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This document has been revised to reflect changes to the Provincial Naloxone Program November 2013

Community-Based Overdose Prevention Education and Naloxone Distribution Resource Document

Resource updated: November 2013

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2012 Ontario Harm Reduction Distribution Program Kingston Community Health Centres 200 Princess Street Kingston, ON K7L 1B2 Tel: 613‐ 544‐9735 or 1‐866‐316‐2217 Fax: 613‐544‐1980 or 1‐866‐316‐2218 Website: www.ohrdp.ca

This resource document builds on the program developed by The Works, Toronto Public Health, in particular Shaun Hopkins and Chantel Marshall, and The Waterloo Region Crime Prevention Council and Preventing Overdose Waterloo Wellington (POWW), in particular Michael Parkinson. Their commitment

and contribution to spearheading

overdose prevention within their regions are greatly appreciated.

This document was originally written and compiled by Meghan O’Leary, OHRDP and Funding for this resource document was provided by the Ontario Ministry of Health and Long Term Care. Views

reviewed by: Nadia Zurba, Program Manager, OHRDP, Kingston Community Health Centres

herein do not necessarily represent

Ron Shore, Director, OHRDP, Kingston Community

those of the Ministry.

Health Centres Dr. Kieran Moore, MD, CCFP(EM), FCFP, MPH, DTM&H, FRCPC, Associate Medical Officer of Health, KFL &A Public Health Dr. Meredith MacKenzie, MD, BSc, CCFP, FCFP

A downloadable PDF version of this document is available at www.ohrdp.ca and hard copies available by request to OHRDP. Permission is granted to copy,

This document was revised in November 2013 by: Despina Tzemis, Health Promoter, OHRDP Nadia Zurba, Program Manager, OHRDP

modify and rebrand this work for educational, non‐profit use.

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Graphic layout and design by Diana Tovilla.

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Table of Contents The Context / Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Section 1: The Ontario Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Opioid Overdose in Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Accidental Overdoses are Preventable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Provincial Initiative: Supporting Opioid Overdose Prevention. . . . . . . . . . . . . . . . . . . . 12 Community�Based Naloxone Programs: Successfully Saving Lives . . . . . . . . . . . . . . . 13 Section1: Appendix of Supporting Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 1. The Point Program Fact Sheet by The Works, Toronto Public Health . . . . 16

Section 2: Overview of Naloxone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Why Dispense Naloxone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 How Naloxone Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Provincial Complimentary Overdose Prevention Kits Content . . . . . . . . . . . . . . . . . . 22 Section2: Appendix of Supporting Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1. Naloxone Product Monograph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2. Naloxone: Question and Answer page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 3. Sample identifier card (for inclusion in the kits) . . . . . . . . . . . . . . . . . . . . . . . . 38 4. Sample Overdose Response Pamphets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

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Section 3: Provincial Opioid Overdose Prevention Training Support Documents Supporting Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 1. Staff Information Poster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 2. Staff Training pamphlet by Preventing Overdose Wellington Waterloo. . . 51 3. Prevent Overdose Poster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 4. Overdose Signs and Symptoms Poster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 5. Opioid Overdose Prevention for Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 6. Drug Categories Poster. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Section 4: Site‐Specific Considerations for Implementing a Community‐Based

Naloxone Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Agency Measures to Help Reduce Opioid Overdoses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Community Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Program Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Supporting Documentation Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Suggested Dispensing Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Overdose Response: Best Practice Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 i. Summary Q and A of Evidence for CPR Best Practices . . . . . . . . . . . . . . . . . . . . 67 ii. Detailed Excerpts of Evidence‐Based CPR Best Practices . . . . . . . . . . . . . . . . . 70 Section 4: Appendix of Supporting Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 1. Sample Medical Directive – Toronto Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 2. Pre ‐ Post Knowledge Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 3. Knowledge Checklist and Order to Dispense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 4. Overdose History Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 5. Evaluation‐ Follow‐up for Naloxone Received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 6. Evaluation ‐ follow‐up for Naloxone Administered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 7. Sample documentation forms-Streetworks, Edmonton . . . . . . . . . . . . . . . . . . . . . . . . 93 8. Canadian Red Cross News Release 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 9. Harm Reduction Coalition-Alert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

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Section 5: Sample Educational Materials and Client Resources . . . . . . . . . . . . . . . . . . . . . . .111 Client Training and Educational Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Section 5: Appendix of Supporting Documents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 1. Naloxone Training Guide: The Point, Toronto Public Health. . . . . . . . . . . . . . . . . 115 2. OASIS Program, Sandy Hill CHC, Ottawa‐ training resources . . . . . . . . . . . . . . . 134 3. Breakaway Addiction Services ‐ Staying Safer When Using Opiates . . . . . . . . 159 4. OHRDP‐ ‘What’s Your Score’ with notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 5. OHRDP – Overdose Quiz and answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

Section 6: Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Resources on Opioid Misuse in Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Web Resources on Overdose Prevention and Naloxone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Film Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Literature Review on Community‐Based Naloxone Programs . . . . . . . . . . . . . . . . . . . . . . . 170 i. Brief Summary of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 ii. Reference List of Publications, Reports, and Supporting Evidence . . . . . . . . . 173 Section 6: Appendix of Supporting Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 1. Opioid Advice: Memo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 2. Opioid Advice: Withdrawal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178 3. Opioid Advice: Switching . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 4. Opioid Advice: Intoxication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 5. Literature Review by Waterloo Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

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Definitions OHRDP: Ontario Harm Reduction Distribution Program OPDP: Ontario Public Drugs Program The terms ‘take‐home’ and ‘community‐based’ Naloxone program are interchangeable terms. Overdose prevention kit and Naloxone kit both refer to ‘the kit’ . Eligible and approved programs received naloxone from the MOHLTC's Provincial Naloxone Program and complimentary supplies from OHRDP.

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The Context

Executive Summary

Death from drug‐related overdose is a leading cause of accidental death in Ontario. Each year in Ontario between 300 and 400 people die from overdose involving prescription opioids, most commonly oxycodone (OPDP Notice, 2012). With the recent removal of OxyContin from the canadian market in early 2012 thousands of people are at greater risk of accidental overdose as they transition to using other substances.

This resource document was developed by the OHRDP to help agencies implement a Naloxone program. In this document you will find:

Complimentary overdose prevention supplies are distributed through the OHRDP. These supplies are for eligible and approved programs only .

In 2013, the Ministry of Health and Long Term Care (MOHLTC), AIDS and Hepatitis C Programs rolled out a Provincial Naloxone Distribution Program. The MOHLTC is working with the Ontario Government Pharmaceutical and Medical Supply Service (OGPMSS) to distribute Naloxone and the Ontario Harm Reduction Distribution Program (OHRDP) to distribute complimentary Naloxone kit supplies to eligible and approved agencies.

Naloxone can reverse the effects of an opioid overdose and helps restore breathing and consciousness – it can help SAVE a LIFE.

Naloxone is injected into a muscle and takes only minutes to work.

An example of a medical directive.

Training programs for Naloxone programs come in all shapes and sizes. Examples from several programs are available in this resource document for your convenience.

If you have any questions or concerns about this document please contact: nadiaz@ohrdp.ca.

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Community‐Based Naloxone Distribution: Resource Document Introduction This resource document provides the broader context and background information to assist harm reduction program staff in establishing their site‐ specific protocol for overdose prevention training and community based naloxone distribution to clients at their program site. It is divided into six main sections: Section 1: The Ontario Context Section 2: Overview of Naloxone Section 3: Provincial Opioid Overdose Prevention Training Support Documents Section 4: Site-Specific Considerations for Implementing a Community‐Based Naloxone Distribution Program Section 5: Sample Educational Materials and Client Resources Section 6: Additional Resources This document is intended to help inform staff as they engage in discussion at their agency and with the wider community about the importance of educating clients on opioid overdose prevention and community based naloxone distribution, in addition to other harm reduction messaging. It is to be referenced by agency staff to support community-based Naloxone distribution programs and provide examples of the supporting documentation needed to ensure the program is implemented in a sustainable and comprehensive way.

It is intended to provide a simple framework and is not meant to be exhaustive as there are other resources that go into further detail about many of the topics covered in this document. It provides a starting point for discussion at the site level and to get staff thinking about the various pieces required to effectively deliver an overdose prevention and Naloxone distribution program at their agency, or within their community. The document was produced by the Ontario Harm Reduction Distribution Program and incorporates a substantial amount of information and program documents developed by The Works, Toronto Public Health and The Waterloo Region Crime Prevention Council and Preventing Overdose Waterloo Wellington (POWW), strong supporters and innovators of harm reduction services in their respective communities. The information provided will better inform harm reduction service providers and health care staff about: •

The Ontario context in regards to opioid overdose

The importance of an opioid overdose prevention initiative

The evidence‐based, health benefits (public and individual) of having Naloxone widely available.

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Section

1:

The Ontario Context

This section covers: • Opioid Overdose in Ontario • Accidental Overdoses are Preventable • Provincial Initiative: Supporting Opioid Overdose Prevention • Community‐Based Naloxone Programs: Successfully Saving Lives • Section 1: Appendix of Supporting Documents 1. The Point Program Fact Sheet, The Works, Toronto Public Health

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Section 1: The Ontario Context Opioid Overdose in Ontario Overdoses and deaths involving prescription opioids are a major public health concern. Death from drug‐related overdose is a leading cause of accidental death in Ontario. Each year in Ontario between 300 and 400 people die from overdose involving prescription opioids, most commonly oxycodone (OPDP, 2012). The Institute for Clinical and Evaluative Sciences (ICES) studies trends in opioid prescription as well as opioid‐related mortality in Ontario. Between 1991 and 2007, prescriptions of oxycodone increased by 850%. Opioid‐related deaths doubled from 13.7 per million in 1991 to 27.2 per million in 2004. The studies also highlight that the addition of long‐acting oxycodone to the drug formulary was associated with a 5‐fold increase in oxycodone‐related mortality and a 41% increase in overall opioid‐related mortality (Dhalla et al, 2009). These detailed studies point to the basic fact that opioid‐related deaths in Ontario are alarmingly high. Between 2002 and 2009, in Toronto alone, there were a total of 229 deaths due to toxic amounts of oxycodone, including OxyContin. These deaths have steadily increased, from 9 in 2003 to a total of 54 in 2009 (Shahin and Hopkins, 2012). Non‐medical use of fentanyl, through injection, has been on the rise in Toronto in recent years and has recently seen a widespread increase across most of the province as a result of the discontinuation of OxyContin (as recorded as antidotal evidence at a front‐line service providers teleconference organized by OHRDP, April 12, 2012). Fentanyl is a very strong opioid pain reliever that is prescribed in skin patches. Preliminary analysis shows that between 2002 and 2009 there were 40 recorded deaths in Toronto attributed to fen-

Section 1: The Ontario Context

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tanyl. Between 2008 and 2009, fentanyl‐related deaths rose 100%, from six to 12 deaths in Toronto (Shahin and Hopkins, 2012). There is concern expressed by harm reduction service providers across the province that the number of fentanyl‐ related overdoses could rise as more people experiment with fentanyl as they find a replacement drug of choice in lieu of OxyContin. These staggering statistics in Ontario demonstrate the immediate need to focus on overdose prevention education and a community‐based Naloxone distribution program as the primary initiatives to reduce the number of opioid drug overdoses in Ontario.

Accidental Overdoses are Preventable An overdose occurs when a person uses more of a drug, or combination of drugs, than the body can handle. As a consequence, the brain is not able to control basic life functions. The person may pass out, stop breathing, have heart failure, or experience seizures.

Anyone can overdose: first time users, long‐ time users, old people, young people, people being released from jail or treatment, etc.

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Risk factors include: •

Mixing drugs (licit and illicit) and alcohol: There is no ex-act formula for determining how much of a certain drug or combination of drugs, will lead to an overdose.

Using alone

Using in an unfamiliar environment

Using after a period of abstinence (including treatment programs and prison); statistically, there is an increased risk of overdose during the first 2 weeks after release from prison (Marshall, 2012).

Switching opioids: from one to another, as the strength and potency varies between each type of opioid. As well, a person’s tolerance also varies among different drugs.

Using without testing first.

Using from an unknown source or a new dealer, as you don’t know what you’re getting.

An individual’s physical characteristics: weight, health, tolerance for a drug, drug potency, route of administration, or frequency/amount of use.

According to the recently released Report of the Toronto and Ottawa Supervised Consumption Assessment Study, 2012, about 65% of respondents who injected with other people reported that they most commonly injected with a close friend and about 30% reported that they most commonly injected with a regular sex partner (Bayoumi and Strike et al., 2012, p.6). In situations where people are using

drugs in the company of others, there is an opportunity to intervene in the case of overdose. Opioid users who do use alone are encouraged to use in the presence of others as part of overdose prevention training. This is increasingly important as people are currently transitioning from OxyContin to other unfamiliar substances, for which they have different tolerance levels, thereby increasing their risk of overdose. Further, the risk of overdose death would also decrease with the availability of Naloxone for a peer or family member to administer. About 1 in 5 people who use drugs in Toronto and Ottawa reported that they had overdosed in the last 6 months (Bayoumi and Strike et al., 2012, p.10).

Therefore, there is an important role for service providers to play in educating people about the risks of overdose, how to reduce those risks, and how Naloxone can help to save a life.

Provincial Initiative: Supporting Opioid Overdose Prevention With OxyContin’s removal from the Canadian market and replacement by a new formulation called OxyNeo, thousands of people are at greater risk of accidental overdose if they transition to using other substances. The provincial government is working to address the negative repercussions from the reduced availability of OxyContin and is committed to working collaboratively to expand harm reduction measures, ensure a coordinated response to meet the needs of people addicted to opioids and ensure access to the supports most needed to reduce harm. Specifically, “the government has devoted new resources to collect real time information on withdrawal, expand access to addiction treatment and deploy emer-

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gency overdose kits across the province, including to First Nation communities” (Honourable Minister Deb Matthews, MOHLTC, The Star, April 6th, 2012). Efforts are underway to coordinate awareness and prevention education messaging on a provincial scale to deal with the impact on people and communities resulting from the reduced availability of OxyContin, with one initiative being overdose prevention training and Naloxone distribution.

