First Responder Naloxone Grant Webinar

July 18th, 2016

Sarah Ruiz, MSW, Naloxone Pilot Program, Massachusetts Department of Public Health

Alexander Walley, MD, MSc, Medical Director, MDPH Opioid Overdose Prevention Pilot Program

Brittni Reilly, MSW, Naloxone Pilot Program, Massachusetts Department of Public Health

Agenda1) The Overdose Problem and Public Safety

2) Fentanyl

3) Naloxone Formulations & OEMS

4) Good Samaritan Law

5) Innovative Public Safety – Public Health Models

6) Roll Call

7) Grant Details and Data Collection

8) Review of Overdose Response Training if needed

The Overdose Problem

Current Statistics

Among the 1,319 individuals whose deaths were opioid-related in 2015 where a toxicology screen was also available, 754 of them had a positive screen result for fentanyl. http://www.mass.gov/eohhs/docs/dph/quality/drugcontrol/county-level-pmp/data-brief-overdose-deaths-may-2016.pdf

Why Police and Fire?• First to the scene of an overdose

• Frequent interaction with high risk populations

• With the right tools, police and fire can make a public health impact

• Builds bridges to active users and their social networks

• Overdose is a true crisis and police and fire can help

Goal of the First Responder Naloxone Grants

For First Responders to carry and administer naloxone in communities most affected by the opioid epidemic

Brockton Police and Fire

Chelsea Police and Fire

Everett Police and Fire

Fall River Police and Fire

Falmouth Police and Fire

Haverhill Police and Fire

Lowell Police and Fire

Lynn Police and Fire

Malden Police and Fire

Medford Police and Fire

New Bedford Police and Fire

Plymouth Police and Fire

Revere Police and Fire

Salem Police and Fire

Saugus Police and Fire

Somerville Police and Fire

Taunton Police and Fire

Worcester Police and Fire

Chicopee Fire

Leominster Fire

Pittsfield Fire

Quincy Fire

Westfield Fire

Yarmouth Fire

Beverly Police

Boston Police

Fitchburg Police

Framingham Police

Lawrence Police

North Attleborough Police

Weymouth Police

Winthrop Police

Rescues and deaths, 2010-2015

Police and Fire naloxone rescues in MA 2010-2015Massachusetts DPH First Responder Pilot

First Responder Naloxone Programs Lessons Learned

• Ensure First Responders perform rescue breathing and wait 3-5 minutes between doses of naloxone

• Do not administer multiple doses without a pause

• Practice ambu-bag skills

• Reinforce that the goal is to restore breathing not full alertness

• Be sure First Responders follow assessment protocol – not every unconscious patient is in an opioid overdose

• Integrate overdose response and naloxone administration into annual re-training

Fentanyl

FentanylFentanyl: a synthetic short-acting opioid 40-50x more

potent than pure heroin

Illicitly manufactured fentanyl is sold in the illicit

market often mixed with heroin and/or cocaine

as a combination product — with or without the

user’s knowledge — to increase its euphoric effects

Fentanyl-related overdoses can be reversed with naloxone, however a higher dose or multiple number of doses per overdose event may be required due to its high potency

http://emergency.cdc.gov/han/han00384.asp

Nasal with separate atomizer

“Multi-step”*

Auto-injector*NEW: Nasal Spray

“Single-Step”

Intramuscular Injection

* In OEMS Clinical Protocols for First Responders

Naloxone formulations

Currently includes only Multi-Step and Auto-Injector

http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-2015-1.pdf

Office of Emergency Medical ServicesPre-Hospital Statewide Treatment Protocols

Good Samaritan & Naloxone Law

Passed August 2012

OEND program rescues: 2006-2016

Active use, in treatment, in

recovery N=4,854

Non-User (family, friend,

staff) N=551

911 called or public safety present 40% 68%

Stayed until alert or help arrived 91% 95%

Program data

Help-seeking (calling 911 or EMS present) by people reporting rescues with MDPH naloxone

Program data

26%

34% 32%37% 37%

42%46% 47% 49%

2007/8 2009 2010 2011 2012 2013 2014 2015 2016 todate

Example of incorporating MGL c.94C s34A into Department Policy

911 Good Samaritan Campaign“Make the Right Call”

Collaboration between DPH and the Office of the Attorney General.

Campaign includes a Roll-Call video done in collaboration with the Mass Chiefs of Police Association.

www.mass.gov/maketherightcall

1. 911 Good Samaritan Campaign “Make the Right Call” video – did you see it? How was it received?2. What are you seeing in your community during overdose response calls? What is standing out to your officers at the scene of the event?3. DPH IM / Single-Step Field Trial - have you seen the IM/Single-Step in the field?4. What else is your department doing besides carrying naloxone?

Roll Call

First Responder Naloxone Grant

Grant Program• New departments: Full grant award will be

deposited into the EFT account on record with the state once paperwork is complete.

• Renewed departments: When paperwork is finalized, 30% of the FY16 award will be deposited into the EFT account on record with the state. Remainder of award will be determined as soon as possible, followed by notifications to departments.

