Sarz Maxwell MD FASAMSarz Maxwell MD FASAMsarzmaxmd @yahoo.com. sarzmaxmd @yahoo.com.

www. AnyPositiveChange.orgwww. AnyPositiveChange.org

“… he was nodding and then I looked over and he was … well,

there’s a smell, you know? I knew he was dead.

And I didn’t know what to do, I just parked the car and got on the bus.

He was dead. What could I do?”

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The diagnosis and management of anaphylaxis.

SOURCE(S): J Allergy Clin Immunol 1998 Jun;101(6 Pt 2):S465-S528 [337 references] MAJOR RECOMMENDATIONS: Patient education may be the most important preventive strategy. Patients should be carefully instructed about hidden allergens, cross-reactions to various allergens, unforeseen risks during medical procedures and when and how to use self-administered epinephrine.

Standards of medical care for patients with diabetes mellitus.

SOURCE(S): Diabetes Care 2001 Jan;24(Suppl 1):S33-S43 [32 references] MAJOR RECOMMENDATIONS:Family members and close associates of the patient who uses insulin should be taught to use glucagon.

Pure opiate antagonist >40 years experience by emergency

personnel for OD reversal Only effect is blockade of opiate

receptor Not addictive; no potential for

abuse No side effects except precipitation

of withdrawal Dose- and delivery-sensitive

Options Advantages Disadvantages

Single-dose pre-loaded syringe

Pre-measuredNo add’l equipment

Cost (~$15 USD /dose)Fragile apparatusSingle dose

Intranasal atomizer

No needlesPremeasured

Cost (~10 USD /dose)Slightly less efficacySingle dose

Multi-dose multi-use 10cc vial

Cost (~$0.27 /dose)Multiple dosesVery portable / durable

Need add’l needles?contamination?

Average heroin user has witnessed 4 OD’s, at least 1 of them fatal

Deaths of peers & personal experience with OD do not ‘teach’ actively-using heroin addicts to stop using heroin

Heroin addicts are interested in helping other addicts in trouble

Participants definitely motivated to intervene in OD situations

Participant focus groups informed program developmentLow thresholdMulti-dose vial formulation

89% approve the idea 92% express willingness to attend

training session Concerns:

Police harrassment & legality of naloxone possession

Fear of dopesickness Dose- and delivery-sensitive Wright et al 2006 UK

Kerr et all 2008 Australia

“I was just freakin’ out, thinking: ‘I wish I knew

how to do CPR’… and I was like,

‘Oh, why don’t I know this?’”

Death of CRA co-founder in 1997 Begin distributing naloxone in 1997 2000 actively expanding program Train all CRA operatives to educate and

distribute

US law allows a prescription to be written when a doctor-patient relationship exists Chart Documentation of education RE prescription

Medical director trained CRA operatives to educate & distribute

Intake form developed with brief history, checklist for education, and standing order

OEND occurred at all 22 weekly SEP sites plus cell phone on-call

Participants quickly became distributors

OD Prevention Early Recognition

› Unresponsive› Before cyanosis

Rescue Breathing Naloxone administration

› 1 cc (0.4 mg) IM› > 1” needle› Multi-use vial

Aftercare › Do not use more opiate!

High will return in 30-40 min› Return of OD› Transport for medical f/u

Age > 34 Using in combination with other drugs

AlcoholCocaine

PONSRespiratory CentreOpiates depress respiratory drive

MEDULLACardiac Centre

Cocaine stimulates heartbeat, blood

pressure

Mixing drugs Using alone Recent period of abstinence – as

brief as 3 days will decrease toleranceDetox programIncarceration

… I put myself in detox and I got out, shot up a bag … and he was with me, thank god, because I went out.”

“He got out of the joint… came back, thought he had the same tolerance… but he didn’t…

Drug Duration potency

Methadone 24 hr ++++

Heroin 6 – 8 hr +++++

Oxycodone 3 – 6 hr +++++

Codeine 3 – 4 hr +

Demerol 2 – 4 hr ++

Morphine 3 – 6 hr +++

Fentanyl 2 - 4 hr ++++++++++++++++++++++++

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HopeHopeFuture-orientationFuture-orientation

NALOXONENALOXONE

EmpowermentEmpowerment++

New Message:New Message:““it matters if you it matters if you

live or die”live or die”

community, community, altruismaltruism

“I did something that made a difference. The whole world can’t see it

but I know it made a difference. And that’s important… to me.”

Statewide program supported by state DPH Operating in 13 communities SEPs, drop-in centers, treatment programs ( detox,

OTP, residential tx, inpt), ER, home visits, street outreach

>9000 enrolled, ~1000 reversals (11%)

Top 3 most common sites for OTP patient naloxone refills: Needle Exchange Program (40%) Drop-in Center (30%) Methadone Clinic (9%)

Slide courtesy Maya Doe-Simkins

70 patients with opioid dependence syndrome in abstinence-based program trained & given naloxone

6 mos later, participants had retained knowledge, still had the naloxone, but none had used it Transportability Stigma Fear of police

Harm Reduct J, 2009 Sep 24; 6:26

Low threshold – on demand, easily accessible, minimal paperwork

Education – duration; by whom Venue – user-friendly Formulation – simple, durable Doses and Refills – multiple doses

OD relapse Multiple simultanerous victims Abundance >> Confidence

““It used to be, overdose, you always It used to be, overdose, you always

talked about it in past tense: ‘I HAD talked about it in past tense: ‘I HAD

a friend who OD’d.’ Now, overdose a friend who OD’d.’ Now, overdose

is in the present tense: ‘I HAVE a is in the present tense: ‘I HAVE a

friend who OD’d last week’.friend who OD’d last week’.

Naloxone did that.”Naloxone did that.”

Dan Bigg Karen Stanczykiewiz Greg Scott Suzanne Carlberg –

Racich John Gutenson

Susie Gualtieri Sharon Sereda Esther, Cheryl, Cliff, Andrew …

All of our courageous participants, who make this

program work

the end(s)

www. AnyPositiveChange .orgsarzmaxmd @ yahoo.com