This document was one of the recommendations of the Minister’s Expert Working Group on Narcotic Addiction, as was making overdose prevention kits available in the province. In the last week of March, 2012, OHRDP coordinated a webinar series on overdose prevention and Naloxone distribution which was based on the training currently being offered at The Works, Toronto Public Health and through The Waterloo Region Crime Prevention Council and Preventing Overdose Waterloo Wellington (POWW). Training consisted of 3 sessions: 1) Opioid overdose prevention and identification 2) How to develop and operate a community‐ based Naloxone program and

3) Discussion on the legal, liability, and practice issues related to the operation of a Naloxone program. Links to these training sessions remain available on the OHRDP website and are available in hard copy and DVD upon request. OHRDP collaborated with OHTN undertaking an evaluation of the effectiveness of the webinar training sessions as well as determining future training needs and support around opioid overdose prevention. Section 1: The Ontario Context

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Community‐Based Naloxone Programs: Successfully Saving Lives As a public health response to high rates of opioid overdose deaths, community‐based Naloxone programs have been established for years in a handful of countries. In 1995, England and Germany became the first countries to distribute Naloxone to opioid users. As stated in the Drug Misuse and Dependence: UK Guidelines on Clinical Management, 2007 regarding dealing with overdose: “All services working with [people who use drugs] should have an emergency protocol in place that covers the management of drug overdoses. This should include rapid ambulance call and competent preservation of a clear airway, and may include protocols for the emergency administration of interim Naloxone while awaiting the arrival of the ambulance. Suitable resuscitation training and equipment should be available for clinical settings. Naloxone, and staff competent to administer it, may be made available in suitable services working with [people who use drugs]…. There is a need to provide a range of overdose measures to carers of opioid misusers. These might include information, advice and training on avoiding overdose, recognizing the signs of overdose and first aid, and might also include the use of Naloxone” (p.71). In the United States, drug overdose deaths have tripled since 1990. In 2008, there were over 36,000 drug overdose deaths. This actually topped car crashes as the leading cause of accidental deaths. That same year, more than 20,000 people died from a prescription painkiller overdose (CDC, 2012)

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The United States started distributing Naloxone in 1999 and as of 2010, 150 programs in 19 states operate a take‐home Naloxone program. One example, the Chicago Recovery Alliance, has conducted more than 4600 trainings and Naloxone prescriptions resulting in 416 overdose reversals reported between 1999 and 2006 (CDC, 2012). A report by the Centre for Disease Control and Prevention (CDC) on community‐based Naloxone programs in the United States found that these programs help to reduce overdose deaths by giving members of the community the right information, training, and tools. The report concludes that Naloxone could save thousands of lives if public health agencies distributed it more broadly (CDC, 2012). The CDC report summarizes the findings for the 48 programs that completed the survey and the 188 local programs represented by the responses. Since the first opioid overdose prevention program began distributing Naloxone in 1996, the respondent programs reported training and distributing Naloxone to 53,032 persons and receiving reports of 10,171 overdose reversals. Providing opioid overdose education and Naloxone to persons who use drugs and to persons who might be present at an opioid overdose can help reduce opioid overdose mortality, a rapidly growing public health concern (CDC, 2012). Refer to Section 6: Additional Resources in this document for a literature review and an extensive list of publications, reports and evidence on the efficacy and outcomes of community‐based

(take‐home) Naloxone programs. As well, the Naloxone Distribution Programs: A Review of the Literature document is included in Section 6: Appendix and provides a brief summary of the leading take‐home Naloxone programs operating in the United states as well as the Edmonton Streetworks program. It also provides details as to how these programs operate and their various program components. As of early 2012, Edmonton and Toronto are the only cities in Canada with a needle syringe program providing Naloxone kits to their clients in tandem with overdose prevention training. The Point Program at The Works, Toronto Public Health was launched in August 2011 as part of a comprehensive plan to reduce overdose deaths in Toronto, by providing take‐home Naloxone kits to people who use opioids, who have received training. People who use opioids are trained by nurses at Toronto Public Health. Once the client is deemed qualified to administer Naloxone, they are provided with an overdose prevention kit. The Works has developed an extensive policies and procedures manual for Naloxone training including; a prescription process, criteria for dispensing to clients, a Naloxone training program for clients, and staff/nurse training. As well, they have developed educational materials and training materials for clients/peers and staff. The Point Program Fact Sheet outlines the program and is included in the Appendix at the end of this section.

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Section 1: Appendix

The supporting documents referenced in this section include: 1. The Point Program Fact Sheet by The Works, Toronto Public Health

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The Point Program Fact Sheet by The Works, Toronto Public Health

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Section

2:

Overview of Naloxone

This section covers: • Why Dispense Naloxone • How Naloxone Works • Provincial Complimentary Overdose Prevention Kits Content • Section 2: Appendix of Supporting Documents 1.Naloxone Product Monograph 2.Naloxone: Question and Answer page 3. Sample identifier card (for inclusion in the kits) 4. Sample Overdose Response Pamphlets (for inclusion in the kits)

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Section 2: Overview of Naloxone Naloxone is indicated for the complete or partial reversal of opioid overdose. It reverses the effects of opioids including respiratory depression, sedation, and hypotension. It is a very effective antidote to opioid overdose with the added benefit of having little or no risks when given as described in the overdose prevention kits. It has not been shown to produce tolerance or cause physical or psychological dependence (Product Monograph, 2005).

In Canada, Naloxone is a prescription drug that can be administered intramuscularly, intravenously or subcutaneously and is most commonly administered by paramedics in an emergency situation or in a hospital setting. In hospitals throughout Canada, it can be used to rouse patients from opiate over‐ sedation. As well, emergency medical services (EMS) are trained to use Naloxone in opioid overdose situations and it is a staple in emergency medical kits. •

The average cost of 1 ampoule is $11.20 (hospital cost in 2012).

Why Dispense Naloxone •

Naloxone is a crucial intervention that can help SAVE A LIFE.

Naloxone is injected into a muscle and takes only minutes (usually 2-3 minutes) to work.

Naloxone stops an opioid overdose and helps restore regular breathing and consciousness. Once injected, Naloxone can reverse an overdose as quickly as under a minute. Since Naloxone is an opiate antagonist, it is not effective to stop an overdose from cocaine, alcohol, or benzodiazepines. A copy of the Product Monograph for Section 2: Overview of Naloxone

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Naloxone can be found in the Appendix at the end of this Section. As noted in Ontario studies (Bayoumi and Strike et al., 2012, and I‐track survey results), overdose commonly occurs in the user’s home and in the company of others. Although emergency medical staff are trained to administer Naloxone in the case of opioid overdose, these trained medical staff are not always called to respond to overdose or it can be too late by the time help arrives. There is a critical period of time when an intervention can take place to reverse overdose if the people present have access to Naloxone and are trained on how to administer it. Therefore, the Province is supporting the dispensing of Naloxone to people who use opioids as well as their family and friends, in tandem with training on opioid overdose prevention and how to administer the life‐ saving drug.

How Naloxone Works Naloxone is only effective with opioids. Naloxone works by displacing opioids from their receptor sites. It binds to the same receptors in the brain that opioids do. However, Naloxone binds more effectively to these receptors and temporarily removes the opioids and their harmful effects. Naloxone can reverse the effects of overdose if used within a short period following an opioid overdose. Once administered intramuscularly it starts to work in approximately 1 to 3 minutes. Since Naloxone only temporarily removes the opioids from the receptor sites in the brain, the opioids will return back to these receptors and the overdose symptoms can return. Therefore, it is still critical to call 911 before administering Naloxone outside of a medical or hospital setting (Marshall, 2012). Note that the half‐life of Naloxone Hydrochloride 21 12-07-10 6:22 PM


S2

is shorter than most opioid drugs so repeat doses may be required. It is important to remember the half‐life of Naloxone is much shorter than methadone and other opioids. Naloxone produces withdrawal symptoms when administered in an opioid‐dependent person, therefore discouraging misuse. The only contraindication to receiving Naloxone would be previous hypersensitivity. A Question and Answer page with more information answering common questions about Naloxone is included as an Appendix at the end of this Section.

Provincial Complimentary Overdose Prevention Kit Supplies The complimentary kit supplies are an additional harm reduction supply item that complements the existing inventory of products already available and being distributed by the OHRDP. Only eligible and approved programs can order these complimentary overdose prevention kit supplies from the OHRDP.

Existing programs use complimentary supplies which include: •

2 retractable syringes: 1cc ‐ 25G x1”

2 alcohol swabs

Non‐latex gloves

Rescue breathing barrier (for agencies that recommend rescue breathing) •

Client identifier card

Overdose Response pamphlet

Samples of the client identifier card and Overdose Response: pamphlets are included in Section 2: Appendix of Supporting Documents. The components of the kit will be shipped to the agency and it is the responsibility of agency staff to assemble the kits and ensure that agency contact information is provided to clients. It is recommended to indicate agency contact info on the identifier card and overdose response steps pamphlet.

Each agency has the ability to customize the kit beyond what is supplied through OHRDP to ensure that the kit reflects agency and community need. The kit contents are also dependent on an agency’s own policies and procedures.

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Section 2: Appendix

The supporting documents referenced in this section include: 1. Product Monograph: Naloxone Hydrochloride 2. Naloxone: Question and Answer page 3. Sample client identifier card (for inclusion in kits) 4. Sample Response pamphlets

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Product Monograph: Naloxone Hydrochloride

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Naloxone: Question and Answer page

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Sample client identifier card (for inclusion in kits)

    This is to acknowledge that: 

    This is to acknowledge that: 

 ___________________________________________ 

 ___________________________________________ 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    Issued:  ____ / _____    Naloxone Expires:  _____  / _____      Issued:  ____ / _____    Naloxone Expires:  _____  / _____     MM       YY                                             MM        YY     MM       YY                                             MM        YY 

    This is to acknowledge that: 

    This is to acknowledge that: 

 ___________________________________________ 

 ___________________________________________ 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    Issued:  ____ / _____    Naloxone Expires:  _____  / _____      Issued:  ____ / _____    Naloxone Expires:  _____  / _____     MM       YY                                             MM        YY     MM       YY                                             MM        YY 

    This is to acknowledge that: 

    This is to acknowledge that: 

 ___________________________________________ 

 ___________________________________________ 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    Issued:  ____ / _____    Naloxone Expires:  _____  / _____      Issued:  ____ / _____    Naloxone Expires:  _____  / _____     MM       YY                                             MM        YY     MM       YY                                             MM        YY 

    This is to acknowledge that: 

    This is to acknowledge that: 

 ___________________________________________ 

 ___________________________________________ 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    Issued:  ____ / _____    Naloxone Expires:  _____  / _____      Issued:  ____ / _____    Naloxone Expires:  _____  / _____     MM       YY                                             MM        YY     MM       YY                                             MM        YY 

    This is to acknowledge that: 

    This is to acknowledge that: 

 ___________________________________________ 

 ___________________________________________ 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    has been trained in prevention and response       to opioid overdose, including administration      of naloxone. 

    Issued:  ____ / _____    Naloxone Expires:  _____  / _____      Issued:  ____ / _____    Naloxone Expires:  _____  / _____     MM       YY                                             MM        YY     MM       YY                                             MM        YY 

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Sample Response pamphlets

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Section

3:

Provincial Opioid Overdose Prevention Training Supporting Documents

This section covers: • Supporting Documents 1. Staff Information Poster 2. Staff Training pamphlet by Preventing Overdose Wellington Waterloo 3. Prevent Overdose Poster 4. Overdose Signs and Symptoms Poster 5. Opioid Overdose Prevention for Staff 6. Drug Categories Poster

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Section 3: Supporting Documents

The supporting documents referenced in this section include: 1. Staff Information Poster 2. Staff Training pamphlet by Preventing Overdose Wellington Waterloo 3. Prevent Overdose Poster 4. Overdose Signs and Symptoms Poster 5. Opioid Overdose Prevention for Staff 6. Drug Categories Poster

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Staff Information Poster

OVERDOSE PREVENTION Education and Naloxone can save a life

In Ontario, between 300 to 400 people die every year from overdose involving prescription opioids- most commonly oxycodone. Do your clients use opioids like OxyContin, OxyNeo, heroin, Hydromorphine, Fentanyl, Dilaudid? • If so, they are at risk of overdose

What can you do? •

Ask about staff training on opioid overdose prevention and Naloxone so that you can educate clients and help make overdose prevention kits available at your program site. OHRDP has a few resources to help with implemation of your agency

1-866-316-2217

info@ohrdp.ca

Overdose prevention complimentary kit supplies are available to eligible and approved programs.

ontario harm reduction distribution program

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Debriefing and Self-Care – discussion on how to take care of self both before and after a traumatic event.

A step-by-step guide to responding to an overdose.

Signs and symptoms of overdose relating to depressants and stimulants.

Preventing overdoses and reducing the risk factors

Overview of harm reduction strategies

Overview of factors that will influence the use of drugs and the patterns of drug use.

Overview of the influence of depressant, stimulants and hallucinogenics

Topics include:

Each 3 hour workshop includes films, presentation and discussion.

Overdose Prevention & Intervention Training

“Saving Lives: Overdose Intervention and Prevention Projects in Select North American Cities” (2008)

Naloxone Distribution Programs: A Review of the Literature (2010)

Harm Reduction Coalition Overdose http://www.harmreduction.org

Streetworks in Edmonton: http://www.streetworks.ca

Overdose Prevention Alliance http://overdoseprevention.blogspot.com/

Web Resources

By request from POWW:

“A First Portrait of Drug-Related Overdoses in Waterloo Region” (2008)

Local Resources: Available at www.preventingcrime.ca

Toll Free: 1-866-448-1603 x 221 Email: stpeterh@cmhagrb.on.ca

For information about Overdose Training please contact POWW (Preventing Overdose Waterloo Wellington) at:

Saving Lives, Preventing Harm

Preventing Overdose Waterloo Wellington

• v. / ˈōvәrˌdōs; ˌōvәrˈdōs/ [intr.] take an overdose of a drug: he was admitted to the hospital after overdosing on opiates.

• n. / ˈōvәrˌdōs/ an excessive and dangerous dose of a drug or drugs: she took an overdose of alcohol.

o·ver·dose

Overdoses

An Opportunity to Prevent Drug-Related

Staff Training pamphlet by Preventing Overdose Wellington Waterloo

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In Ontario in 2006, opiod deaths from overdose were equal to the number of drivers killed in motorvehicle collisions.

Overdose is the second leading cause of death in the U.S.A.

For each person who dies of an overdose, an average of 30 people have overdosed but did not die.

From 2004-2008, local hospitals treated 2,670 overdose incidents.

Many overdoses are not reported.

In 2006, at least 28 people died of an overdose in Waterloo Region.

60 per cent of people who die from a drug related overdose are men.

60 per cent of people seen at the hospital for an overdose incident are women between the ages of 11-24.

In Waterloo Region…

An overdose occurs when the dose of a drug or a combination of drugs is so toxic that the body cannot manage. Serious injury or death can result.

Overdose Facts…

Overdose prevention and intervention programs do exist in the U.S.A. where overdose deaths exceed automobile collisions.

We pay honourariums to trainers but have no source of funding.

Participants- both people who use drugs and service providersconsistently rate the usefulness and applicability of the training very high.

Space and logistical arrangements are the responsibility of the host.

Each session is limited to a maximum of 25 participants.

Included in the fee is a 3 hour training session with take home materials and workbook.

Two trainers: $325 Three trainers: $400

A period of abstinence (e.g. after detox, rehab, prison etc.) places a person at a greater risk of an overdose.

Alcohol, cocaine, opiates and psychotropic drugs such as benzodiazepines are some drugs that can lead to an overdose.

The use of Narcan (Naloxone) is effective in opiate overdoses. Like an epi-pen used for allergies, effective overdose programs provide Narcan (Naloxone).

Combining service providers and persons with lived experience is an effective training model to reduce death and prevent overdose -related injuries.

People who use drugs are interested in and capable of saving lives.

Waterloo region is the 2nd community in Canada to offer O.D. training.

The leading cause of death among people who use drugs is overdose. The majority of these deaths are preventable.

POWW’s first priority is to provide training to those who need it, regardless of ability to provide funds.

We encourage those with the means to consider meeting or exceeding the following fee schedule.

Prevention & Intervention Opportunities…

Overdose Training: Fee For Service


OHRDPmanualprinting.indd 59

Be careful when switching drugs

Don’t Use Alone

Prevent Overdose

Mixing your drugs is dangerous

Know Your Drugs

Be aware of changes in your tolerance

ontario harm reduction distribution program

Prevent Overdose Poster

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Overdose Signs and Symptoms Poster

Opioid Overdose Signs And Symptoms Don’t use alone

• Breathing will be slow or gone

• Lips and nails are blue

• Person may be choking

• Person is not moving

• You can hear gurgling sounds or snoring

• Skin feels cold and clammy

• Can’t be woken up

s

• Pupils are tiny

ontario harm reduction distribution program

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Opioid Overdose Prevention for Staff

OVERDOSE PREVENTION: MIXING DRUGS IS DANGEROUS:

{

• Most opioid overdose deaths in Ontario involve mixing other depressants such as Benzos and alcohol

• Benzos stay in system for days and can still cause problems if drugs are used even a few days later

Be careful when switching drugs

• Some drugs (heroin) are cut with contaminants and vary in potency.

Other drugs (pills) can be tampered with. It is difficult to ensure you are getting what you pay for.