Bulk Purchasing Program• As a First Responder department, you may

purchase naloxone directly from the State Office of Pharmacy Services (SOPS)

• The legislation establishing the trust fund authorizes DPH to reduce the cost of naloxone for municipal first responder agencies below the negotiated SOPS purchase price

• Contact: Edward Cavallari– Edward.Cavallari@massmail.state.ma.us

– 978‐858‐2153

Data Collection

Every time naloxone is administered by your department during the grant period you are required to complete and submit an MDPH First Responder Naloxone Report to DPH.

Why is this data important and what do we use it for?

Technical AssistanceOnline Resources:MassTAPP Page:

http://masstapp.edc.org/first-responder-naloxone-narcan-technical-assistance

DPH-BSAS Page:

http://www.mass.gov/eohhs/gov/departments/dph/programs/substance-abuse/prevention/naloxone-access.html

Go to getnaloxonenow.org

for an online module for first responders (EMTs, firefighters, and law

enforcement officers) with post-test

Overdose ResponseTraining Review

Updated Opioid-Associated Life Threatening Emergency (ADULT) Algorithm –

American Heart Association Guidelines, October 2015

Remember “Four Rights” for medication administration

Massachusetts Office of Emergency Medical Services Minimum Standards for First Responder Training in First Aid, Epinephrine Auto-Injector and Naloxone

Use AR-2-100

• Right Patient (opioid overdose)

• Right Medication (Naloxone-check for clarity)

• Right Date (check expiration)

• Right Dose (spray half (1ml) in each nostril)

• Intranasal naloxone needs to be dispensed with the mucosal atomization device

• If there is nasal trauma or bleeding, do not administer naloxone

Benefits of Intranasal Naloxone

• Nose is an easy access point

• Painless

• Eliminates risk of contaminated needle sticks and needle dispensing

Nasal Naloxone with atomizer – Multi-step

1. Remove both yellow caps from the ends of the syringe

2. Twist the nasal atomizer onto the tip of the syringe

3. Remove the purple cap from the naloxone

4. Twist the naloxone on the other side of the syringe

Give Naloxone: Nasal with atomizer

• Push 1ml (1mg) of naloxone into each nostril

• Administer the entire contents of the 2ml syringe with approximately one half (1ml) administered in each nostril

• Administering one half in each nostril maximizes absorption

Give Naloxone: Nasal with atomizer

NEW: Nasal Spray

NEW: Nasal Spray Administration

Four important points for the New Nasal Spray Single Step

• Do not prime the spray

– you will end up wasting it

• Insert the tip until your fingers are against the nose

• One dose is one nostril

• Nasal trauma will reduce the effectiveness

• Each auto-injector contains only 1 dose

• Inject into muscle or skin of the outer thigh

• Can be injected through clothing if needed

• Device injects intramuscularly or subcutaneously, delivers the naloxone, and retracts the needle fully into its housing

• Needle not visible before, during, or after

Auto-injector Naloxone

• Practice with the Trainer to make sure you are able to safely use the auto-injector in an emergency

• The Trainer does not contain a needle or medicine

• It can be reused to practice your injection

• The red safety guard can be removed and replaced on the Trainer

Auto-injector Naloxone

Give Naloxone: Auto-injector

Give Naloxone: Auto-injector

Give Naloxone: Auto-injector

Give Naloxone: Auto-injector

How does a person respond to Naloxone?

Range of responses:1. Gradually improves breathing and becomes responsive within 3

– 5 minutes 2. Immediately improves breathing, responsive, and is in

withdrawal3. Starts breathing within 3 – 5 minutes but remains unresponsive4. Does not respond to first dose and naloxone must be repeated

in 3 – 5 minutes (keep rescue breathing)5. No response to multiple doses of naloxone

Withdrawal symptoms after naloxone rescue (2010-2014)

Program data – 2008-2016 Other = confused, disoriented, headache, aches

and chills, cold, crying, diarrhea, happy, miserable

• Continue rescue breathing with 1 ventilation every 5 seconds until EMS arrives

• After 3-5 minutes, if the patient is still unresponsive with slow or no breathing, administer another dose of naloxone

After Administering Naloxone

If victim is breathing, but unresponsiveplace in recovery position

Naloxone Deployment Options

• Vehicles, front desk, booking area, holding area

• Vehicle glove compartment

• Vehicle pelican case

• Attached to AED case in passenger compartment

• First in bag

• Issued per shift

• Issued per officer

Naloxone Storage

• Nasal with separate atomizer: Storage between 59°F to 86°F – Avoid extremes in temperatures for long periods of time

– Replace every 6-12 months, before expiration date

• New Narcan Nasal Spray: 59°F to 77°F – Replace before expiration

• Auto-injector: 59°F to 77°F– Temperature excursions are permitted between 39°F and 104°F

– Keep in outer case until needed

– If solution through viewing window is discolored, cloudy, then replace

– Replace before expiration date

Thank you!!

Questions?