Overdose Prevention & Naloxone Policy and Procedures Effective date:

I. PURPOSEThepurposeofthispolicyistoprovideapprovedstaffwithguidelinestoutilizenaloxoneinordertoreducefatalopioidoverdosewhileengagingclientsinthetreatmentsetting.

II. POLICYItisthepolicyof(Youragency)fortrainedstafftoadministernaloxone,inaccordancewithstatelawandtheadministrativemedicaldirector’sguidelinesandoversight,topersonssufferingfromopioidoverdoseattheearliestpossibleopportunitytominimizechanceofdeath.

III. DEFINITIONSA. EMS:EmergencyMedicalServicesthatprovidepre-hospitalemergencymedicalcare;suchpractitionersprovideoutofhospitalcareforthosewithanillnessorinjuryB. Naloxone:AnopioidantagonistandantidoteforopioidoverdoseproducedinintramuscularandintranasalformsC. Opioids:Catchalltermforprescription,synthetic,semi-synthetic,ornaturalopiatedrugsD. Opiates:Naturallyderiveddrugsfromthepoppyplant,suchasheroinoropiumE. OpioidOverdose:Anacuteconditioncausedbythefloodingoftheopioidreceptorsinthebrainbyopioids.Itcancauseextremephysicalillness,decreasedlevelofconsciousness,respiratoryarrest,ordeath.F. IMNaloxone:Referstotheintramuscular(IM)administrationofnaloxone,eitherfromavialandsyringe(manufacturedbyHospira)oranauto-injector(manufacturedbyKaleo,brandedEvzio)G. INNaloxone:Referstotheintranasal(IN)administrationofnaloxone,eitherfromanasalspraydevice(manufacturedbyAdapt,brandedNarcan)ora2mg/2mlsyringewithnasaladaptor(manufacturedbyIMS/Amphastar)

IV. ON-SITENALOXONEUSEPROCEDURES

A. (Youragency)shallappointaNaloxoneCoordinator.TheNaloxoneCoordinator’sresponsibilitieswillinclude:

1. Workingwithadministrativemedicaldirectortocreateanagency-widestandingorderfornaloxone(seeAppendix1fortemplate)2. Collaboratingwithlocalpartnerstoobtainnaloxone,eitherdirectlyorbyprescription3. Choosekeyareastostorenaloxone,ensuringthatstoragetemperaturesdonotexceedrecommendedrange4. Ensurethatnaloxonekitsarecurrentandnotpastexpirationdate5. Ensurethatauthorizedstaffareadequatelytrainedinoverdoserecognition,naloxoneuse,andstorage(seesubsectionsIV.D.andIV.E.)6. Createandmaintainnaloxoneusereportformandlog(seeAppendix2fortemplate)7. Replacenaloxonekitsthataredamaged,unusable,expired,orused.

B. EachIM(intramuscular)naloxonekitshallinclude:

1. Instructionsforadministrationofnaloxone(seeAppendix3forexample);2. TwoIMsyringes(preferably22-25g,1-1.5”,3cc)and3. Twovials0.4mg/mLnaloxonebyHospira;OR4. OneboxEvzioauto-injectorbyKaleo(comeswithtwodevices);5. OneCPRfacemask/barrierdeviceformouth-to-mouthresuscitation

C. EachIN(intranasal)naloxonekitshallinclude:1. Instructionsforadministrationofnaloxone(seeAppendix4forexample);2. OneboxNarcannasalspraybyAdapt(comeswithtwodevices);OR3. Twovials2mg/2mLnaloxonebyAmphastarand4. Two2mLLuer-JetLuer-Lockneedlelesssyringeand5. Twomucosalatomizerdevices(MAD-300);6. OneCPRfacemask/barrierdeviceformouth-to-mouthresuscitation

D. IndicationsandUse1. Authorizedstaffshallcheckforresponsivenessifclientisbelievedtobesufferingfromanopioidoverdose.Informationthataclientissufferingfromanopioidoverdoseincludes,butisnotlimitedto:

• Noresponsetoexternalstimulation,suchasasternumrub• Blueorgrayskin,lips,orfingertips• Depressedorslowrespirations• Difficultybreathing(labored,shallow,orhaltedbreaths)• Decreasedpulserate• Pinpointpupils,eveninadarkenedenvironment• Evidenceofingestion,inhalation,orinjection(needles,cookers,

tourniquets,needletracks,aluminumfoil,etc.)2. StaffshallsummonEMSbycalling911andcommunicatingthatthepatientisnotbreathingorinsuspectedoverdose,andthatnaloxoneadministrationisintended3. StaffshallmaintainuniversalprecautionsagainstpathogensbyusinglatexglovesifusingIMnaloxone,andusingaCPRfaceshieldorbarrierifperformingrescuebreathing.4. Staffshalladministeronedoseofnaloxone5. Ifpossible,staffshallbeginrescuebreathingfortwominutes.Rescuebreathingconsistsofonedeepbreathinthesubject’smoutheveryfiveseconds,ensuringthatclientislyingontheirback,headistiltedup,andnoseisplugged.6. Ifnoresponseaftertwominutes,staffshalladministerseconddoseofnaloxoneandresumerescuebreathinguntilclientbeginsbreathingontheirownorEMSarrives7. StaffshallensureaccuratecommunicationtoEMSforproperpatientrecorddocumentationbeforetransporttohospitalemergencydepartment8. Supervisornotificationshouldbemadeassoonaspracticable9. Documentationofnaloxoneuseshouldberecorded.

E. Maintenance,Storage,andReplacementofNaloxone1. StaffwhousenaloxoneshallcommunicatewithNaloxoneCoordinatortoensurenaloxoneisreplaced2. Missing,damaged,orexpirednaloxonekitswillbereporteddirectlytotheNaloxoneCoordinatorandreplaced3. Temperaturestorage:

• IMHospirakitsstoreat68-77°F• IMEvziostoreat59-77°F,incursionspermittedfrom39-104°F• INNarcanspraystoreat59-77°F,incursionspermittedfrom39-104°F• INAmphastarkitsstoreat59-86°F

V. DISTRIBUTING/PRESCRIBINGNALOXONETOCLIENTSA. Identifyingclientswhomaybenefitfromoverdoseprevention/naloxonetraining:

1. Clientswithopioidusedisorderdiagnosis;2. Clientswithhistoryofopioiduse,abuse,ordependence;3. Currentopioidusers;4. Pastopioiduseandrecentreleasefromjail,prison,detox,inpatient,hospital,orafteranyperiodofsustainedabstinence;5. Friendsorfamilymembersofanyoftheabove.

B. Educatingclientsonintake,assessment,orbeforerelease

1. Identifyclientinneedofoverdoseprevention/naloxonetraining2. Askclientiftheyhavewitnessedorexperiencedanoverdose,andwhattheyknowaboutoverdoseprevention3. Reviewthe5componentsofoverdoserisk:

• Mixingdrugs• Tolerancechanges• Quality/purity• Physicalhealth• Usingalone

4. Teachclienthowtorecognizeanoverdose:• Noresponsetoexternalstimulation,suchasasternumrub• Blueorgrayskin,lips,orfingertips• Depressedorslowrespirations• Difficultybreathing(labored,shallow,orhaltedbreaths)• Decreasedpulserate• Pinpointpupils,eveninadarkenedenvironment

• Evidenceofingestion,inhalation,orinjection(needles,cookers,tourniquets,needletracks,aluminumfoil,etc.)

5. Educateclientonnaloxoneinformation:• Onlyworksonopioids,maynotworkonpoly-drugOD• Wearsoffafter45-90minutes,overdosemayreoccur• Patientwillbesickandmaywanttouseagain• Naloxonecannothurtaperson

6. Educateclientonnaloxoneuse• Checkforresponsivenesswithsternumrub• Call911• Administer1doseofnaloxone• Rescuebreathefortwominutes• Ifnoresponse,administer2nddoseofnaloxone• Continuetorescuebreatheuntilparamedicsarrive

7. Encourageclienttoreportanyuseofnaloxoneforoverdosereversalandtoobtainarefillifused,lost,expired,stolen,ordestroyed8. Obtainsigneddocumentfromclientstatingthatstafftrainedthemonoverdoseprevention,recognition,andresponse(seeAppendix5)

C. PrescribeorDispenseNaloxone

1. Toprescribe:PrescriptionmaybewrittentoclientbyanMD,NP,PA,orDO2. Staffwillobtainprescribednaloxoneforclient,eitherdirectlyatthepharmacyorfromadeliveringpharmacyandensurethatclientreceivesthemedicationassoonaspossible3. AHCCCScoversallformulationsexceptforEvzioautoinjector;mostotherprivateinsurancescovernaloxoneaswell4. Todispense:Naloxonemaybeobtainedthroughseveralavenues:

• Staffcanpurchasenaloxoneforclientfromapharmacistwithoutaprescription.NotethatasofJanuary2017,insuranceswillnotcoverover-the-counternaloxone