• Most cocaine and crack in Canada has been contaminated with Levamisole.

KNOW YOUR DRUGS:

Levamisole can cause immune system problems which can lead to death.

Talk to your health care provider or harm reduction service about signs and symptoms of Levamisole poisoning.

• Do you know your dealer? Has your dealer changed? Is it a new supply? Are you trying a new opioid? Test a small amount first (you can always take more).

BE AWARE OF CHANGES IN YOUR TOLERANCE:

DON’T USE ALONE:

{ {

• Fentanyl is a highly concentrated opioid. When you cut up a fentanyl patch it is difficult to determine how much drug is in that piece.

• When you use opioids regularly, your body develops tolerance to the drug and you need more to get the same effect.

• You can lose your tolerance. If you haven’t used in a while or have been in treatment, or in jail, using the same amounts as before can kill you.

• Your tolerance can also change depending on many things like your weight, recent illnesses, stress, liver health or infections.

• Even if you’ve been using for 20 years, you can still overdose

If you know your tolerance is lower because of any of the above, use

smaller amounts so you don’t overdose. You can always add more if needed.

• If you’re alone and you overdose there is no one who can help you. You won’t be able to call the ambulance and you might die.

• Use with a friend (separate works), leave your door unlocked, or call

someone to let them know you are going to use so they can check on you.

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Drug Categories Poster

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Section

4: Site‐Specific Considerations for Implementing a Community‐ Based Naloxone Program

This section covers: • Agency Measures to Help Reduce Opioid Overdoses • Community Engagement • Program Policies and Procedures • Supporting Documentation Forms • Suggested Dispensing Procedures • Overdose response: Best Practice Recommendations • Summary Q and A of Evidence of CPR Best Practice • Detailed Excerpts of Evidence‐Based CPR Best Practice • Section 4: Appendix of Supporting Documents 1. Sample Medical Directive – Toronto Public Health 2. Pre ‐ Post Knowledge Test 3. Knowledge Checklist and Order to Dispense 4. Overdose History Form 5. Evaluation‐ Follow‐up for Naloxone Received 6. Evaluation ‐ Follow‐up for Naloxone Administered 7. Sample Documentation Forms-Streetworks, Edmonton 8. Canadian Red Cross News Release 2010 9. Harm Reduction Coalition-Alert

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Section 4: Site‐Specific Considerations for Implementing a Community‐ Based Naloxone Program

The purpose of the following section it to provide suggested considerations and guidelines that aim to promote a consistent standard of service, support and training pertaining to naloxone distribution to people who use opioids. For the introduction and implementation of take‐ home Naloxone at a harm reduction program, there are four key elements that should be addressed to effectively implement and deliver a community‐ based Naloxone program: 1. Community engagement and partnership building 2. The development of site specific protocols, procedures, and medical directives that address responsibilities and procedures in order to train and support clients and dispense Naloxone. 3. Development of standardized documentation forms for information collection and program monitoring, integral to program accountability. 4. Appropriate training for staff, as well as clients who will be administering Naloxone, around opioid overdose prevention and Naloxone. Discussing and working through these four pieces at your agency is a large part of implementing the program at your site, and will help prepare staff to deliver the program. By adopting a comprehensive approach to overdose management agencies can help reduce risk of overdose amongst clients. The following measures are starting points for discussion amongst agency staff.

Agency Measures to Help Reduce Opiate Overdoses Assessing a client’s risk of overdose and level of risk behaviour and practices is an important step in reducing the risk of death due to overdose. It also provides an opportunity to introduce appropriate harm reduction resources and education to reduce a client’s risk of overdose. Agencies can further reduce risk of death by adopting a comprehensive approach to overdose management. The following measures could be discussed amongst agency staff to help reduce drug‐related fatalities.

Development of an overdose policy and procedure The organization should develop and practice an overdose policy and procedure. This could include; who takes responsibility for key actions – client care, contacting emergency services, building management etc. It could also detail what actions will need to be taken during and after any incidents. Once in place all staff need to be trained in the policy and it should be reviewed and tested periodically.

Site safety The agency building should be risk‐assessed in terms of overdose and client safety, considering issues such as; do doors open outwards and can washrooms locks be over‐ridden from outside; could a casualty become wedged and immovable in washrooms; is there a telephone easily accessible in a public space; are First‐Aid kits and resuscitation shields available and in full

Section 4: Suggested Guidelines: Site‐Specific Considerations for Implementing a Community‐Based Naloxone Program

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S4 working order. At the agency level, policies should be discussed about clients possibly using on‐site (e.g. Are there bio bins in the washroom? Does this pose an issue for staff safety?).

Adoption of an effective drug policy A community or regional drug policy should make it clear that residents will not get in to trouble for seeking help in the event of overdose. “Zero tolerance” policies (either on‐site or in the community) or those that involve police in all episodes may deter people from seeking help in the event of trouble. Policies that force use off‐site may increase risk of undetected overdose. Policies should not discourage people having a friend present when they are using. Toronto and Waterloo both have thorough examples of community drug strategies that encompass a harm reduction philosophy and are available on‐line.

Training Staff should have training on identifying and responding to overdose. This includes training staff on administering and distributing Naloxone and preparing them to train clients on how to use Naloxone in an opioid overdose situation.

dose policies and procedures at your agency. Emergency services should be aware of the agency’s Naloxone distribution program so that there is a better understanding of what the program’s intentions are, the availability of training and also so EMS staff can be aware of what the overdose preventing kits look like so that they do not confiscate them from clients who have received training to use Naloxone, if needed. A named contact within each service can help ensure good communication and post‐incident review.

Access to coordinated care Pathways should be in place to assist and facilitate with referrals to drug treatment, mental health services, or other social or health care supports to ensure that a client’s needs are being met and that they are receiving comprehensive, multi‐disciplinary care from the most appropriate service provider or health care professional. Disclaimer: this tool is for guidance only and does not guarantee to identify all risk taking behaviour. No liability can be taken for a failure on the part of this tool to anticipate overdose. Source: Content adapted from Kevin Flemen’s Hostel Opiate Overdose Risk Assessment Tool (HOORAT), used with permission. http://www. kfx.org.uk/resources/HOORAT%20‐%20v1.pdf

Working collaboratively with emergency services and police Discussion with police and ambulance services should take place to contribute to a community drug strategy and also to discuss the over-

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Community Engagement It can be effective to organize a meeting with community partners so that related services and organizations are aware of the availability of overdose training for clients and especially overdose prevention kits. The benefit is two‐fold; more at‐risk people could hear about the program and benefit from accessing training and an overdose prevention kit and also foster a better sense of understanding as to what the program is all about. For example, by meeting with law enforcement and police, they gain an understanding for the importance of training opioid users on overdose prevention, they can critically review how they address situations when they respond to drug overdose calls, and also making them aware of the usefulness of Naloxone and being able to recognize an overdose prevention kit and not confiscate it from people. Identify Community Partners: Understanding who is already in support of overdose prevention training and Naloxone distribution and who may have concerns early on is critical. Consider the following list of potential partners and community stakeholders (although this is not an exhaustive list): •

EMS and hospitals

AIDS Service Organizations (ASOs)

Supportive housing, emergency shelters

Corrections staff, release planners, corrections nurses, etc.

Law enforcement/ police

Other local community‐based organizations

Public Health Unit, LHIN staff

Methadone and other drug treatment programs

By contacting and engaging these partners early in the needs assessment process, you will be able to gauge their level of support or resistance to the program, can gain insight into their experiences with people who use drugs in the community and address any concerns that they may have proactively. Also, early inclusion of as many stakeholders as possible may avert unanticipated roadblocks, can strengthen proposals for funding if there is multi‐agency collaboration and will generally result in a more thorough understanding of community needs.

Program Policies and Procedures Each site requires their own medical directives authorizing staff to dispense Naloxone and train clients. It is intended that, under medical directives, staff at harm reduction programs can dispense take‐home overdose prevention kits to clients who have received training from the staff at their agency. Agencies should also discuss and develop an on‐site overdose protocol with staff, if they have not already. As an example to assist in the development of an agency’s own medical directive, Toronto Public Health’s Medical Directive is included in the Appendix at the end of this Section. For more general information on developing medical directives and delegation of authority along with a toolkit and guide to help, visit the Federation of Health Regulatory Colleges of Ontario website at: mdguide.regulatedhealthprofessions.on.ca

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S4 It is up to each program site to decide which program staff positions to include in the medical directive, delegating them to dispense Naloxone to clients. Each agency may also want to establish a process to identify appropriate staff. For example, setting a minimum amount of training required, the need to demonstrate knowledge and key competencies on overdose prevention and Naloxone, etc, before being able to train clients and dispense kits. It may also be valuable for a program to have a train‐the‐trainer component/educational opportunity so that staff can learn from someone who is experienced to train clients and provide overdose prevention kits. Each agency should also define a clear list of dispensing criteria that can easily explain which clients may be able to receive training and a kit. For example, consider the following: •

Has a history or is currently using opioids

Will family and friends of opioid users also be considered?

Willing to take overdose training (which may or may not include first aid and some basic CPR training)

Willing to come back for follow‐up if Naloxone is administered •

No previous hypersensitivity

As part of ongoing program accountability, OHRDP recommends that staff use standard documentation forms to keep track of clients who have received training. A client chart should be started, an intake form should be completed that gathers basic client demographics and some basic background information on drug use history. It should also be documented when clients receive training and going through a ‘knowledge checklist’ with the clients, having them sign it and keeping it in the client file, could be helpful. Other sites have produced a ‘certificate of training’ that is given out upon completion of training. It has been noted that these certificates were well received by clients. It is important to establish a designated system to keep track of the number of clients who have received training and overdose prevention kits, in order to follow‐up with clients as needed. Agencies are encouraged to develop mechanisms to ensure clients return for follow‐up if Naloxone is administered. It is recommended that re‐training clients be considered and that a mechanism be devel-oped to notify trained clients as to when their overdose prevention kits approach the expiry date. As well as keeping client records, keep a separate record of Naloxone being dispensed. The following section provides sample templates of standard documentation forms that could be used to help organize the program.

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Supporting Documentation Forms Supporting documents have been developed by The Works, at Toronto Public Health as well as Streetworks, Edmonton and have been shared for provincial application and can be adapted to suit individual agencies. Staff at harm reduction programs are encouraged to modify these documentation forms to make them site‐specific. It is important to open files for clients who receive training and an overdose prevention kit and to document training and any follow‐up. All the sample templates are available on the OHRDP website and the sample templates listed below are also included in the Appendix at the end of this Section:

Complete the training sheets with the client, going over the information sheets on overdose prevention and the use of Naloxone.

Review the pre and post knowledge test with clients to ensure they have an understanding of how to administer Naloxone and its appropriate use.

Go over the knowledge checklist and order to dispense form with the client. Note the Date of training and date issued an overdose prevention kit.

Pre‐post knowledge test

Knowledge checklist and order to dispense

Explain the components in the overdose prevention kit, using demos of some supplies as examples, if needed.

OD history form

Evaluation‐follow‐up for Naloxone received

Stress the importance of the client coming back to follow‐up in the case of administering or receiving Naloxone.

Evaluation follow‐up for Naloxone administered

Training protocol checklist

Note the expiry date of the Naloxone with the Client. Also note the expiry date in their client folder, as an opportunity to follow‐up.

Suggested Dispensing Procedures These suggested points, below, can be considered for inclusion as part of the dispensing procedures, but it is not an exhaustive list and should reflect an agency’s policies and protocols. •

Collect standard demographic data similar to the agency’s information form/standard intake forms.

Record any relevant health information regarding drug use history and behaviours. Fill in information on the Naloxone history form.

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Overdose Response: Best Practice Recommendations As part of the training on responding to an overdose, some CPR education needs to be provided to clients. Agency decisions around offering full CPR training or simply staff providing some basics to clients will have to be included as part of the medical directives for this program. As well, decisions will need to be made regarding training clients to perform rescue breathing vs. chest compressions when treating an overdose. Therefore, the information compiled on the following pages is intended to help inform the discussions at the agency level around training requirements and what best practices an agency will implement. There currently is debate amongst leading authorities that develop guidelines and training around what the standard of practice should be for CPR. The Questions and Answers highlight the debate. It is important to consider the evidence as decisions will have to be made at the agency level around the extent of first aid and CPR training that will be offered to clients responding to an overdose. This is partly dependent on an agency’s capacities and capabilities and after reviewing the evidence, deciding what is most appropriate for your clients. This decision will impact what information is provided on an agency’s ‘Overdose Response pamphlet which should be included in each overdose prevention kit, (Samples of this pamphlet are included in the Appendix in Section 2).

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Summary Q and A of Evidence for CPR Best Practice The information below is compiled from three main sources; ILCOR, American Heart Association, Canadian Heart and Stroke Foundation.

Q: How does someone die from an opioid overdose? A: The main cause of death resulting from overdoses of opiate type drugs such as heroin, morphine or codeine is ‘depressed’ breathing (slow, shallow breathing which can potentially lead to unconsciousness and subsequent death) which is caused by a lack of oxygen reaching the body. Opioids suppress activity in the brain causing the body to lose its ability to react to the chemical changes (such as harmful levels of carbon dioxide) which would usually trigger the mechanisms responsible for breathing. Depressed breathing can also cause excess fluid in the lungs which is called pulmonary oedema. This can happen either gradually or else so quickly that this in itself can be a direct cause of death (Drug‐Aware, 2012).

Q: How are best practices determined for CPR guidelines in Canada? A: The International Liaison Committee on Resuscitation (ILCOR) is the international body that aggregates evidence based practice and research in order to discuss and determine consensus for the international community around EMS and CPR

best practice. Training organizations are able to pick and choose various pieces from the ILCOR guidelines and Canadian organizations (the 5 main agencies that provide CPR training) work to establish a consensus. These 5 main agencies are; Canadian Heart and Stroke Foundation, Canadian Red Cross, St. John Ambulance, Canadian Ski Patrol, and Lifesaving Society. The 2010 guidelines are based on input from 356 resuscitation experts from 29 countries.

Q: Is there always a Canadian consensus on all aspects of guidelines? A: Currently there is debate around the necessity to do rescue breathing along with chest compressions, as there are new studies and literature that demonstrate a lay person is more likely to attempt CPR on a stranger if they do not have to do rescue breathing. And any attempt at resuscitation is better than doing nothing. This is becoming standard practice in the United States, and as recently stated by Canadian Red Cross, Canada is also adapting this recent change in practice (refer to the Canadian Red Cross News Release, included in the Appendix at the end of this Section). That being said, ILCOR, as well as the American Heart Association/ Heart and Stroke Foundation of Canada Guidelines and the Canadian Red Cross, state specific exceptions to this general new practice in which rescue breathing remains essential‐ including in the case of drug overdose. 67

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Refer to the Harm Reduction Coalition Alert included in the Appendix of this Section for a more detailed explanation.

Q: If chest compressions are so important, why aren’t rescue breaths eliminated completely?

A: Studies have shown that CPR that combines chest compressions and rescue breaths is the most effective method for treating children and infants, because cardiac arrest in children and infants is typically secondary to conditions that compromise or prevent breathing (hypoxia). A combination of compressions and breaths is also the most effective in the treatment of adult cardiac arrest caused by near‐drowning, trauma, drug overdose and other non‐cardiac causes (Heart and Stroke Foundation of Canada‐ FAQs, 2010). “It is important to remember that many patients such as children and victims of intoxications or near‐drowning have a primary respiratory problem. With or without cardiac arrest, they do not have the same intact oxygen stores in the lungs and blood as patients with cardiac cause of the arrest. In some areas, the number of young patients with drug overdose, who require assisted ventilation only, is much higher than the number of patients with cardiac arrest” (Steen, 2007). Therefore, rescue breathing continues to play an important role in these circumstances. According to the Canadian Red Cross, compression‐only CPR should not be used when the oxygen in the victim’s body has likely been used up ‐ such as with drowning or when a respiratory emergency may have caused the cardiac arrest (Canadian Red Cross, 2010). This Canadian Red

Cross News Release is included in the Appendix at the end of this Section The challenge in adopting compression‐only CPR as the ONLY form of CPR is that rescuers would not be prepared to give ventilations (rescue breathing) to those who need them the most. If two forms of CPR are taught, rescuers also would need to be trained to differentiate between cardiac arrests caused by different circumstances– either resulting from cardiac or respiratory causes. This would complicate training, especially for bystanders, and reduce the likelihood that they would take correct and prompt action in an emergency (Heart and Stroke Foundation of Canada‐ FAQs, 2010).

