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SAMHSA

Opioid Overdose Prevention

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Five Essential Steps for First Responders

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

O

verdose is common among persons who use illicit opioids such as heroin and among those who misuse medications prescribed for pain such as oxycodone, hydrocodone, methadone, buprenorphine, and morphine. The incidence of opioid overdose is rising nationwide. In 2016, more than 42,000 of the drug overdose deaths in the United States involved some type of opioid, including heroin.^1 To address the problem, emergency medical personnel, health care professionals, people who use drugs, and other community members who may witness and respond to an overdose are being trained in the use of the opioid antagonist medication naloxone, which can reverse the potentially fatal respiratory depression caused by opioid overdose. (Note that naloxone has no effect on non-opioid overdoses, such as those involving cocaine, benzodiazepines, or alcohol.^2 ) The steps outlined in this section are recommended to reduce the number of deaths resulting from opioid overdoses.

STEP 1: EVALUATE FOR SIGNS OF OPIOID OVERDOSE

Signs of OVERDOSE , which often results in death if not treated, include:^2

 Unconsciousness or inability to awaken.

 Slow or shallow breathing or breathing difficulty such as choking sounds or a gurgling/snoring noise

from a person who cannot be awakened.

 Fingernails or lips turning blue/purple.

If an opioid overdose is suspected, stimulate the person:

 Call the person’s name.

 If this doesn’t work, vigorously grind knuckles into the sternum (the breastbone in middle of chest) or

rub knuckles on the person’s upper lip.

 If the person responds, assess whether he or she can maintain responsiveness and breathing.

 Continue to monitor the person, including breathing and alertness, and try to keep the person awake

and alert. If the person does not respond, call 911, provide rescue breathing if the person is not breathing on their own, and administer one dose of naloxone.

STEP 2: CALL 911 FOR HELP

AN OPIOID OVERDOSE NEEDS IMMEDIATE MEDICAL ATTENTION. An essential step is to get someone with medical expertise to see the person as soon as possible. If no emergency medical services (EMS) or other trained personnel is on the scene, activate the 911 emergency system immediately. All you have to say is “Someone is unresponsive and not breathing.” Be sure to give a specific address and/or description of your location. After calling 911, follow the dispatcher’s instructions. If appropriate, the 911 operator will instruct you to begin CPR (technique based on rescuer’s level of training).

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

STEP 3: ADMINISTER NALOXONE

If the person overdosing does not respond within 2 to 3 minutes after administering a dose of naloxone, administer a second dose of naloxone. Naloxone should be administered to anyone who presents with signs of opioid overdose or when opioid overdose is suspected. Naloxone is approved by the Food and Drug Administration (FDA) and has been used for decades by EMS personnel to reverse opioid overdose and resuscitate individuals who have overdosed on opioids. Research has shown that women, older people, and those without obvious signs of opioid use disorder are undertreated with naloxone and, as a result, have a higher death rate.^3 Therefore, it is also important to consider naloxone administration in women and the elderly found unresponsive with opioid overdose. Naloxone can be given by intranasal spray and by intramuscular (into the muscle), subcutaneous (under the skin), or intravenous injection.^4 All naloxone products are effective in reversing opioid overdose, including fentanyl-involved opioid overdoses, although overdoses involving potent (e.g., fentanyl) or large quantities of opioids may require more doses of naloxone.

DURATION OF EFFECT. The duration of effect of naloxone depends on dose, route of administration, and overdose symptoms^5 and is shorter than the effects of some opioids. The goal of naloxone therapy should be to restore adequate spontaneous breathing, but not necessarily complete arousal.^5 More than one dose of naloxone may be needed to revive someone who is overdosing. People who have taken longer acting or more potent opioids may require additional intravenous bolus doses or an infusion of naloxone.^6 Comfort the person being treated, as withdrawal triggered by naloxone can feel unpleasant. Some people may become agitated or confused, which may improve by providing reassurance and explaining what is happening. SAFETY OF NALOXONE. The safety profile of naloxone is remarkably high, especially when used in low doses and titrated to effect.^2 When given to individuals who are not opioid intoxicated or opioid dependent, naloxone produces no clinical effects, even at high doses. Moreover, although rapid opioid withdrawal in opioid-tolerant individuals may be unpleasant, it is not life threatening. Naloxone can be used in life-threatening opioid overdose circumstances in pregnant women.^7 The FDA has approved an injectable naloxone, an intranasal naloxone, and a naloxone auto-injector as emergency treatments for opioid overdose. People receiving naloxone kits that include a syringe and naloxone ampules or vials should receive brief training on how to assemble and administer the naloxone to the victim. The nasal spray is a prefilled, needle-free device that requires no assembly and that can deliver a single dose into one nostril. The auto-injector is injected into the outer thigh to deliver naloxone to the muscle (intramuscular) or under the skin (subcutaneous). Once turned on, the currently available device provides verbal instruction to the user describing how to deliver the medication, similar to automated defibrillators. Both the nasal spray and naloxone auto-injector are packaged in a carton containing two doses to allow for repeat dosing if needed.

