Physical Health (liver functioning, weight loss, asthma, immune system problems, dehydration, malnutrition, etc.) l

Risk Factors & Prevention Messages

Mixing:

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Use one drug at a time Reduce amounts of everything Don t mix alcohol with heroin/pills If drinking or taking pills with heroin, do heroin first Have a friend with use who knows what you took

Risk Factors & Prevention Messages

Tolerance:

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Use less when sick, or after jail or detox Be aware of your body, physical health impacts tolerance If using after period of not using, go slow Do a tester shot, or go slow Use different method, i.e. snort instead of inject

Risk Factors & Prevention Messages

Quality/Purity:

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Using Alone:

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Do a tester shot Try to use the same dealer Talk to others who copped from same source—share info!

Fix with a friend Leave door unlocked Call someone trusted

Risk Factors and Prevention Messages

Physical Health

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Drink lots of water or other fluids, try to eat

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Avoid pills, especially with Tylenol in them if you have liver damage

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Carry your inhaler if you have asthma, tell your friends where it is, and that you have trouble breathing

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Go slow if you ve been sick, lost weight, or have been feeling under the weather or weak—this can effect your tolerance.

What is a stimulant overdose?

Some users call it overamping when the effects of a stimulant like cocaine (powder), crack or speed become distressing or dangerous. l Can be a problem with the body, or it can be psychological, or both. l Sometimes overamping is considered part of the high for some users, not always negative. l

Can it be fatal or harmful?

Yes. It is more likely that cocaine will cause a fatal overdose than speed though, because cocaine use greatly increases the risk of having a heart attack. l Other serious medical complications from stimulant use include seizure, stroke, and overheating (hyperthermia). l Drug-induced psychosis can result in people putting themselves in dangerous situations, or feeling suicidal. l

Symptoms of a Stimulant OD Physical: l l l l l l l l l l l l l

Nausea and/or Vomiting Falling asleep/passing out (but still breathing) Chest pain or a tightening in the chest High Temperature/sweating profusely, often with chills Fast Heart Rate, Racing pulse Irregular Breathing or shortness of breath Convulsions, or tremors Limb jerking or rigidity Feeling paralyzed but you are awake Severe headache Hypertension (elevated blood pressure) Teeth grinding Insomnia or decreased need for sleep

THESE SYMPTOMS COULD LEAD TO HEART ATTACK, SEIZURE, STROKE, or OVERHEATING

Psychological: l l l

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Extreme Anxiety Panic Extreme Paranoia, Delusions, Hallucinations, Obsessions (Speed Psychosis) Extreme Agitation Increased Aggressiveness Agitation, restlessness, irritability Hypervigilance (being super aware of your environment, sounds, people, etc.)

Enhanced sensory awareness Suspiciousness Suicidal ideation

Prevention Strategies l

A healthy body is the best prevention for overdose.

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Make sure you get your heart checked out, your blood pressure, cholesterol, circulation, etc.

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Having high blood pressure or an irregular heart beat or other types of heart disease can put you at really high risk for a heart attack, especially when you when you smoke, shoot or snort coke because it puts a lot of stress on your heart

If you re on medication for high blood pressure, make sure you take it, if you re diabetic, make sure you try to manage your diabetes, try to eat, sleep and drink fluids even on a run.

How to respond to a Stimulant OD? First, figure out what is needed, medical assistance, or support and rest? l There is no antidote to a stimulant OD, like Naloxone. l A stimulant OD can result in serious medical emergencies like seizure, stroke, overheating or heart attack. l If the problem is primarily with the body, these are some important things you can do. l

Strokes The symptoms of stroke are distinct because they happen quickly: l

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Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body) Sudden confusion, trouble speaking or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause

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Strokes are caused by a blood clot that blocks or plugs a blood vessel or artery in the brain or a blood vessel in the brain that breaks and bleeds into the brain.

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If you believe someone is having a stroke – if he or she suddenly loses the ability to speak, or move an arm or leg on one side, or experiences facial paralysis on one side – call 911 immediately.

Seizures: l

The brain is full of electrical activity. It is how the brain talks to the rest of the body.

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If there is abnormal or excess electrical activity in a part of the brain it can cause a misfire and result in a seizure or convulsion.

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Seizures fall into two general groups: general and partial. A partial seizure affects small parts of the brain. A general seizure affects the whole brain and can cause loss of consciousness and/ or convulsions. This is the type that most people think of when the word seizure is mentioned.