Q: Is there consensus on the need for rescue breathing when doing CPR for an overdose? A: Ventilations should be provided if the victim has a high likelihood of an asphyxial cause of the arrest (a severely deficient supply of oxygen to the body) eg, infant, child, or drowning victim. (AHA, part 4, 2010). Evidence from studies assessing other endpoints (efficacy of naloxone), as well as animal studies, support the use of assisted ventilation (rescue breathing) before giving naloxone in opioid‐poisoned patients with severe cardiopulmonary toxicity. In adults with severe cardiovascular toxicity caused by opioids, ventilation [rescue breathing] should be assisted using a bag‐mask, followed by naloxone, Naloxone should be given intravenously or intramuscularly.

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In the patient with known or suspected opioid overdose with respiratory depression who is not in cardiac arrest, ventilation should be assisted by a bag mask, followed by administration of naloxone and placement of an advanced airway if there is no response to naloxone (AHA, part 12, 2010).

Q: What should be recommended to people who do not receive full CPR training? A: All rescuers, regardless of training, should provide chest compressions to all cardiac arrest victims. Because of their importance, chest compressions should be the initial CPR action for all victims regardless of age. Rescuers who are able should add ventilations to chest compressions. (AHA, 2010). Opening the airway (with a head tilt–chin lift or jaw thrust) followed by rescue breaths can improve oxygenation and ventilation. However, these maneuvers can be technically challenging and require interruptions of chest compressions, particularly for a lone rescuer who has not been trained. Thus, the untrained rescuer will provide Hands‐Only (compression‐only) CPR (ie, compressions without ventilations), and the lone rescuer who is able should open the airway and give rescue breaths with chest compressions. Ventilations should be provided if the victim has a high likelihood of an asphyxial cause of the arrest (eg, infant, child, or drowning victim) (AHA, 2010).

Q: How can bystander CPR be effective without rescue breathing? A: Some healthcare providers and laypersons indicate that reluctance to perform mouth‐to‐mouth ventilation for victims of cardiac arrest could be a potential barrier to performing bystander CPR. In that case, hands‐only (compression‐only) bystander CPR substantially improves survival following adult out‐of‐hospital cardiac arrests compared with no bystander CPR (AHA, 2010). Rescue breathing is an important component for successful resuscitation from pediatric arrests, asphyxia (deficient oxygen supply) cardiac arrests (eg, drowning, drug overdose) and from prolonged cardiac arrests, conventional CPR with rescue breathing is recommended for all trained rescuers (both in hospital and out of hospital) for those specific situations (AHA, 2010). Initially during SCA (sudden cardiac arrest) with VF (Ventricular fibrillation), rescue breaths are not as important as chest compressions because the oxygen level in the blood remains adequate for the first several minutes after cardiac arrest. But in other causes of cardiac arrest, rescue breathing is required for successful resuscitation.

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Detailed Excerpts of Evidence‐Based CPR Best Practice

Currently there is debate around the necessity to

Expanding on the content provided in the Ques-

sions, as there is new studies and literature that

tions and Answers above, more detailed excerpts

demonstrate a lay person is more likely to at-

from international and Canadian guidelines pro-

tempt CPR on a stranger if they do not have to do

vide more information and evidence‐base to in-

rescue breathing. And any attempt at resuscita-

form best practices for CPR in the case of opioid

tion is better than doing nothing. This is becom-

overdose. What follows is the evidence from the

ing standard practice in the United States, and as

key primary sources to help inform the discussion

recently stated by Canadian Red Cross, Canada is

and decision‐making within your agency.

also adapting this recent change. That being said,

do rescue breathing along with chest compres-

ILCOR, as well as the American Heart Association/

ILCOR Guidelines

Heart and Stroke Foundation of Canada Guide-

The International Liaison Committee on Resusci-

lines and the Canadian Red Cross, state specific

tation (ILCOR) was founded in 1992, and currently includes representatives from around the world. Its mission is to identify and review international science and knowledge relevant to cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) and when there is consensus to offer treatment recommendations. Emergency cardiovascular care includes all responses necessary to treat sudden life‐threatening events affecting the cardiovascular and respiratory systems,

exceptions to this general new practice in which rescue breathing remains essential‐ including in the case of drug overdose. The following excerpts are taken from ILCOR the International standard providing evidence base for CPR best practice and recommended guidelines, for which all organizations base their teaching and guidelines on ‐ including all 5 of the major CPR training organizations in Canada, as well as

with a particular focus on sudden cardiac arrest.

the US.

ILCOR is the international body that aggregates

2010 International Consensus on Cardiopulmo-

evidence‐based practice and research in order to discuss and determine consensus for the international community around EMS and CPR best practice. Training organizations are able to pick and choose various pieces from the ILCOR guidelines and Canadian organizations (the 5 main agencies that provide CPR training) work to establish a consensus, although that’s not always achieved on every specific detail.

nary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. (accessible at http://www.ilcor.org/en/home/) Cardiac arrest in special situations (page 9) The ALS (Advanced Life Support) Task Force reviewed special situations associated with cardiac arrest, including avalanche, pregnancy, asthma, anaphylaxis, drug overdose and poisoning, coro-

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nary catheterisation, heart surgery, cardiac tam-

by opioids. Evidence is limited to studies of mild,

ponade, pulmonary embolus, and electrolyte dis-

moderate, and severe cardiovascular toxicity (LOE

orders.

5 for cardiac arrest). Evidence from studies assessing other endpoints (efficacy of naloxone), as

Cardiac arrest caused by drug overdose and

well as animal studies, support the use of assisted

poisoning

ventilation before giving naloxone in opioid‐poi-

The majority of questions concerning cardiac ar-

soned patients with severe cardiopulmonary tox-

rest caused by drug toxicity remain unanswered.

icity. The use and safety of naloxone is supported

The 2010 International Consensus Conference

by human studies as well as those assessing other

reviewed treatment of cardiac arrest caused by

endpoints (alternate routes of administration).

local anesthesia, benzodiazepines, ‐blockers,

Naloxone can be given intravenously, intramus-

calcium channel blockers, carbon monoxide, co-

cularly, intranasally, and into the trachea.

caine, cyanide, tricyclic antidepressants, digoxin, and opioids.

Treatment recommendation There is insufficient clinical evidence to suggest

Epidemiological studies are required to docu-

any change to cardiac arrest resuscitation treat-

ment the incidence of cardiac arrests caused

ment algorithms for patients with cardiac arrest

by drugs, current treatment strategies, and the

caused by opioids. In adults with severe cardio-

safety and efficacy of existing treatments. Animal

vascular toxicity caused by opioids, ventilation

models, controlled clinical trials, and pharmaco-

[rescue breathing] should be assisted using a

dynamic studies are needed to advance the treat-

bag‐mask, followed by naloxone, and tracheal

ment of cardiac arrest caused by drugs. Most of

intubation if there is no response to naloxone.

the evidence is limited to case reports, extrapo-

Naloxone should be given intravenously or intra-

lations from nonfatal cases (including severe car-

muscularly. Intranasal or tracheal routes may be

diovascular toxicity cases), and animal studies.

used if conditions preclude IV or intramuscular administration.

Opioid toxicity (page 112) In adult cardiac arrest (prehospital or in‐hospital) caused by opioids, does use of any specific interventions, as opposed to standard care (according to treatment algorithm), improve outcome (e.g. ROSC, survival)? Consensus on science There are no RCTs evaluating conventional versus alternative treatments for cardiac arrest caused

The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. (Accessible on ILCOR website or http://circ.ahajournals.org/content/122/18_suppl_3/S685.full) The Heart and Stroke Foundation of Canada is co‐author of the 2010 Guidelines for CPR and Emergency Cardiovascular Care (ECC) in North America and the Canadian leader in resuscitation

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science, education and training. The guidelines are reviewed every five years and updated only when evidence is clear that changes will improve survival rates. The 2010 guidelines are based on input from 356 resuscitation experts from 29 countries. Part 4: Conceptual Framework for CPR: Interaction of Rescuer(s) and Victim CPR traditionally has integrated chest compressions and rescue breathing with the goal of optimizing circulation and oxygenation. Rescuer and victim characteristics may influence the optimal application of the components of CPR. Rescuer Everyone can be a lifesaving rescuer for a cardiac arrest victim. CPR skills and their application depend on the rescuer’s training, experience, and confidence. Chest compressions are the foundation of CPR. All rescuers, regardless of training, should provide chest compressions to all cardiac arrest victims. Because of their importance, chest compressions should be the initial CPR action for all victims regardless of age. Rescuers who are able should add ventilations to chest compressions. Highly trained rescuers working together should coordinate their care and perform chest compressions as well as ventilations in a team‐based approach. Airway and Ventilations Opening the airway (with a head tilt–chin lift or jaw thrust) followed by rescue breaths can improve oxygenation and ventilation. However, these maneuvers can be technically challenging and require interruptions of chest compressions, particularly for a lone rescuer who has not been trained. Thus, the untrained rescuer will provide Hands‐Only (com-

pression‐only) CPR (ie, compressions without ventilations), and the lone rescuer who is able should open the airway and give rescue breaths with chest compressions. Ventilations should be provided if the victim has a high likelihood of an asphyxial cause of the arrest (eg, infant, child, or drowning victim). Part 5: Adult Basic Life Support Hands‐Only CPR Only about 20% to 30% of adults with out‐of‐hospital cardiac arrests receive any bystander CPR. Hands‐Only (compression‐only) bystander CPR substantially improves survival following adult out‐of‐hospital cardiac arrests compared with no bystander CPR. Observational studies of adults with cardiac arrest treated by lay rescuers showed similar survival rates among victims receiving Hands‐Only CPR versus conventional CPR with rescue breaths. Of note, some healthcare providers and laypersons indicate that reluctance to perform mouth‐ to‐mouth ventilation for victims of cardiac arrest is a theoretical and potential barrier to performing bystander CPR. When actual bystanders were interviewed, however, such reluctance was not expressed; panic was cited as the major obstacle to laypersons performance of bystander CPR. The simpler Hands‐Only technique may help overcome panic and hesitation to act. How can bystander CPR be effective without rescue breathing? Initially during SCA with VF, rescue breaths are not as important as chest compressions because the oxygen level in the blood remains adequate for the first several minutes after cardiac arrest. In addition, many cardiac arrest victims exhibit gasping or agonal gasps, and gas exchange allows for some oxygenation and carbon dioxide (CO2)

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elimination. If the airway is open, passive chest recoil during the relaxation phase of chest compressions can also provide some air exchange. However, at some time during prolonged CPR, supplementary oxygen with assisted ventilation is necessary. The precise interval for which the performance of Hands‐Only CPR is acceptable is not known at this time. Laypersons should be encouraged to provide chest compressions (either Hands‐Only or conventional CPR, including rescue breaths) for anyone with a presumed cardiac arrest (Class I, LOE B). No prospective study of adult cardiac arrest has demonstrated that layperson conventional CPR provides better outcomes than Hands‐Only CPR when provided before EMS arrival. A recent large study of out‐of‐hospital pediatric cardiac arrests showed that survival was better when conventional CPR (including rescue breaths) as opposed to Hands‐Only CPR was provided for children in cardiac arrest due to non‐cardiac causes. Because rescue breathing is an important component for successful resuscitation from pediatric arrests (other than sudden, witnessed collapse of adolescents), from asphyxial cardiac arrests in both adults and children (eg, drowning, drug overdose) and from prolonged cardiac arrests, conventional CPR with rescue breathing is recommended for all trained rescuers (both in hospital and out of hospital) for those specific situations.

Naloxone is a potent antagonist of the binding of opioid medications to their receptors in the brain and spinal cord. Administration of naloxone can reverse central nervous system and respiratory depression caused by opioid overdose. Naloxone has no role in the management of cardiac arrest. In the patient with known or suspected opioid overdose with respiratory depression who is not in cardiac arrest, ventilation should be assisted by a bag mask, followed by administration of naloxone and placement of an advanced airway if there is no response to naloxone. Administration of naloxone can produce fulminate opioid withdrawal in opioid‐dependent individuals, leading to agitation, hypertension, and violent behavior. For this reason, naloxone administration should begin with a low dose (0.04 to 0.4 mg), with repeat dosing or dose escalation to 2 mg if the initial response is inadequate. Some patients may require much higher doses to reverse intoxication with atypical opioids, such as propoxyphene, or following massive overdose ingestions. Naloxone can be given IV, IM, intranasally, and into the trachea. The duration of action of naloxone is approximately 45 to 70 minutes, but respiratory depression caused by ingestion of a long‐acting opioid (eg, methadone) may last longer. Thus, the clinical effects of naloxone may not last as long as those of the opioid, and repeat doses of naloxone may be needed.

Part 12. 7: Cardiac Arrest Associated With Toxic Ingestions Opioid Toxicity Resuscitation from cardiac arrest should follow standard BLS and ACLS algorithms.

Patients with life‐threatening central nervous system or respiratory depression reversed by naloxone administration should be observed for resedation. Although a brief period of observation may be appropriate for patients with morphine or heroin

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overdose, a longer period of observation may be required to safely discharge a patient with life‐threatening overdose of a long‐acting or sustained‐release opioid. Benzodiazepines There are no data to support the use of specific antidotes in the setting of cardiac arrest due to benzodiazepine overdose. Resuscitation from cardiac arrest should follow standard BLS and ACLS algorithms. Flumazenil is a potent antagonist of the binding of benzodiazepines to their central nervous system receptors. Administration of flumazenil can reverse central nervous system and respiratory depression caused by benzodiazepine overdose. Flumazenil has no role in the management of cardiac arrest. The administration of flumazenil to patients with undifferentiated coma confers risk and is not recommended (Class III, LOE B). Flumazenil administration can precipitate seizures in benzodiazepine‐dependent patients and has been associated with seizures, arrhythmia, and hypotension in patients with coingestion of certain medications, such as tricyclic antidepressants. However, flumazenil may be used safely to reverse excessive sedation known to be due to the use of benzodiazepines in a patient without known contraindications (eg, procedural sedation). 12.9 Because severe hypothermia is frequently preceded by other disorders (eg, drug overdose, alcohol use, or trauma), the clinician must look for and treat these underlying conditions while simultaneously treating hypothermia.

Steen PA. Does active rescuer ventilation have a place during basic cardiopulmonary resuscitation? Circulation. 2007;116:2514 –2516. “More epidemiological studies are in the pipeline, and we eagerly await the results. The clinical studies published so far strongly indicate that continuous chest compressions without ventilation are at least not worse than standard BLS, at least for patients with cardiac cause of the arrest. This indication should create the basis for initiating larger, well‐controlled clinical trials comparing chest compressions with or without mouth‐ to‐mouth ventilation, as suggested 10 years ago by a working group of the AHA. At the same time, it is important to remember that many patients such as children and victims of intoxications or near‐drowning have a primary respiratory problem. With or without cardiac arrest, they do not have the same intact oxygen stores in the lungs and blood as patients with cardiac cause of the arrest. In some areas, the number of young patients with drug overdose, who require assisted ventilation only, is much higher than the number of patients with cardiac arrest. Mouth‐to‐mouth ventilation must not be a forgotten art.” “Recognizing the difficulties in guideline implementation, there has been a strong attempt to simplify the CPR guidelines. Removing ventilation from BLS in witnessed cardiac arrest would greatly simplify the treatment of these patients, but will it result in confusion on a higher level? Can lay persons be expected to remember what patients to give chest compressions only and who still requires mouth‐ to‐mouth? We sorely lack good studies on the implementation of guidelines and protocols, not only on this topic but in general and for professionals.”