• Agencycancollaboratewithothercommunitypartnerstoreceivenaloxonekitsfordistributiontoclientswithbarrierstoobtainingprescriptionsorprescribedmedication

• AsofJanuary2017,agenciescanapplyfordonatedproductfromClintonFoundation(forAdaptNarcannasalspray)orKaleo(forEvzioautoinjector)

5. Ifdispensingwithoutaprescription,agencymustuseastandingorder(seeAppendix1)

VI. TrackingNaloxoneDistributionandReversalReportsRecordingnaloxoneprescription,distribution,andorreversalreportsshowsuccessoftheprogramandisveryimportantkeepalogwithinformation,includingbutnotlimitedto:A. Clientname(OPTIONAL!)B. Engagement/trainingdateC. Typeofnaloxonegiven(IMorIN)D. DateprescriptionwaswrittenE. DateprescriptionwasfilledornaloxonedispensedF. Dateofreporteduseforreversal

InformationshouldbetrackedandloggedbyNaloxoneCoordinator.Ifpartneringwithanoutsideagencytoobtainnaloxone,reportinformationtothatagency.

Appendix1Standingordertemplate

OverdoseEducationandNaloxoneDistributionProject

NALOXONESTANDINGORDER

Naloxoneisindicatedforthereversalofopioidoverdoseinducedbynaturalorsyntheticopioidsinthesettingofrespiratorydepressionorunresponsiveness.Itiscontraindicatedinpatientsknowntobehypersensitivetonaloxonehydrochloride.

Thisstandingordercoversthepossessionanddistributionofnaloxonekits,toincludenaloxonehydrochloride,intramuscularsyringes,andoverdosepreventionmaterials,inconjunctionwiththeSPWOverdoseEducationandNaloxoneDistributionProject.

1. ThisstandingorderauthorizesalltrainedstaffandvolunteersattheAGENCY NAMEtomaintainsuppliesofnaloxonekitsforthepurposeofusingthemtorescueaparticipantthoughttobeoverdosingonopioids;anddistributingthemtoapersonatriskofexperiencinganopioid-relatedoverdoseortoafamilymember,friend,orotherpersoninapositiontoassistanindividualatriskofexperiencinganopioid-relatedoverdose.

OrdertoDispenseUponsatisfactoryassessmentthatthepersontoreceivethenaloxonekitisapersonatriskofexperiencinganopioid-relatedoverdoseorafamilymember,friend,orotherpersoninapositiontoassistapersonatriskofexperiencinganopioid-relatedoverdose,anduponcompletionoftrainingregardingrecognizingandrespondingtosuspectedopioidoverdose,dispenseonenaloxonekit,toincludeataminimum:

§ Two1mlvialsofnaloxonehydrochloride§ Twointramuscularsyringes§ Printedmaterialstoincludehowtorecognizeandrespondtosuspectedopioidoverdose,

howtousethedevice,howtodisposeofsyringes,andtheimportanceofsummoningemergencyresponders

Theauthorizeddispenserwilllogalldispensednaloxoneandoverdoserescuesonaformapprovedbytheorderingphysician.

DirectionsforAdministrationAdministernaloxonetoapersonsuspectedofanopioidoverdosewithrespiratorydepressionorunresponsivenessasfollows:

1. Ifpractical,summonemergencymedicalservices2. Removelidfromnaloxonevial3. Insertsyringeintovialanddrawup1mlofnaloxone4. Administer1mlofnaloxoneviaintramuscularinjectionintoupperarm,buttock,orthigh5. Initiaterescuebreathingandmonitorrespirationandresponsivenessofnaloxone

recipient

6. Ifnoresponseafter2-3minutes,administeranother1mldoseofnaloxoneviaintramuscularinjection

_______________________________________ _____________________Physician’sSignatureandLicenseNo. Date

_______________________________________ __________________PhysiciansName(print) OrderExpiration

Appendix2Naloxonedistribution&usetrackinglog

OverdoseEducation&NaloxoneDistributionTracking

Distributionsite:Clientname:

Trainername:

#&typeofkitsprescribed:

Dateprescriptionwritten:

Dateclientobtainednaloxone:

Dateofreporteduse:

Locationofreporteduse:

Naloxoneusedbywhom:

Appendix3Intramuscularnaloxoneinstructions

Ifyoususpectanopiateoverdose,rubtheperson’ssternumhardwithyourknuckles.Iftheydonotrespondtothepain,call911,&thengivethepersonnaloxone.