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

pupils, and increased blood pressure. These symptoms are uncomfortable, but not life threatening. After an overdose, a person dependent on opioids should be medically monitored for safety and offered assistance to get into treatment for opioid use disorder. If a person does not respond to naloxone, an alternative explanation for the clinical symptoms should be considered. The most likely explanation is that the person is not overdosing on an opioid but rather some other substance or may be experiencing a non-overdose medical emergency. In all cases, support of ventilation, oxygenation, and blood pressure should be sufficient to prevent the complications of opioid overdose and should be given priority if the response to naloxone is not prompt.

DO’S AND DON’TS WHEN RESPONDING TO OPIOID

OVERDOSE

 DO attend to the person’s breathing and cardiovascular support needs by administering oxygen

or performing rescue breathing and/or chest compressions.

 DO administer naloxone and utilize a second dose, if no response to the first dose.

 DO put the person in the “recovery position” on the side, if you must leave the person

unattended for any reason.

 DO stay with the person and keep the person warm.

 DON’T slap or forcefully try to stimulate the person; it will only cause further injury. If you cannot

wake the person by shouting, rubbing your knuckles on the sternum (center of the chest or rib cage), or light pinching, the person may be unconscious.

 DON’T put the person into a cold bath or shower. This increases the risk of falling, drowning, or

going into shock.

 DON’T inject the person with any substance (e.g., saltwater, milk, stimulants). The only safe

and appropriate treatment is naloxone.

 DON’T try to make the person vomit drugs that may have been swallowed. Choking or inhaling

vomit into the lungs can cause a fatal injury. NOTE: All naloxone products have an expiration date, so it is important to check the expiration date and obtain replacement naloxone as needed.

REFERENCES

(^1) Centers for Disease Control and Prevention. Opioid overdose. https://www.cdc.gov/drugoverdose/index.html. Accessed Feb 28, 2018. (^2) Sporer KA. Acute heroin overdose. Ann Intern Med. 1999;130(7):584-590. (^3) Sumner S A, Mercado-Crespo MC, Spelke MB, Paulozzi L, Sugerman DE, Hillis SD, Stanley C. Use of naloxone by emergency medical services during opioid drug overdose resuscitation efforts. Prehospital Emergency Care. 2016; 20(2):220-225. (^4) Prescribe to Prevent. Welcome to PrescribeToPrevent.org. http://prescribetoprevent.org. Accessed Feb 28, 2018. (^5) Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367(2):146-155. (^6) LoVecchio F, Pizone A, Riley B, Sami, A, D’Incognito C. Onset of symptoms after methadone overdose. Am J Emerg Med. 2007;25(1):57-59. (^7) Kampman, K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the use of medications in the treatment of addiction involving opioid use_. J Addict Med_. 2015;9(5):358-67. doi:10.1097/ADM. (^8) Somerville NJ, O'Donnell J, Gladden RM, Zibbell JE, Green TC, Younkin M, Ruiz S, Babakhanlou-Chase H, Chan M, Callis BP, Kuramoto-Crawford J. Characteristics of fentanyl overdose-Massachusetts, 2014-2016. MMWR Morb Mortal Wkly Rep. 2017 Apr;66(14):382-386. (^9) Faul M, Lurie P, Kinsman JM, Dailey MW, Crabaugh C, Sasser SM. Multiple naloxone administrations among emergency medical service providers is increasing. Prehospital Emergency Care. 2017 Apr 26:1-8. (^10) Centers for Disease Control and Prevention. Health alert network: recommendations for laboratory testing for acetyl fentanyl and patient evaluation and treatment for overdose with synthetic opioid; 2013. https://www.firstwatch.net/cdc-health-alert- network-advisory-recommendations-laboratory-testing-acetyl-fentanyl-patient-evaluation/. Accessed Mar 1, 2018. (^11) Takase I, Koizumi T, Fujimoto I, et al. An autopsy case of acetyl fentanyl intoxication caused by insufflation of “designer drugs.” Legal Medicine. 2016;21:38-44. (^12) Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: special circumstances of resuscitation, 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S501–S518. doi: 10.1161/CIR.0000000000000264. (^13) World Health Organization. Community Management of Opioid Overdose. Geneva, Switzerland: World Health Organization;

2014. http://apps.who.int/iris/bitstream/10665/137462/1/9789241548816_eng.pdf?ua=1&ua=1. Accessed Mar 1, 2018.

HHS Publication No. (SMA) 18 4742PT2. First printed 2013. Revised 2014, 2016, 2018