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Section 4: Appendix

The supporting documents referenced in this section include: 1. Sample Medical Directive – Toronto Public Health 2. Pre ‐ Post Knowledge Test 3. Knowledge Checklist and Order to Dispense 4. Overdose History Form 5. Evaluation ‐ Follow‐up for Naloxone Received 6. Evaluation ‐ Follow‐up for Naloxone Administered 7. Sample Documentation Forms-Streetworks, Edmonton 8. Canadian Red Cross News Release 2010 9. Harm Reduction Coalition-Alert

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Sample Medical Directive – Toronto Public Health

*E-mail info@ohrdp.ca to request an updated version of this medical directive. 76

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Pre � Post Knowledge Test

b

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Knowledge Checklist and Order to Dispense

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Overdose History Form

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Evaluation ‐ Follow‐up for Naloxone Received

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Evaluation ‐ Follow‐up for Naloxone Administered

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Sample Documentation Forms-Streetworks, Edmonton

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Canadian Red Cross News Release 2010

NEWS RELEASE

Compression-only CPR means more Canadians can save lives Compression-only CPR offers simple approach for untrained members of public that witness an adult suddenly collapse October 18, 2010 (Ottawa) – The Canadian Red Cross supports the use of compression-only CPR as an acceptable alternative to full CPR with rescue breaths. Compression-only CPR is sometimes the preferred method for members of the public who witness an adult suddenly collapse and are unable to perform full CPR. Compression-only CPR uses chest compressions to pump the heart, circulating oxygen already in the person’s body. This makes compression-only CPR suitable when: • • •

An adult suddenly collapses. A responder is unwilling, unable, untrained or unsure how to perform full CPR (cycles of 30 chest compressions and 2 rescue breaths). A bystander does not have a breathing barrier and does not want to perform unprotected rescue breaths.

Compression-only CPR should not be used when the oxygen in the victim’s body has likely been used up, such as with a drowning victim or when a respiratory emergency may have caused the cardiac arrest. Performing CPR on an infant or child requires rescue breaths. When an infant or child’s heart stops, it’s usually because of a respiratory emergency, such as choking or asthma, which uses up their body’s oxygen. The most important thing for Canadians to know right now is that the CPR they’ve been trained to perform is still right. All Canadian Red Cross CPR courses will continue to teach full CPR. Performing full CPR in conjunction with an automated external defibrillator (AED) immediately following cardiac arrest can double a person’s chance of survival. Canadians are most likely to perform CPR on someone they know. Seventy per cent of cardiac arrests happen at home, yet only one in seven people knows how to perform CPR. The Canadian Red Cross CPR courses cover the skills needed at home and in the workplace to recognize and respond to cardiovascular emergencies and choking, and also include training on the use of AEDs. Find a course near you or contact us. – 30 – Journalists, to schedule a demonstration or interview, call the national media line at 613-740-1928 or contact your local Canadian Red Cross office. 104 OHRDPmanualprinting.indd 115

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CANADIAN RED CROSS FIRST AID REVIEW 2011 Bulletin 1: June 2011

Behind the scenes: Understanding the changes to first aid & CPR guidelines

The Canadian Red Cross would like Canadians to understand the process for developing the first aid and CPR guidelines we teach in our programs. The International Liaison Committee on Resuscitation (ILCOR) was formed in 1992 to provide a forum for discussion between principal resuscitation organizations worldwide. The committee reviews published scientific evidence in the health care field and releases recommendations on resuscitation procedures every five years. An ILCOR subcommittee co-chaired by the American Red Cross and the American Heart Association was also established to research first aid treatment guidelines, known as the International First Aid Science Advisory Board. The Canadian Red Cross is the only Canadian member of this expert first aid committee. Recommendations from both committees are intended to improve the effectiveness of first aid & CPR techniques, and to further reduce injury and mortality. Each review of the research allows for further refinement on how to improve survival rates. Following the release of recommendations from these committees, first aid training agencies around the globe consider the implications and update their training programs and materials accordingly. Once the new recommendations are made public, the Red Cross technical advisory groups comprising the National Medical Advisory Committee and the First Aid Technical Advisory Committee assemble, discuss the scientific worksheets using various criteria, and determine guidelines for Canadians (based on our legislation, etc.) and how the Canadian Red Cross should implement them. The Red Cross believes in using the same or similar protocols wherever possible, regardless of the organization delivering the training. Consistent protocols taught across the country are in the best interest of employers, first aiders, and all Canadians. To this end, we have worked closely with the other three national first aid training agencies (St. John Ambulance, Canadian Ski Patrol, and Lifesaving Society) and have established common protocols for our respective training programs. In November 2010, all four agencies prepared a description of the guideline changes resulting from the 2010 recommendations. This document was distributed to the provincial and territorial governments who regulate first aid training in Canadian workplaces. This list of guideline changes and the rationale for each is included below for your information and reference. All changes are based on the recommendations from ILCOR and the International First Aid Science Advisory Board, and subsequent discussions between the four national first aid training agencies. The Canadian Red Cross National Medical Advisory Committee and the National First Aid Technical Advisory Committee have also reviewed and approved all the changes.

1

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Harm Reduction Coalition-Alert

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Section

5: Sample Educational Materials and Client Resources

This section covers: • Client Training and Educational Resources • Section 5: Appendix of Supporting Documents 1. Naloxone Training Guide by The Point, Toronto Public Health 2. OASIS Program, Sandy Hill CHC, Ottawa‐ training resources 3. Breakaway Addiction Services ‐ Staying Safer When Using Opiates 4. ‘What’s Your Score’ Quiz with notes for service providers 5. Overdose Quiz with notes for service providers

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Section 5: Sample Educational Materials and Client Resources

Client Training and Educational Resources Building on the framework of what was presented at the webinar sessions in March 2012, led by The Point at Toronto Public Health and Waterloo Crime Prevention Council and Preventing Overdose Waterloo Wellington (POWW), it is the responsibility of each agency to provide training materials for clients. Once an agency has decided that it will establish a community‐based naloxone program, it is essential that the appropriate staff have access to training and resources that will enable them to train clients and distribute Naloxone. Identified staff at each site will be responsible for providing opioid overdose training and information to clients. Staff should be competent in delivering clear messaging and following up with clients who have either administered Naloxone or had an overdose. Staff should also be aware of other related support services in their community that they can refer clients to. It is essential that clients receive training and that staff gauge a client’s comprehension of the basic components of opioid overdose prevention and the process for administering Naloxone, in order to provide a client with a take‐home Naloxone kit. The aim of training is to reduce the risk of overdose of people who use opioids through both basic first aid skills and education on how to administer Naloxone. Ultimately, achieved by clients feeling comfortable with the knowledge and skills that they have been able to retain from the training and apply in an emergency overdose situation.

As a basis, training should cover: • Main risk factors for opioid overdose • Signs and symptoms of opioid overdose • Drug classifications • How to recognize when someone has overdosed • Common myths and dangerous practices in response to overdose • • • • • • •

The importance of always calling 911 Putting someone in the recovery position How to respond with Naloxone How Naloxone works Practice injecting Naloxone with demo equipment Relevant pieces of basic first aid Need for debrief and support after overdose

To assist in the development of client training materials, sample training resources from the OASIS Program at Sandy Hill Community Health Centre and Toronto Public Health’s Naloxone Training Guide are included in the Appendix of this Section, as well as Breakaway Addiction Services’ Staying Safer When Using Opiates information sheet. In addition, sample quizzes compiled by OHRDP are included in the Appendix and can be used, adapted and modified for an agency’s own training materials. The Quizzes, What’s Your Score and Overdose Quiz are for clients and are intended as engagement tools to ignite conversation around overdose prevention to raise awareness and reduce risk of overdose. Notes and quiz answers for service providers accompany the quizzes.

As well, OHRDP has developed simple educational posters with prevention messaging, geared toward clients. In particular, the Prevent Overdose Poster, the Overdose Signs and Symptoms Poster, and the Drug Categories Poster may be useful to put up at a harm reduction program site and to use as part of client training. The posters can be found in the Appendix of Section 3 of this document and are available to order from the OHRDP website ‐ www.ohrdp.ca Section 5: Sample Educational Materials and Client Resources 113

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Section 5: Appendix

The supporting documents referenced in this section include: 1. Naloxone Training Guide by The Point, Toronto Public Health 2. OASIS Program, Sandy Hill CHC, Ottawa‐ training resources 3. Breakaway Addiction Services ‐ Staying Safer When Using Opiates 4. ‘What’s Your Score’ Quiz with notes for service providers 5. Overdose Quiz with notes for service providers

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Naloxone Training Guide by The Point, Toronto Public Health

Naloxone Training Guide Meghan O'Leary

>POINT

Prevent Overdose in Toronto

Developed by: Chantel Marshall RN, BScN The Works, Toronto Public Health Updated – April 2012

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2

Contents Page o Naloxone…………………………………..………………..……….3 o Naloxone Kit Contents…………………….……………..………..4 o Overdose…………………………………………………………….5 o Overdose Prevention……………………………………...………6 o Opioid Comparison Graph……………………………………….7 o Drug Categories……………………………………………...…....8 o Recognizing Symptoms of an Overdose…………..........…....9 o Overdose Response Myths………………………………………10 o Responding to an Opioid Overdose with Naloxone……...11-16 o Recovery Position…………………………………………………..17 o Creating an Overdose Response Plan………………………...18 with your Peers/Family o Follow-up/Debriefing………………………………………………18 o Care of Naloxone and Refill Procedure…………………….....18 o Program Evaluation………………………………………………..19

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3

Naloxone Naloxone is an antidote to opioid overdose. Naloxone binds to the same receptors in the brain that opiates do. However, naloxone binds more effectively to these receptors and temporarily removes the opioid(s) and their harmful effects. This in turn reverses the respiratory depression that can lead to a fatal overdose. Naloxone is only available by prescription in Canada. Participants of this program will be issued a prescription of naloxone following training and assessment of their knowledge

Naloxone is only effective with opioids. Once administered, naloxone will start to work in approximately 1-5 minutes. Naloxone stays active in the body for about 60-90 minutes. Since Naloxone only temporarily removes the opioids from the receptor sites in the brain, the opioids will return back to those receptors and the overdose symptoms can return. It is important to call 911 before administering naloxone outside of a medical or hospital setting.

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4

Contents of the Naloxone Kit: • Two - ampoules of 1cc .4mg Naloxone Hydrochloride • Three - 1cc 25g 1 inch safety engineered intramuscular syringes(an extra syringe if one malfunctions)

• Naloxone Prescription Identifier Card • Naloxone step by step instruction pamphlet • Alcohol Swabs(for opening ampoule)

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5

Overdose An overdose occurs when a person uses more of a drug, or combination of drugs, than the body can handle. As a consequence, the brain is not able to control basic life functions. The person may pass out, stop breathing, have heart failure, or experience seizures. • Anyone can overdose: first time users, long-time users, old people, young people, people being released from jail or treatment, etc… • There is no exact formula for determining how much of a certain drug or combination of drugs, will lead to an overdose. • An individual's physical characteristics play a role: weight, health, tolerance for a drug at that particular time, drug potency, route of administration, or frequency/amount of use. • Statistically, there is an increased risk of overdose during the first 2 weeks after release from prison.

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6

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7

Opioid Comparison Graph 750

Times stronger than 30 mg of Codeine (Tylenol 3)

3.6

6

10

20

40

50

70

Adapted from: London Pain Clinic – Opiate Conversion Table - 2008

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8

Drug Categories Depressants:

Slow down the activity of the brain and nervous system.

Stimulants:

Stimulate the brain and central nervous system, speeding up communication between the two.

Hallucinogens:

interfere with the brain and central nervous system in a way that results in distortion of reality and hallucinations. These drugs are sometimes called psychedelics.

Depressants

Stimulants

•Opioids: Buprenorphine,Codeine, Demerol, Fentanyl, Heroin, Hydrocodone(Vicodin), Hydromorphone(Dilaudid), Oxycodone(Oxycontin, OxyNEO, percodan, percocet), Pentazocine

•Cocaine •Crack cocaine •Amphetamine (speed, crystal, meth) •Methylphenidate(Ritalin) •Khat

Hallucinogens •LSD(acid) •Magic Mushrooms •PCP •MDMA •DMT •2C-B

•Benzodiazepines: Ativan, Halcion, Restoril, Rohypnol, Serax, Valium, Xanax •Barbituates: Amytal, Nembutal, Seconal •Zopiclone •Alcohol •GHB

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9

Recognizing an Overdose: *Keep in mind that drugs may be combined, and therefore you may see a combination of different symptoms.

Opioids

Stimulants

Hallucinogens

• Breathing is very slow, erratic, or not at all • Finger nails &/or lips blue or purple • Body is limp • Deep snoring or gurgling sounds • Vomiting • Loss of consciousness • Unresponsive to stimuli • Pinpoint pupils

•Seizures •Pressure/tightness in chest •Foaming at the mouth •Racing pulse •Perfuse sweating •Vomiting •Headache, dizziness, ringing in ears •Difficulty breathing •Sudden collapse •Loss of consciousness

•Psychosis •Catatonic syndrome (person may sit in a trancelike state) •Seizures •Nausea, vomitting

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10

Overdose Response Myths

Do Not Put the person in a bath/cold water Induce vomiting Inject them with anything (saltwater, cocaine, milk) other than naloxone

Implications could drown or put person into shock could choke will not help and could cause more harm

slap too hard, kick them in the testicles, burn the bottom of their feet

could cause serious harm

Let them sleep it off!

could stop breathing and die

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11

Responding to an Opioid Overdose with Naloxone

Stimulation Call 911 Give Naloxone Chest Compressions Is It Working?

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12

1)Stimulation: Can they be awakened? Shout their Name, Shake at Shoulders

*If Unresponsive*

2)Call 911 Talking with Police/EMS: When calling 911: o Quiet the scene down, speak clearly and calmly, tell the dispatcher that the victim is not responding to shake and shout. You do not have to tell them your name, that you suspect an overdose or that drugs are involved. o Tell the dispatcher exactly where you are, the address and room number. If you are outside, give them the nearest street intersection and a landmark. If you can, get someone else to watch for the ambulance while you stay with the person who has overdosed. o Once the paramedics arrive, tell them as much as you know about what drugs the person was using and what you did, including how much naloxone you gave. This will ensure that they can provide the best care and response.

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3)Give Naloxone How to Administer Naloxone: ™ Break open the naloxone ampoule using the alcohol swab

TIP: If there is liquid above the white line in the ampoule, gently tap your finger to get all the liquid to the bottom part of the ampoule

TIP:

Protect your hands from broken glass by wrapping alcohol swab package(do not open) around the ampoule

™ Insert a new syringe into the ampoule and slowly draw up all of the naloxone (1cc)into the syringe ™ Inject all of the naloxone the (1cc) into upper arm muscle or thigh muscle at a 90 degree angle

Upper Arm

Thigh

*If you cannot remove the clothing, the needle is long enough to reach through light clothing.