Some typical symptoms of a general seizure are: l Drooling or frothing at the mouth l Grunting and snorting l Tingling or twitching in one part of the body l Loss of bladder or bowel control l Sudden falling l Loss of consciousness l Temporary absence of breathing l Entire body stiffening l Uncontrollable muscle spasms with twitching and jerking limbs l Head or eye deviation (fixed in one direction) l Aura before the seizure which may be described as sudden fear or anxiety, a feeling of nausea, change in vision, dizziness, or an obnoxious smell (not as common with drug-related seizures). l Skin color may be very red or bluish.

Seizure continued… l

If someone is having a seizure, make sure there is nothing within reach that could harm them (objects that could fall, furniture they could bump themselves on, etc).

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Do not hold the person down

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Do not put anything in the person's mouth.

Heart Attacks: l

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Even though a heart attack may be related to drugs, it will still look similar to the heart attacks that might not be drug-related.

Keep an eye out for the same symptoms, although sometimes it may be tricky to figure out what is from the drug (sweating, for example) and what may be the signs of a heart attack.

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Things to look out for: l Uncomfortable pressure, fullness, squeezing, or pain in the center of the chest.

These symptoms can range from mild to severe, and they may come and go. l Discomfort in other areas, such as the neck, arms, jaw, back, or stomach. l Shortness of breath, lightheadedness, nausea, or breaking out in a cold sweat

Overheating (hyperthermia): What does it look like? l l

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Hot, dry skin is a typical sign of hyperthermia.

The skin may become red and hot as blood vessels dilate in an attempt to get rid of excess heat, sometimes leading to swollen lips.

The dehydration associated with overheating can produce nausea, vomiting, headaches, and low blood pressure.

Dehydration can lead to fainting or dizziness, especially if the person stands suddenly.

The person may become confused or hostile, and may seem intoxicated.

Overheating can be fatal

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Slow down and stop agitated movements Try to cool down with ice packs, mist and fan techniques.

Make sure they are drinking water or a sports drink with electrolytes so they don t dehydrate.

Place cool, wet cloths under the armpits on back of knees, and/or on the forehead.

Open a window for fresh air.

When the body temperature reaches about 104 F, or if the person is unconscious or showing signs of confusion, hyperthermia is considered a medical emergency CALL 911

Psychological Symptoms: If you are confident that the problem is not medical in nature (seizure, stroke, heart attack, overheating), but you or your friend is experiencing anxiety or other psychological symptoms of overamping there are things you can do as well

Some tips from fellow users: l l l l l l l l l l

Drink water or a sports drink, eat some food Try to sleep Switch how you re doing your speed or coke, sometimes if you re shooting, switching to smoking can help Change your environment or the people you re with Take a benzo (a small, safe dose, like an Ativan or other sedative/hypnotic) Breathing or meditation exercises Physical contact, like massaging yourself or having someone else do it for you Walking, walking, walking—walk it off!

Take a warm shower Get some fresh air

Speed Psychosis Speed Psychosis can consist of a variety of psychological symptoms, including paranoia, delusions, hallucinations and obsessions. l Sometimes speed psychosis can lead to someone becoming a danger to themselves or others. l In some cases, people have checked themselves into Psych ER for help, and in cases they have been sent involuntarily l

Recognizing a Depressant OD REALLY HIGH

OVERDOSE

Muscles become relaxed

Deep snoring or gurgling (death rattle) or wheezing

Speech is slowed/slurred

Blue skin tinge- usually lips and fingertips show first

Sleepy looking

Pale, clammy skin

Will respond to stimulation like yelling, sternum rub, pinching, etc.

Heavy nod, will not respond to stimulation

Nodding out

Breathing is very slow, irregular, or has stopped/faint pulse

If an OD happens‌

Calling 911 Clearly give address or nearest intersection l Keep loud noise in background to a minimum —if it sounds chaotic, they will dispatch police to secure the scene and protect the paramedics l Avoid using words like drugs or overdose— stick to what you see: l

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Not breathing, turning blue, unconscious, nonresponsive, etc.

Recovery Position

Narcan reversing an OD Heroin

Narcan Opioid receptor

Narcan has a stronger a ff i n i t y t o t h e o p i o i d receptors than the heroin, so it knocks the heroin off the receptors for a short time and lets the person breathe again.

Using IM Narcan: Administer one dose (1cc) intramuscularly into the upper arm, thigh or butt l Return to Rescue Breathing l Narcan should work in about 1-3 minutes, if it doesn t work in 3 minutes or so give 2nd dose l Narcan wears off in 20 minutes-1 hour l OD could come back, stay with the person or transfer care to EMS. l

Thank You

Eliza Wheeler DOPE Project Harm Reduction Coalition 510.444.6969 x 16 wheeler@harmreduction.org