1. Poptheorangelidoffofonevial.Stickanintramuscular1”needleintothethinfilm&pullupalloftheliquid.Ifyoudon’thaveanintramuscularneedle,youcanuseaninsulinsyringe,thoughitisnotideal.

2. Stickthatbadboyinyourfriend’sarmorthighandinjectallofthemedication.Noneedtolookforavein.

3. Whileyou’rewaitingforittokickin,performrescuebreathingontheperson.Noneedforchestcompressions,justtilttheirheadback,plugtheirnose,andgiveadeepbreathevery5seconds.

4. Ifthefirstdosedoesn’twakeyourfriendupwithin2minutes,givethemtheseconddose.Useanewsyringe.5. Continuetorescuebreatheforthemuntiltheycanbreatheontheirown.6. Oncethey’rebreathingontheirown,placethemontheirsidewiththeirhandundertheirhead.

Importantinfotoknow:

• Evenwithnaloxone,yourfriendmaystillbeatriskofdeathiftheyhavetakenamixtureofbenzos(Xanax,Valium,etc.)oralcoholwiththeopiates,oriftheiropiateswerecutwithfentanylorotherlong-actingopioids.

• Yourfriendwillfeelverysickwhentheywakeup,asnaloxonebringsonimmediatewithdrawal.DONOTLETTHEMUSE,eventhoughtheymaywantto.Otherwisetheymayoverdoseagain.Theymaybeatriskofoverdosingagain1-3hoursafterthenaloxonewearsoffeveniftheydon’tuse,sogetthemmedicalattention.

• Whencalling911:Allyouneedtosayisthatyourfriendisnotbreathing.Ifthedispatcheraskswhy,youarenotobligatedtostateitisanoverdose.Thiswillincreasethelikelihoodthatonlytheparamedicsshowup,notthepolice.Generally,theparamedicsjustwanttohelptheperson&leave,somakesureyoutellthemeverythingyouknowwhentheygetthere.

Whatputsyouatriskofanoverdose?

Overdosehappenswhentheopiatereceptorsinyourbraingetsofilledwithopiates,thatyourbreathingslowstothepointofrespiratoryfailure.Whenyoustopbreathing,yourbrainstopsfunctioning,leadingtodeath.

Thisusuallyhappenswhenyoutakemoreopiatesthanyourbodycanhandle.

Thisoccurswhen:

• Yourtoleranceislowered,duetorecentlygettingoutofdetox,treatment,orjail• Youareusingdope/pillsthatarestrongerthanyouareusedto,i.e.newcut,newdealer,highermg• Yourimmunesystemisweakenedbecauseyouaresickorrecentlygotoverbeingsick• Yourecentlystartedinjecting,orregularlyswitchbetweensmoking/snorting&injecting• Youaremixingopiateswithbenzos(Xanax/Valium,etc)oralcohol–thisisverydangerous!!

Waystoavoidoverdosing:

• Ifyouhaveanewsource,oryouhavebeenusinglessornotatall,testitout!!Youcanalwaysdomore–butyoucan’tdoless.

• Considersmokingorsnortinginsteadofinjectingsoyouknowhowstrongitis.• Trynottousealone.Thisway,ifyoufallout,therewillbepeoplearoundtowitnessit.• Ifyouareusingalone,letpeopleinthehouseknow,ifyoucan,&don’tlockthedoor.

Appendix4Intranasalkitinstructions

Ifyoususpectanopiateoverdose,rubtheperson’ssternumhardwithyourknuckles.Iftheydonotrespondtothepain,call911,&thengivethepersonnaloxone.

1. Layyourfriendontheirback.2. PeelthesilverbackingoffoftheNarcanpackage.3. DONOTtestthedevice.Onceyoupushtheplunger,itallcomesoutatonceandyouwill

notbeabletosprayanymore.4. Stickthetipofthedeviceintoyourfriend’snostrilandpushtheplunger,expellingallof

themedication.5. Whileyou’rewaitingforittokickin,performrescuebreathingontheperson.Noneed

forchestcompressions,justtilttheirheadback,plugtheirnose,andgiveadeepbreathevery5seconds.

6. Ifthefirstdosedoesn’twakeyourfriendupwithin2minutes,givethemtheseconddose.Useanewsyringe.7. Rescuebreatheforthemuntiltheycanbreatheontheirown.8. Oncethey’rebreathingontheirown,placethemontheirsidewiththeirhandundertheirhead.

Importantinfotoknow:

• Evenwithnaloxone,yourfriendmaystillbeatriskofdeathiftheyhavetakenamixtureofbenzos(Xanax,Valium,etc.)oralcoholwiththeopiates,oriftheiropiateswerecutwithfentanylorotherlong-actingopioids.