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14

4) Start Chest Compressions

• Push hard and fast with both hands on the center of the chest. • Position arms in locked position. • Push down at least 2 inches with each compression. • Continue chest compressions until EMS arrives • If able, switch persons doing compressions every 2 minutes to avoid fatigue

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15

5)Is it working? • If person does not start breathing on their own within 3-5 minutes, administer a second dose of naloxone following the same procedure as above & continue chest compressions until EMS arrives When the naloxone starts working the individual may: o o o o o

Wake up suddenly Wake up slowly Be disorientated Want to use more drugs Be agitated and may become combative

Naloxone may cause mild to severe withdrawal symptoms (agitation, anxiety, muscle aches, sweating, nausea, vomiting) for someone who is dependent on opioids. Once the naloxone wears off these withdrawal symptoms tend to subside.

How can you help? o Stay with the person until EMS arrives. o When they wake up, explain that they overdosed o Urge them to not use more drugs. Using more drugs will not make them feel any better, and will increase their chance of overdose once the naloxone wears off o Watch for signs & symptoms of overdose returning

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16

Duration of Action Duration of action is the length of time that a particular drug is active in the body. The duration of action of naloxone is shorter than most opioids, therefore the effects of the original opioid taken may return after the administration of naloxone. Drug Codeine Fentanyl IV

.5 - 1

Hydrocodone

4-6

Meperedine

2-4

Methadone

24 - 48

Morphine

4-5

Oxycodone

3-6

Buprenorphine Naloxone o

Duration of Action (hours) 4-6

24

< 1 hour

Adapted from e-CPS: Drug Monographs December 2010- Opioids

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17

Recovery Position If at any point you need to leave the person alone, place them in the recovery position. Placing a person in the recovery position gives gravity assistance to the clearance of physical obstruction of the airway by the tongue, and also gives a clear route by which fluid can drain from the airway and prevent choking.

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Follow up – Debriefing: Being part of an overdose can be a very traumatic experience, whether you’re the person overdosing or the witness: • Talk with your friends and or family. • Contact a nurse/ counselor at The Works • If you are connected with a health professional seek support

Creating an Overdose Response Plan with Your Peers/Family: Talk with your friends or partners about overdose, and create a plan that you can realistically use in the event of an overdose. Ensure that your peers and family know where you keep your Naloxone Kit.

Refills Visit The Works for a refill, or check to see if there is a Naloxone Training occurring in your community.

Naloxone Kit Care Store in a cool dark place & ensure that it is with you at all times when you are using. Watch expiry date on the naloxone ampoules. If it’s getting close to the expiry date come in to The Works for a refill. Routinely check that all supplies are in your Naloxone Kit.

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19

Program Evaluation In order for us to provide the most useful and effective training we need the input from individuals who are using the program. This feedback is essential in adapting our program to reflect the needs of the community. After a participant has been involved in an overdose situation, they are to contact The Works. A short evaluation form will be filled out either by phone or in person. This form is confidential and the same rules apply in regards to documentation and storage of the forms. This is also a good opportunity to get a refill of naloxone.

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OASIS Program, Sandy Hill CHC, Ottawaâ&#x20AC;? training resources

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Tylenol (T3’s ) and Percocet both contain acetaminophen. When taken in high doses they can have a toxic effect on the body resulting in liver failure. Avoid taking high amounts of acetaminophen.

The potency of any batch of heroin is inconsistent, and it is almost always cut with other substances.

Injecting Fentanyl is dangerous because the medication is not spread equally throughout Fentanyl patches; there is no exact way to measure the amount of medication you could be taking out of it at a time.

Here are some things to keep in mind:

Some opiates are more complicated than others, and present greater risks to your health.

It gets complicated...

Phone: 416-537-9346 Fax: 416-537-2598

Breakaway Addiction Services The Satellite 21 Strickland Avenue Toronto, ON M6K 3E6

Toronto Withdrawal Management Services: 1-866-366-9513

CAMH: (416) 595-6111 (within Toronto) or 1-800-463-6273 (toll free).

Toronto Public Health – The Works: (416)-392-0520

Breakaway Addiction Services – Satellite Opiate Services: (416)-537-9346

The Ontario Drug and Alcohol Helpline: 1-800-565-8603

There are harm reduction supports and treatment options available to people who use opiates. For more information, you can contact:

An overdose prevention resource

Staying Safer When Using Opiates

Breakaway Addiction Services ‐ Staying Safer When Using Opiates

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Your existing tolerance

Interactions with other drugs you have on board

Whether it’s a short or long acting medication

How you take the drug (IV, snorting, chewing, swallowing)

How your body breaks down the drugs

Drug potency

Not all opiates are the same and your body can react differently because of:

Your tolerance to one opiate will not be the same as with another. Even if you are a regular user of something (ie: oxycontin), you risk an overdose if you use something new or different than what your body is used to at that time.

Not all opiates are created equal

Mixing opiates with other depressant drugs such as alcohol, benzos, other opiates and many prescription medications increases the risk of overdose.

Don’t mix your drugs

If you stop or even cut down on opiates, it only takes a few days for your tolerance to drop (ex. time in hospital, detox, or jail). After a few days without opiates like oxycontin, heroin, or methadone, a dose that at one time would have been fine for you to take could now kill you.

Be aware of changes in your tolerance

When making a change in your pattern of use, you should take the time to find out some information about the new drug you’re trying. Information is often available from harm reduction services or public health services. Always consider reducing your use of a new drug by 50%; you can always add more if needed, but can’t take it back if you have taken too much.

Be careful when switching

Tips for staying safer

Whether you are looking to reduce your use, get some information, safety tips, or access treatment, there’s support for you. Getting connected with harm reduction or treatment services greatly reduces the risks you face.

Seek out support

People who use opiates, or spend time with people who do, should connect with their local public health service, needle exchange or doctor to talk about overdose prevention and training. You can get trained in the use and prescription of Naloxone, which is a medication used to help reverse the effects of an opiate overdose.

Get training

Stay safer by connecting with people you trust and let them know what you’re doing and when. If you’re using with a friend, take some time to talk about an overdose plan and how you will help each other if something goes wrong.

Don’t use alone


‘What’s Your Score’ Quiz with notes for service providers

Ontario Harm Reduction Distribution Program

What's Your Score? Instructions 1. If the answer to a question is <yes> circle the score; if <no> do not circle the score for that question 2. Make any notes related to your answer as required 3. Add up the total score from the circled answers to establish the level of risk

Risk Factors

Score

1. I’m a current heroin user

1

2. I currently inject drugs

3

3. I started injecting within the last six months

3

4. I’m on a methadone/Suboxone script

-1

5. I recently switched my drug of choice

2

6. I use street methadone

1

7. I drink alcohol until drunk

2

8. I use non-scripted benzos

2

9. I mix drugs

2

10. I’ve been drug free in prison, hospital or residential drug treatment in the last month

3

11. I’ve overdosed (but not in past year)

1

12. I’ve overdosed once in past year

2

13. I’ve overdosed two or more times in past year

3

14. I have access to Naloxone

-2

15. I’ve been using drugs for more than five years

1

16. I’m using larger amounts to get a high

1

17. I find it harder to get a high

2

18. I enjoy a really big high

3

19. I’ve told the people I inject with, I’ll stay with them if they go over

-1

20. I’m currently experiencing severe low mood or depression

3

21. I usually use alone

3

22. I’ve got health problems (e.g hepatitis, respiratory problems)

2

DATE

Notes

TOTAL SCORE

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Ontario Harm Reduction Distribution Program

What's Your Score? Service Provider Notes Do clients know how at-risk they are of an overdose? This quick test can help you/or a client measure how risky a client’s drug use is, and it only takes a few minutes. Clients can complete the test on their own or with a service provider. As a basic assessment, it will give a general idea of the opiate overdose risk of the client. It also acts as an engagement tool to begin discussions around OD prevention and education to reduce risk, by starting to raise awareness of a client’s risk factors. It is intended as a motivational tool to help bring about change in behaviour. This test can be used in a group setting or one-on-one to ignite conversation around OD risk. -

Scoring Interpretation Scores less than 5

Low risk: while there is always a risk of overdose, the person has a relatively low risk profile. Work can still be done to further reduce risk factors and reinforce harm reduction messaging.

Scores of 5 to 10

Moderate risk: a number of risk factors exist making overdose more likely. Identify areas or ways to reduce risk and provide prevention education.

Scores 10+

High risk: client is much more likely to overdose and this will need to be reflected in the interventions used to reduce risk, such as one-on-one sessions to discuss ways to reduce risks. Address all risk factors, especially high risk activities. Provide OD training and education.

Score 15+

Very high risk: Urgent changes needed for this person to avoid becoming an OD statistic. The likelihood of an imminent overdose is high. Hopefully this high score can be reduced through interventions, discussions and more thorough harm reduction messaging and education. A high level of support, staff diligence and training will be needed to reduce risk of fatality.

Disclaimer: These tools are not clinically validated and are for guidance only. They do not guarantee to identify all risk- taking behaviour. No liability can be taken for a failure on the part of this tool to anticipate overdose. Source: Adapted from The Overdose Awareness Workshop by Nigel Brunsdon. www.injectingadvice.com with original content from “What’s your score” is derived from Kevin Flemen’s Hostel Opiate Overdose Risk Assessment Tool (HOORAT), used with permission. www.ixion.demon.co.uk

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Overdose Quiz with notes for service providers

Ontario Harm Reduction Distribution Program

Overdose Quiz 1. Injecting cocaine/crack will stop an OD

True ⃝

False ⃝

2. More than half of overdoses happen with another person in the room

True ⃝

False ⃝

3. If someone ODs you should walk them around

True ⃝

False ⃝

4. Injecting salt water will stop an OD

True ⃝

False ⃝

5. New users are more likely to overdose

True ⃝

False ⃝

6. Each year in Ontario there are between 300 to 400 overdose deaths involving prescription opioids- most commonly oxycodone.

True ⃝

False ⃝

7. If someone is snoring they’re OK

True ⃝

False ⃝

8. Most OD deaths are deliberate suicides

True ⃝

False ⃝

9. Using an unfamiliar substance increases the risk of overdose

True ⃝

False ⃝

10. If someone ODs you should put them in a cold bath

True ⃝

False ⃝

11. Naloxone/Narcan reverses opiate ODs

True ⃝

False ⃝

12. ODs are fast (‘Trainspotting’ style)

True ⃝

False ⃝

13. Ambulance staff don’t call police if someone ODs

True ⃝

False ⃝

14. Making someone vomit will slow down a heroin OD

True ⃝

False ⃝

Disclaimer: this tool is for guidance only and does not guarantee to identify all risk taking behaviour. No liability can be taken for a failure on the part of this tool to anticipate overdose. Source: Adapted from The Overdose Awareness Workshop by Nigel Brunsdon. www.injectingadvice.com

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Ontario Harm Reduction Distribution Program

Overdose Quiz Service Provider Notes Clients can complete the quiz on their own or with a service provider. It is intended to serve as an engagement tool to ignite conversation around overdose prevention and education. 1. Injecting cocaine/crack will stop an OD

FALSE

Injecting crack will actually make the OD happen faster. Crack speeds up your heart rate making the body require more oxygen, however heroin slows down breathing. 2. More than half of overdoses happen with another person in the room

TRUE

AT LEAST 50% have another person there, however this number may be far higher. In Australia studies have found its around the 70% mark. 3. If someone ODs you should walk them around

FALSE

All you’re doing is wasting time, in fact you may even be speeding up the overdose. Also there is always the chance that the person you walk about will fall over and bang their head. Then you’ll have an overdose AND a head injury. 4. Injecting salt water will stop an OD

FALSE

No it won’t! And neither will injecting; milk, water, orange juice etc, all you might manage to do is add to their problems. 5. New users are more likely to overdose

FALSE

There are many things that effect overdose risk. Even spending one night in the cells is enough to drop your tolerance down far enough that injecting what you normally inject will lead to an OD. Using a substance that you are not familiar with and do not know your tolerance for, does put you at greater risk for accidental overdose. People who have been using for years are also at risk because their liver may not work as fast to process the opioid as well. 6. Each year in Ontario there are between 300 to 400 overdose deaths involving prescription opioids- most commonly oxycodone. TRUE Opioid Overdose in Ontario is a major public health concern. According to ICES research studies and the Ontario Public Drug Programs, each year in Ontario there are between 300 and 400 overdose deaths involving prescription opioids.

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Ontario Harm Reduction Distribution Program

7. If someone is snoring they’re ok

FALSE

If someone who has used heroin or other opioids is snoring it’s a sign that they’re struggling to breathe and you need to get them help. 8. Most OD deaths are deliberate suicides

FALSE

Most deaths are accidental, there are of course sometimes people use heroin to deliberately commit suicide though. Because of the way deaths are recorded its really difficult to say without the presence of a suicide note. 9. Using an unfamiliar substance increases the risk of overdose

TRUE

With the discontinuation of OxyContin in early 2012, thousands of Ontarians are at greater risk of accidental overdose as they transition to using other substances (which they may not be familiar with). Although dangerous OxyContin was pharmaceutical grade – meaning you knew the strength and potency of a pill – this is not the case with heroin or other substances, with no idea what you may be getting. Someone’s tolerance level differs with different substances. 10. If a friend ODs you should put them in a cold bath

FALSE

You can change body temperature really fast and put them into shock. There is also a drowning risk, plus trying to get an unconscious person out of a bath when they are wet and slippy is a nightmare. 11. Naloxone/Narcan stops ODs

TRUE

This is what ambulance crews and some drug services give you if you OD, beware though that it only has a short effect so you may go back into overdose again when it wears off. Stay with the medics and never NEVER go and use again straight away because you’re withdrawing. 12. ODs are fast (‘Trainspotting’ style)

FALSE

While some overdoses can be fast, a large number of deaths happen within a few HOURS of using. 13. Ambulance staff don’t call police if someone ODs

TRUE

It is not standard practice for ambulance staff/EMS to call the police unless there are threats/history of violence, the property is known to contain weapons, or there is thought to be a child at risk. 14. Making someone vomit will slow down a heroin OD

FALSE

All this will do is increase the chances of them choking to death, heroin stops your gag reflex which makes choking more likely.

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Section

6:

Additional Resources

This section covers: • Resources on Opioid Misuse in Ontario • Web Resources on Overdose Prevention and Naloxone • Film Resources • Literature Review on Community‐Based Naloxone Programs • Brief Summary of Evidence • Reference List of Publications, Reports, and Supporting Evidence • Section 6: Appendix of Supporting Documents 1. Opioid Advice: Memo 2. Opioid Advice: Withdrawal 3. Opioid Advice: Switching 4. Opioid Advice: Intoxication 5. Literature Review by Waterloo Region

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Section 6: Additional Resources

This section provides a multitude of reference lists for web resources, reports and publications around overdose prevention information and community‐based Naloxone distribution programs. These resources may be useful to program staff as evidence‐based information to reference while working through implementing a community‐based Naloxone program and client training at their harm reduction program site.

Ministry of Health and Long‐Term Care and Centre for Addiction and Mental Health (CAMH). The materials are available on their respective websites and copies of the resource materials are also included in the Appendix at the end of this Section, which includes: •

Memo to provincial health care provider organizations and local health integration networks (LHINs) from the Assistant Deputy Minister, Health System Strategy and Policy Division.

Resources on Opioid Misuse in Ontario

Opioid Advice: Detection and Management of Acute Opioid Withdrawal

Opioid Advice: Switching Opioids Safely

Opioid Advice: Detection and Management of Acute Opioid Intoxication

The Institute of Clinical and Evaluative Sciences (ICES) is the primary research body publishing data and information on opioid prescription rates and death rates in Ontario. They have numerous published articles that provide useful Ontario data, one example is: Prescribing of opioid analgesics and related mortality before and after the introduction of long‐ acting oxycodone. Irfan A. Dhalla, MD MSc, et al. Canadian Medical Association Journal. December 8, 2009. vol. 181 no. 12. http://www.cmaj.ca/content/181/12/891 Another Ontario‐relevant article is: Deaths related to the use of prescription opioids. Benedikt Fischer, Jürgen Rehm. Canadian Medical Association Journal. December 8, 2009 vol. 181 no. 12. http://www.cmaj.ca/content/181/12/881.full There are numerous articles on the public health concerns around opioid deaths in Ontario, and these two are just a sample to outline the discussion around the need to respond with targeted overdose prevention initiatives. A series of resources and information for health care providers called “Opioid Advice” have very recently been developed and disseminated by the Section 6: Additional Resources

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Web Resources on Overdose Prevention and Naloxone The following list provides the name and website of various initiatives and resources related to overdose prevention and community‐based Naloxone programs. 1) Waterloo Region Crime Prevention Coucil www.preventingcrime.net/main.cfm?id=51A4A87F‐ B6A7‐8AA0 652D134862FD5CD0 Which includes the reports: •

Oxy to Oxy: Impacts and Recommendations Informal Summary Report, March 14, 2012

A First Portrait of Drug Related Overdoses in Waterloo Region, September 2008

Saving Lives: Overdose Prevention & Intervention Projects in Select North American Cities, September 2008

2) Preventing Overdose Waterloo Wellington (POWW): This grassroots group, a mix of service providers and

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persons with lived experience, began in 2009 and at the time, was just the second OD Prevention program in Canada. The primary purpose of this group is to deliver OD Prevention and Intervention Training to service providers, people active in their substance use and others who may be in a position to witness an OD. Training has been delivered across Ontario. http://preventingoverdose.ca

Film Resources

3) The Overdose Prevention Alliance: Up to date research and activities on overdose prevention, primarily from the U.S. http://overdoseprevention.blogspot.com/

2) Live! Is a 13min training film provides instruction on how to recognize opioid overdose and respond effectively using a combination of rescue breathing and injectable naloxone. An actual overdose provides the narrative framework in which the opiate overdose rescue process is illuminated. Courtesy Sawbuck Productions, U.S.A. http:// www.youtube.com/watch?v=U1frPJoWtkw

4) Brockton Mayor’s Opioid Overdose Prevention Coalition A group from Massachusetts, U.S.A. that is raising awareness and training parents, people active in substance use, service providers and others. http://opioidoverdoseprevention.org/ 5) Project Lazarus A unique effort to reduce overdose from prescribed opioids that unites health researches and activists, county officials, the military and local communities in North Carolina, USA. http://projectlazarus.org/ 6) Take‐Home Naloxone A U.K. website run by independent academics and healthcare professionals aimed at raising awareness on the use of take‐home naloxone as a mechanism for reducing drug‐related deaths. This site provides a complete guide on the use of take‐home naloxone. http://www.take‐homenaloxone.org/ 7) The British Columbia Take Home Naloxone Program Information on BC's provincial take home naloxone program can be found at: www.towardtheheart.com/naloxone

1) The First Seven Minutes Your workplace likely has protocols for emergencies such as fire, but do you have a protocol for an emergency overdose? This film provides clues for designing an Overdose Protocol for Your Agency, provided courtesy of the Toronto Harm Reduction Network and friends. http://www.ohrdp. ca/2012/03/the‐first‐7‐minutes/

3) Naloxone Saves Lives A U.K. film, made by Salford DAAT, that features paramedics and MDs providing essential O.D. tools suitable for anyone who may witness and intervene in an overdose, including administering naloxone. http://www.youtube.com/watch?v =15lZZWVTspo&list=UUfYFKA1HN7cpuQ8b5bN 076g&index=1&feature=plcp 4) Going Over A short film about drug overdose, produced for a U.K overdose campaign in 2002, with a focus on putting someone in the recovery position. http:// www.youtube.com/watch?v=WHaMk9z5HHo&fe ature=related

Literature Review on Community‐Based Naloxone Programs The following is a brief summary of some of the evidence and evaluations from existing programs highlighting that community Naloxone programs are effective at saving lives.

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1) Community‐Based opioid overdose prevention programs providing naloxone ‐ United States, 2010. Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report. 2012 Feb 17;61:101‐5. http://www.cdc.gov/mmwr/pdf/wk/ mm6106.pdf •

426 individuals participated in the OPP between July 1, 2005, and December 31, 2008.

In October 2010, the Harm Reduction Coalition, a national advocacy and capacity‐building organization, surveyed 50 programs known to distribute naloxone in the United States, to collect data on local program locations, naloxone distribution, and overdose reversals.

89 individuals reported administering naloxone in response to an overdose in a total of 249 separate overdose episodes; participants reported 96% were reversed.

This report summarizes the findings for the 48 programs that completed the survey and the 188 local programs represented by the responses. Since the first opioid overdose prevention program began distributing naloxone in 1996, the respondent programs reported training and distributing naloxone to 53,032 persons and receiving reports of 10,171 overdose reversals. Providing opioid overdose education and naloxone to persons who use drugs and to persons who might be present at an opioid overdose can help reduce opioid overdose mortality, a rapidly growing public health concern.

2) Prevention Point Pittsburgh. National Development and Research Institutes Inc, Public Health Solutions, New York, NY, USA. •

Prevention Point Pittsburgh (PPP) is a public health advocacy organization that operates Allegheny County’s only needle exchange program. In 2002, PPP implemented an Overdose Prevention Program (OPP) in response to an increase in heroin‐related and opioid‐ related overdose fatalities in the region.

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In 2005, the OPP augmented over- dose prevention and response train ings to include naloxone training and prescription.

The data support findings from a growing body of research on similar programs in other cities. Community‐based OPPs that equip drug users with skills to identify and respond to an overdose and prescribe naloxone can help users and their peers prevent and reverse potentially fatal overdoses without significant adverse consequences. 3) Naloxone Program in Wales. Presentation by Welsh Assembly Government: “Introducing ‘take home’ Naloxone in Wales” IHRA 21st International Conference Liverpool, 26th April 2010. •

In 2007 there were 110 drug related deaths recorded in Wales (ONS, 2008) Mainly aged between 20 and 40 years 61% died in own home, 25% at home of family or friends, 8% in public places and 5% in hospital

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CPR was attempted by family or friends in 39% of cases 8% of the deaths involved people released from prison within the last 28 day

High risk groups 11 people accessing treatment at the time of death 23 people had never accessed treatment 25 previously accessed treatment but had dropped out Target group those not accessing structured treatment

5) Legal Aspects of Providing Naloxone to Heroin Users in the United States. California Burris, S. Norland, J. Edlin, B.R. International Journal of Drug Policy 12 (2001): 237‐248. •

A survey of people who inject heroin found that few would use more heroin following administration of Naloxone.

As well, the Naloxone Distribution Programs: A Review of the Literature document is included in the Appendix at the end of the Section. It provides a brief summary of the leading take‐home Naloxone programs operating in the United states as well as the Edmonton Streetworks program. There are also some details provided as to how these programs operate and their various program components.

Impact Over 270 Naloxone kits distributed 20 uses of naloxone 19 successful reversals of overdose

4) Memorandum: Legal Analysis of Switching Naloxone from Prescription to Over the Counter. Temple University of the Commonwealth System of Higher Education, Beasley School of Law, Project on Harm Reduction in the Health Care System 06 July 2005. •

Two European studies found no serious adverse effects and observed no increase in risky behavior associated with naloxone availability.

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Additional Reference List of Publications, Reports and Supporting Evidence on Community Based Naloxone Programs Bazazi, Alexander R;  Zaller, Nickolas D; Fu, Jeannia J;  Rich, Josiah D. (2010) Preventing opiate overdose deaths: examining objections to take-home naloxone. Journal of Health Care for the Poor and Underserved, Volume 21, Issue 4, p. 1108. Bennett, A. S., Bell, A., Tomedi, L., Hulsey, E. G., & Kral, A. H. (2011). Characteristics of an overdose prevention, response, and naloxone distribution program in pittsburgh and allegheny county, pennsylvania. Journal of Urban Health : Bulletin of the New York Academy of Medicine, 88(6), 1020‐1030. Buxton, J; Purssell, R; Gibson, E; Tzemiz, D. (2012) Increasing access to Naloxone in BC to reduce opioid overdose deaths. BC Medical Journal, Volume 54, No 5. Enteen, L., Bauer, J., McLean, R., Wheeler, E., Huriaux, E., Kral, A. H., et al. (2010). Overdose prevention and naloxone prescription for opioid users in san francisco. Journal of Urban Health, 87(6), 931‐941. Foxhall, Kathryn. (2012) OTC naloxone possibleFDA response to OD epidemic. Drug Topics, Volume 156, Issue 5, p. 16. McAuley, A., Lindsay, G., Woods, M., & Louttit, D. (2010). Responsible management and use of a personal take‐home naloxone supply: A pilot project. Drugs: Education, Prevention & Policy, 17(4), 388‐99 (27 ref ).

(2012) U.S. Food and Drug Administration. http:// www.fda.gov/drugs/newsEvents/ucm277119. htm Sherman, S. G., Gann, D. S., Tobin, K. E., Latkin, C. A., Welsh, C., & Bielenson, P. (2009). “The life they save may be mine”: Diffusion of overdose prevention information from a city sponsored programme. International Journal of Drug Policy, 20(2), 137‐142. Strang, J., Manning, V., Mayet, S., Best, D., Titherington, E., Santana, L., et al. (2008). Overdose training and take‐home naloxone for opiate users: Prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses. Addiction, 103(10), 1648‐1657. Tobin, K. E., Sherman, S. G., Beilenson, P., Welsh, C., & Latkin, C. A. (2009). Evaluation of the staying alive programme: Training injection drug users to properly administer naloxone and save lives. International Journal of Drug Policy, 20(2), 131‐136. Wheeler, E.; Davidson, P; Jones, S; Kevin, I. (2010) Community-Based  Opioid Overdose Prevention Programs Providing Naloxone-United States. Journal of the American Medical Association, Volume 307, Issue 13, p. 1358 Yokell, M. A., Green, T. C., Bowman, S., McKenzie, M., & Rich, J. D. (2011). Opioid overdose prevention and naloxone distribution in rhode island. Medicine & Health, Rhode Island, 94(8), 240‐242.

Role of Naloxone in Opioid Overdose Fatality Prevention; Request for Comments; Public Workshop.

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Section 6: Appendix

The supporting documents referenced in this section include: 1. Opioid Advice: Memo 2. Opioid Advice: Withdrawal 3. Opioid Advice: Switching 4. Opioid Advice: Intoxication 5. Literature Review by Waterloo Region

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Opioid Advice: Memo

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Opioid Advice: Withdrawal

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Opioid Advice: Switching

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Opioid Advice: Intoxication

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Literature Review by Waterloo Region

Naloxone Distribution Programs: A Review of the Literature

Compiled by

The Waterloo Region Overdose Prevention and Intervention Working Group September, 2010

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Introduction The intention of this report is to identify and describe overdose prevention programs that aim to prevent opiate overdoses through the provision of peer-based overdose intervention strategies and Naloxone distribution. The distribution of Naloxone is a harm reduction based approach, acknowledging that users of opioids are at risk for many drug related harms, including contraction of Hepatitis C, HIV/AIDs and overdose. Harm reduction is a pragmatic approach that is directed towards reducing the negative social and economic consequences associated with drug use. While harm reduction recognizes that abstinence is valuable outcome it acknowledges that drug use is on a continuum. It does not condone drug use, but acknowledges that individuals will use drugs. Harm reduction is not in opposition to drug treatment, but recognizes that individuals are at various stages of use and it is important to meet drug users “where they’re at” to help reduce harms associated with their drug use. While for some abstinence is a goal, for other drug users reducing the harms associated with drug use such as preventing HIV, Hepatitis C, or overdose, is a more realistic option. The slogan “Any Positive Change”, used by the Chicago Recovery Alliance, refers to the harm reduction ideology that harm reduction is against harm, and in favour of any positive change- as defined by the person making the change. The following principles outline harm reduction practice;

a) For better or worse licit and illicit drug use is part of the world, choosing to minimize its harmful effects rather than simply ignore or condemn them. b) To ensure that drug users and those with a history of drug use have a consistent voice in the creation of programs and policies that are designed to serve them. c) To understand drug use as a complex and many faceted phenomenon that includes a continuum of behaviours from severe use to total abstinence, and that there are some ways of using drugs that are safer than others. d) The quality of individual and community life and well-being is the criteria for successful interventions and policies, not necessarily abstinence. e) The provision of non-judgmental, non-coercive services and resources for individuals who use drugs and the communities in which they live in order to assist them in reducing drug-related harms. f) The vast arrays of social inequalities that are experienced by individuals affect their vulnerability and capacity to effectively deal with drug-related harms. g) Recognizes, without minimizing the real and severe harms and dangers associated with licit and illicit drug use 1.

1

Principles on Harm Reduction: http://harm.live.radicaldesigns.org Harm Reduction Coalition.

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Naloxone Naloxone Hydrochloride is a non-selective opiate antagonist. It acts to prevent or reverse the effects of opioid overdose, including respiratory depression, sedation and hypotension 2. It does not possess the agonistic properties that characterize other opioid antagonists, meaning; in the absence of opioids it exhibits no pharmacologic activity in the body. It has not been shown to produce tolerance or cause physical or physiological dependence. In the presence of physiological dependence on opioids the introduction of naloxone will produce withdrawal symptoms 3. Evidence suggests that naloxone antagonizes opioid effects by competing for the same receptor sites, though its mechanism of action is not fully understood 4. Once administered, naloxone is metabolized in the liver, and excreted in the urine. Naloxone hydrochloride may be administered subcutaneously, intramuscularly, or intravenously. Naloxone is indicated for the complete or partial reversal of opioid depression, including respiratory depression induced by opioids. It is effective for synthetic and natural opioids, propoxyphene, methadone and the agonistantagonist analgesics nalbuphine, pentazocine and butorphanol. The recommended dosage for known or suspected opioid overdose is 0.4 mg to 2mg of naloxone. As the duration of some opioids can exceed that of naloxone, a second dose may be necessary. What are the Risks? The only contraindication for the administration of naloxone for opioid overdose is a known hypersensitivity to it. As naloxone can produce withdrawal symptoms in the case of physiological dependence on opioids, adverse effects of naloxone can include withdrawal symptoms such as nausea, vomiting, sweating, tachycardia, increased blood pressure and tremulousness. Seizures have been reported to occur infrequently following naloxone administration however no causal relationship has been established 5. These reports are rare and may be associated with pre-existing cardiac abnormalities and drug interaction. Additionally, they typically involve significantly higher dose levels than those used in peer overdose interventions. Reports from naloxone training programmers have documented life saving events through peer administration without observed side effects, possibly as a result of the lower doses that are typically used in overdose reversal situations 6. A common criticism of the distribution of naloxone to peers is that the availability of naloxone will cause individuals to use opioids more heavily. However, the evidence indicates that the opposite is the case. Seal et al (2005) found that there was a decrease in heroin use among participants six months after receiving naloxone training 7. Another argument is that individuals who use drugs would not be able to effectively intervene in the

2

Canadian Pharmacists Association, 2009, van Dorp, E, Yassen, A, Dahan, A, 2007 Ibid. 4 Ibid 5 Ibid 6 Gaston, R, Best, D, Manning, V, Day, E. (2009). 7 Seal, Thawley, Bamberger, Kral, Ciccarone, Downing and Edlin, 2005 in Gaston, R, Best, D, Manning, V, Day, E. (2009). 3

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case of overdose. Not only does evidence not support this claim it suggest that people who use drugs are capable and interested in using naloxone in order to treat overdoses in their peers 8. With appropriate training these individuals have been shown to have expertise in recognizing and intervening in the case of overdose as well as administering naloxone. Overdose Prevention and Naloxone Distribution Programs

Heroin overdose is one of the leading causes of death among individuals who are opioid dependent. The leading precipitators of overdose include: polydrug use, using opioids after a period of abstinence, and lastly, experienced long-time users are at higher risk for overdose. Research has shown that a high number of overdoses are witnessed, but medical attention is not sought or it is sought too late 9. It has been reported that emergency medical services are only called in between 30-50% of the cases of overdose, due to fear of arrest, lack of access to telephone, and mistaken beliefs about overdose 10.