• Yourfriendwillfeelverysickwhentheywakeup,asnaloxonebringsonimmediatewithdrawal.DONOTLETTHEMUSE,eventhoughtheymaywantto.Otherwisetheymayoverdoseagain.Theymaybeatriskofoverdosingagain1-3hoursafterthenaloxonewearsoffeveniftheydon’tuse,sogetthemmedicalattention.

• Whencalling911:Allyouneedtosayisthatyourfriendisnotbreathing.Ifthedispatcheraskswhy,youarenotobligatedtostateitisanoverdose.Thiswillincreasethelikelihoodthatonlytheparamedicsshowup,notthepolice.Generally,theparamedicsjustwanttohelptheperson&leave,somakesureyoutellthemeverythingyouknowwhentheygetthere.

Whatputsyouatriskofanoverdose?

Overdosehappenswhentheopiatereceptorsinyourbraingetsofilledwithopiates,thatyourbreathingslowstothepointofrespiratoryfailure.Whenyoustopbreathing,yourbrainstopsfunctioning,leadingtodeath.

Thisusuallyhappenswhenyoutakemoreopiatesthanyourbodycanhandle.

Thisoccurswhen:

• Yourtoleranceislowered,duetorecentlygettingoutofdetox,treatment,orjail• Youareusingdope/pillsthatarestrongerthanyouareusedto,i.e.newcut,newdealer,highermg• Yourimmunesystemisweakenedbecauseyouaresickorrecentlygotoverbeingsick• Yourecentlystartedinjecting,orregularlyswitchbetweensmoking/snorting&injecting• Youaremixingopiateswithbenzos(Xanax/Valium,etc)oralcohol–thisisverydangerous!!

Waystoavoidoverdosing:

• Ifyouhaveanewsource,oryouhavebeenusinglessornotatall,testitout!!Youcanalwaysdomore–butyoucan’tdoless.

• Considersmokingorsnortinginsteadofinjectingsoyouknowhowstrongitis.• Trynottousealone.Thisway,ifyoufallout,therewillbepeoplearoundtowitnessit.• Ifyouareusingalone,letpeopleinthehouseknow,ifyoucan,&don’tlockthedoor.

Appendix5Signedproofofnaloxonetraining

NaloxoneDistributionTrainingChecklistTrainer Initials

The most common drugs identified in an opioid-related death (heroin, oxycodone, hydrocodone, fentanyl) and the physical effects these drugs have (slow, shallow, irregular breathing; low pulse; euphoria; unconsciousness) The main causes of drug overdose (low tolerance, polydrug use, using too much, using alone, injecting drug use, purity levels, adulterants like fentanyl) High-risk times (release from prison/jail, leaving rehab or hospital, recent detox, recent relapse, poor physical or mental health, new source, recent significant life events, cash windfall) The signs & symptoms of suspected opiate overdose (slowed/irregular breathing, blue/gray skin/lip color, no response to noise or touch, loss of consciousness) The common myths (Don’t: inflict pain, “balance out” with other drugs, put in bath/shower, ice down the pants, sleep it off) Knows how and when to call 911 (“Person is not breathing” rather than reporting overdose to dispatcher; call 911 before administering naloxone)

Knows when and how to administer naloxone (After non-responsiveness to stimuli. Second dose if not responsive after 2 minutes. Review different naloxone devices.)

Knows about rescue breathing (Clear airway. Pinch the person’s nose, tilt head back, and give deep breaths every five seconds. No need for chest compressions.) Knows about the recovery position (person on side, airway open)

Knows that naloxone is short acting (the effects of naloxone wear off after 45-90 mins, possible that overdose may return) Knows the importance of staying with the person (do not let the person use any other drugs if they gain consciousness, monitor for relapse into respiratory arrest) Knows the importance of not re using the product or the needle once the pack has been opened and how to dispose of used syringe if intramuscular naloxone was used. Knows that developing a plan is important (raising awareness about Naloxone access and OD prevention) Has been informed where to receive naloxone (doctor, community organizations, pharmacies)

Review: I verify I have received the training outlined above: Printed Name______________

1. Check for responsiveness Signature:_______________ 2. Call 911 Date: __________________ 3. Give 1st dose of Naloxone4. Rescue breathe for 2 minutes5. Give them a 2nd dose, if no response6. If you must leave, put them in the recovery position7. Transfer care to EMT or Emergency Department8. Monitor to make sure they do not overdose again