Emergency medical personnel have used naloxone in the reversal of opioid overdose for the past several decades. However, typically peers or family members of overdose victims are the first responders on site. These individuals are at an ideal position to intervene within an hour of the onset of overdose symptoms 11. “Take Home” naloxone programs involve the prescription and distribution of Naloxone to individuals who use drugs. They are geared toward individuals who use opiates so that they may have naloxone accessible in the case of an opiate overdose, and to train these individuals to recognize signs and symptoms of an overdose and to safely administer naloxone. Currently in Canada there is one Naloxone Distribution program that works out of Edmonton’s Street Works. In the United states, there are several programs that utilise “take-home’ Naloxone programs, notably the Chicago Recovery Alliance 12, New York’s S.K.O.O.P. (Skills and Knowledge on Opiate Prevention), Boston Public Health Commission AHOPE Needle Exchange program 13 and San Francisco’s DOPE Project (Drug Overdose Prevention Education). Currently in Toronto, The Works, a municipally funded needle exchange program is in the process of developing a naloxone distribution program.*

Streetworks is a needle exchange program that operates in Edmonton, Alberta. It is the only Canadian program that distributes naloxone. Streetworks provides a three-part service including a street drug handbook for service users; overdose prevention training, which includes training in emergency life support, and training and provision of naloxone to individuals who use drugs. Trainers are Registered Nurses and training takes between 10-30 minutes to administer. Naloxone is prescribed by a local physician and Streetworks is responsible for distributing the naloxone to users. Since 2005 Streetworks has issued 250 single use vials of naloxone. Weisser, Parkinson, 2008 Gaston, Best, Manning, Day, 2009 10 Weisser, Parkinson, 2008 11 Kim, Irwin, Khoshnood, 2009 8 9

12 13

Chicago Recovery Alliance: http: www.anypositivechange.org Doe-Simkins, Walley, Epstein & Moyer, 2009

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The Chicago Recovery Alliance (CRA) has operated one of the largest naloxone distribution programs to date, currently operating 15 sites of Harm Reduction outreach, storefront sites, and pager and cell phone support 14. The CRA has been prescribing and dispensing naloxone from outreach vans since 1998. In 2000 they developed a program that teaches basic opioid neurophysiology, pharmaco-dynamics and pharmacokinetics of commonly used opiates, and naloxone, risk factors and prevention techniques for opiate overdose, signs and symptoms for the early recognition of opiate overdose, prevention of choking and aspiration in the unconscious patient, techniques of rescue breathing, routes of administration and dosing guidelines for naloxone and protocols for follow up care 15. Since January of 2001, CRA has reported providing approximately 3,500 people with naloxone, resulting in 319 reversals. These reversals were associated with a 20% decrease in overdoses in 2001 and a 10% decrease in 2002 and 2003. This reversed a steady increase in heroin overdoses since 1991 16.

The S.K.O.O.P naloxone training and distribution program provided overdose prevention training for current or former drug users. Each participant received a prescription for Naloxone by an onsite doctor at a syringe exchange program. Overdose prevention training ran for between 10-30 minutes. The training focused on; causes of opiate overdose, how to avoid an opiate overdose, and signs of an opiate overdose. Naloxone training included information on naloxone, calling 911 and rescue breathing, and instructions on naloxone administration. Over the course of one year over 1,000 participants were trained and received a naloxone prescription as well as a naloxone ‘kit’ containing two doses of naloxone, a rescue breathing mask, and written information summarizing the overdose revival steps 17, 18. An evaluation of the S.K.O.O.P program found that 82.2% of participants in the training felt comfortable or very comfortable using naloxone if required, and 82.6% reported that they would want naloxone administered on them if they were overdosing. In addition, 41% of participants refilled their naloxone prescription more than once since their training 19.

The Boston Public Health Commission’s Needle Exchange Program trained nonmedical staff to distribute naloxone to potential overdose bystanders, including peers and family of opioid users. Bystander training ran for 15 minutes, and taught overdose prevention techniques, and how to safely administer naloxone. The program utilized an intranasal method of naloxone administration to decrease the risk of needle stick injuries and needle disposal. Data was collected for 15 months in which time 385 overdose kits were provided to potential overdose bystanders and 74 successful reversals were reported 20. Chicago Recovery Alliance: www.anypositivechange.org Maxwell, Bigg, Stanczykiewicz, Carlberg-Racich, 2006 16 Piper, Rudenstine, Stancliff, Sherman, Nandi, Clear, Galea, 2007 17 Piper, Rudenstine, Stancliff, Sherman, Nandi, Clear, Galea 2007 14 15

Piper, Stancliff, Rudenstine, Sherman, Nandi, Clear, Galea, 2008 Piper, Stancliff, Rudenstine, Sherman, Nandi, Clear, Galea, 2008 20 Doe-Simkins, Walley, Epstein & Moyer, 2009 18

19

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San Francisco’s DOPE Project in collaboration with the San Francisco Department of Public Health, has been distributing naloxone since 2003 through the Naloxone Distribution Program. In 2005 the DOPE project became a program of the harm reduction coalition. This program operates out of local needle exchange sites providing overdose education and take home naloxone prescriptions a syringe exchanges and drop in programs. These training take between 10 and 15 minutes and participants receive a prescription for narcan and a narcan ‘kit’. They also offer one to two hour trainings on overdose for community workers, as well as continuing education units for addictions professionals. Identified Components of Take-Home Naloxone Programs

• • • • • • • • •

Education in recognition of an overdose by opiates How to perform mouth to mouth resuscitation (rescue breathing) and put patients in recovery position How to administer Naloxone (either subcutaneously, intravenously, intramuscularly or intranasal) Education on the necessity of calling EMS and reporting overdose A prescription provided by a licensed health care provider (such as a doctor, psychiatrist, or nurse practitioner) Medical records of the prescription Proper labelling and instructions provided with the drug A system for medication refills Providing family, friends, caretakers and service providers with these above components 21.

Methods of Administration of Naloxone

Naloxone is typically delivered via intravenous or intramuscular injection, however it can also be delivered via intranasal spray. A Boston Public Health Overdose prevention program provided training and distribution of the spray to potential overdose bystanders. This program reported 74 successful overdose reversals and noted very few problems with the intranasal form of administration 22. The nose has absorption rates that are comparable to intravenous administration, and surpass intramuscular transmission. The intranasal administration of naloxone has not been examined as thoroughly as other forms of administration, however some of its benefits for peer-based administration include a reduction in needle stick injuries, and thus the risk for blood borne virus transmission 23. A drawback of this form of naloxone administration is that current preparations of naloxone are not ideal for intranasal administration as the doses required for nasal absorption exceed recommended amounts for intravenous and intramuscular administration. 24 Reported Challenges to Naloxone Distribution

van Dorp, Yassen, Dahan & Leiden, 2007, Weisser & Parkinson, 2008 Doe-Simkins, Walley, Epstein & Moyer ,2009 23 Kerr, Dietze, & Kelly, 2008 24 Kerr et al, 2008 21 22

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• • • • •

Considerable stigma exists surrounding opioid dependence, and the use of naloxone Opiate user misconceptions about naloxone Police involvement and prescription laws as systemic challenges to distributing naloxone 25 Physician reluctance to prescribe naloxone Third party administration of naloxone

Recommendations

In order to meet the needs the diverse opiate using population, the SKOOP project evaluation recommends flexibility in the development, implementation and evaluation of naloxone distribution programs. Overdose prevention training curriculum must be adaptable to be delivered quickly and effectively in a range of settings. They further suggest that when evaluating program components. Utilizing the expertise and feedback from program participants is integral for program success 26.

Some of the identified recommendations for Kitchener based naloxone distribution program include; the need for support of naloxone by a range of professional organizations, policy reform regarding naloxone prescription, promotion of over the counter sales, promotion of intranasal delivery of naloxone as an alternative to injection and developing support from local physicians through physician education about evidence-based harm reduction schemes.

Conclusion

Overwhelmingly, overdose prevention training and naloxone distribution programs have been shown to successfully train individuals who use opioids and potential bystanders in the prevention of overdose through the peer administration of Naloxone. 27 Ultimately, naloxone distribution is not the whole solution to preventing overdoses but it is an integral part of effective overdose prevention and intervention programs that aim to reduce overdose deaths and drug related harms.

Gaston, Best, Manning & Day, 2009 Piper, Rudenstine, Stancliff, Sherman, Nandi, Clear, Galea, 2007 27 Strang et al, 2008, Doe-Simkins et al, 2009, Gaston et al, 2009, Green et al, 2008, Piper, Stancliff, Rudenstine, Sherman, Nandi, Clear & Galea, 2008 25 26

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References Beletsky L, Ruthazer R, Macalino GE, Rich JD, Tan L, Burris S.(2007). Physicians' knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities. Journal of Urban Health. 84, 126-36 Compendium of Pharmaceuticals and Specialties: The Canadian Drug Reference for Health Professionals (44th Edition). Canadian Pharmacists Association: 2009. Doe-Simkins M, Walley AY, Epstein A, Moyer P. (2009). Saved by the nose: bystanderadministered intranasal naloxone hydrochloride for opioid overdose. American Journal of Public Health. 99, 5 788-91 Green TC, Heimer R, Grau, LE. (2008). Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction. 103, 979-89

Gaston, R, Best, D, Manning, V, Day, E. (2009). Can we prevent drug related deaths by training opioid users to recognize and manage overdoses? Harm Reduction Journal, 6 26 Harm Reduction Coalition: Principles on Harm Reduction: http://harm.live.radicaldesigns.org

Kerr D, Dietze P, Kelly AM. (2008). Intranasal naloxone for the treatment of suspected heroin overdose, Addiction. 103, 379-86

Kim D, Irwin KS, Khoshnood K. (2009) Expanded access to naloxone: options for critical response to the epidemic of opioid overdose mortality. American Journal of Public Health 99, 402-7

Maxwell S, Bigg D, Stanczykiewicz, K, Carlberg-Racich, S (2006). Prescribing naloxone to actively injecting heroin users: A program to reduce heroin overdose deaths. Journal of Addictive Diseases, 25, 89-96

Piper, T, Stancliff S, Rudenstine S, Sherman, S, Nandi V, Clear, A, Galea S. (2008). Evaluation of a naloxone distribution and administration program in New York City. Substance Use & Misuse, 43, 858-870.

Piper, T. Rudenstine, S. Stancliff, S. Sherman, S. Nandi, V. Clear, A, Galea S. (2007). Overdose prevention for injection drug users: lessons learned from naloxone training and distribution programs in New York City. Harm Reduction Journal, 4 Seal, K, Thawley, R, Gee, L, Bamberger, J, Kral, A, Ciccarone, D, Downing M, and Edlin, B. (2005). Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study. Journal of Urban Health 82, 303-311 198 OHRDPmanualprinting.indd 208

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Strang, J, Manning, V, Mayet, S, Best, D, Titherington, E, Santana, L, Offor, E, Semmler, C. (2008). Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses. Addiction. 103, 1648-57

Tobin, K, Sherman, S, Beilenson, P, Welsh, C, Latkin, C. (2009). Evaluation of the Staying Alive programme: training injection drug users to properly administer naloxone and save lives. International Journal of Drug Policy, 20, 131-136 van Dorp, E.L., Yassen, A., Dahan A. Leiden (2007). Naloxone treatment in opioid addiction: the risks and benefits. Expert Opinion on Drug Safety. 2, 125-32

Weisser, J, Parkinson, M. (2008). Saving lives: overdose prevention & intervention projects in select North American Cities. Community Safety & Crime Prevention Council: Region of Waterloo.

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Overdose Prevention and Intervention Group Membership Doug Rankin – Community Developer Worker

Kitchener Downtown Community Health Center

Dianne Redding – Public Health Nurse Region of Waterloo Public Health

Heidy Choi-Keirstead – Public Health Planner Region of Waterloo Public Health

Karen Verhoeven – Manager, Aids/STD/Dental Program Region of Waterloo Public Health

Kimberly Zinger RN BScN Family Practice Nurse - Community Volunteer Leesa Stephenson -ACCKWA

Lesa Irish – Support Coordinator Concurrent Disorders and Moblie Crisis Team

Canadian Mental Health Association (CMHA) Lindsay Klassen – Volunteer

Micheal Parkinson - Waterloo Region Crime Prevention Council Sandy Dietrich-Bell – Executive Director ROOF

Susan Collison – Grand River Hospital

Margaret McGee – Public Health Nurse Region of Waterloo Public Health

Brandon Spunar - House of Friendship Brendan McCallum – Natasha Campbell –

Alice Maguire, MSW, RSW- Community Volunteer

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R

References Ontario Public Drug Programs Division. Ministry of Health and Long‐Term Care. Notice from the Executive Officer. February 17, 2012. Honourable Minister Deb Matthews. Ministry of Health and Long‐Term Care. The Star. April 6th, 2012. Irfan A. Dhalla, MD MSc, et al. Prescribing of opioid analgesics and related mortality before and after the introduction of long‐acting oxycodone. Canadian Medical Association Journal. December 8, 2009. vol. 181 no. 12. Dr. Rita Shahin, AMOH and Shaun Hopkins. How to Develop a Peer Based Naloxone Program‐ legal, liability and prescription issues. The Works, Toronto Public Health. March 2012. Marshall, Chantel RN, BScN. Naloxone Training Guide: The Point, Prevent Overdose in Toronto. The Works, Toronto Public Health. April 2012. Bayoumi AM and Strike C, et al. Report of the Toronto and Ottawa Supervised Consumption Assessment Study, 2012. Toronto, Ontario. St. Michael’s Hospital and the Dalla Lana School of Public Health, University of Toronto. April 2012. Department of Health (England) and the devolved administrations. Drug Misuse and Dependence: UK Guidelines on Clinical Management, 2007. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive. 2007. http://www.nta.nhs.uk/ uploads/clinical_guidelines_2007.pdf Community‐Based opioid overdose prevention programs providing naloxone ‐ United States, 2010. Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report. 2012 Feb 17;61:101‐5. http://www.cdc.gov/mmwr/pdf/wk/ mm6106.pdf

References

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The Point Program Fact Sheet. Toronto Public Health. 2011. Product Monograph: Naloxone Hydrochloride Injection USP. Sandoz Canada Inc. September 30, 2005. Kevin Flemen. Hostel Opiate Overdose Risk Assessment Tool (HOORAT). 2010. http://www.kfx.org.uk/ resources/HOORAT%20‐%20v1.pdf Drug Overdose‐ Opiate Withdrawal and Addiction. Drug‐Aware: Your Partners in Patient Care. 2012. http://www.drug‐aware.com/drug‐overdose‐opiate‐withdrawal‐addiction.htm). Frequently Asked Questions. Heart and Stroke Foundation of Canada, 2010 Guidelines for CPR and ECC. October 18, 2010. http://www.heartandstroke. com/atf/cf/%7B99452D8B‐E7F1‐4BD6‐A57D‐ B136CE6C95BF%7D/FAQ_HSF_ENG_1.pdf Steen PA. Does active rescuer ventilation have a place during basic cardiopulmonary resuscitation? Circulation. 2007;116:2514 –2516. Canadian Red Cross First Aid review 2011. Canadian red cross. Bulletin 1: June 2011. News Release: Compression‐only CPR means more Canadians can save lives. Canadian Red Cross. 2010. The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circulation. November 2, 2010, Volume 122, Issue 18 http://circ.ahajournals.org/content/122/18_suppl_3/S685.full) The 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. October 19, 2010, Volume 122, Issue 16. http://www.ilcor.org/en/home/

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Community-Based Naloxone Distribution Guidance Document