Training of Trainers...ORP Training of Trainers 6/7/2016 6 Language •Research demonstrates that the language we use about drug use can affect our attitudes toward people who use

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Training of TrainersMaryland Overdose Response Program

Behavioral Health Administration

Maryland Department of Health and Mental Hygiene

April 20, 2016

INTRODUCTIONPart I

ORP Training of Trainers

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Housekeeping

• Today’s schedule

• Restrooms

• Introductions


Overview

I. Introduction

II. Core Curriculum

III. Tailoring the Training

IV. Practice Teach

V. Maryland Overdose Response Program: Key Elements

VI. Wrap‐up


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Learning Objectives

Participants will:

• Identify 5 signs and symptoms of opioid overdose

• List 5 key steps to respond to an opioid overdose

• Identify 5 ways to prevent opioid overdoses

• Identify ways to tailor overdose response trainings to your audience

• Explain the following key elements of the Maryland Overdose Response Program (ORP):

– How to issue ORP certificate

– How to dispense under standing order


Context

Overdose deaths in Maryland (and in the US) have risen every year since 2010


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Harm Reduction Framework

• Goal: minimize the negative effects of drug use for people who use drugs, their families, and their communities

• Harm reduction approaches:– Are rooted in a commitment to public health & human rights

– Combat stigma – Empower people who use drugs to keep themselves as safe as possible

– Meet people where they are – Aim to attain any positive change

(Harm Reduction Coalition, Harm Reduction International)


Context: Overdose Education & Naloxone Distribution

• Overdose education and naloxone distribution (OEND) has been part of the harm reduction landscape for decades

• Originally provided to those at risk for overdose through syringe exchange programs

• OEND provided crucial education on overdose risk

• Naloxone is an empowerment tool for individual and community


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Evidence Base for OEND

Evidence

OEND is feasible in many settings. • Walley et al. JSAT 2013; 44:241‐7 • Bennett et al. J Urban Health. 2011: 88; 1020‐30 • Enteen et al. J Urban Health 2010:87: 931‐41 • Doe‐Simkins et al. Am J Public Health 2009: 99:

788‐791 • Piper et al. Subst Use Misuse 2008: 43; 858‐70

Participants demonstrate knowledge and skills after training.

• Wagner et al. Int J Drug Policy 2010: 21: 186‐93 • Tobin et al. Int J Drug Policy 2009: 20; 131‐6 • Green et al. Addiction 2008: 103;979‐89

Naloxone does not lead to an increase in risky use, but does lead to an increase in drug treatment.

• Seal et al. J Urban Health 2005:82:303‐11 • Wagner et al. Int J Drug Policy 2010: 21: 186‐93 • Galea et al. Add Beh 2006: 31: 907‐912

OEND contributes to reduction in overdose in communities.

• Maxwell et al. J Addict Dis 2006:25; 89‐96 • Evans et al. Am J Epidemiol 2012; 174: 302‐8 • Walley et al. BMJ 2013; 346: f174


Trauma‐Informed Approach

A trauma‐informed approach recognizes that the impact of trauma is widespread and strives to avoid re‐traumatizing people.

• Why might the material in this training be difficult for some participants?

• As a trainer, how can you be sensitive to overdose‐related trauma?


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Language

• Research demonstrates that the language we use about drug use can affect our attitudes toward people who use drugs.

• Our attitudes, in turn, impact our actions and our policies.

• As a trainer, part of your role is to model how to use non‐stigmatizing language.

More at http://www.facesandvoicesofrecovery.org/sites/default/files/resources/2016%20Kelly%20et%20al.%20‐%20Language%20SUDs%20and%20Policy%20%2800000002%29.pdf


Model Respectful Language

Avoid Use this instead:

Substance abuserAddictJunkie

Person with a substance use disorderPerson who uses drugs

“Dirty” Positive urinalysis

“Clean” Negative urinalysisSubstance‐free

Substance abuse Substance useSubstance misuseNon‐medical useRisky use


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Applying Adult Learning Principles

• Rather than assuming participants don’t know anything about the subject matter, find out what they know & build on it.

• Give people a chance to practice assembling and using naloxone devices.

• Ask people to teach you.


CORE CURRICULUMPart II

ORP Core Curriculum

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Core Curriculum Overview

A. What is an Opioid?

B. Recognizing an Opioid Overdose

C. Responding to an Opioid Overdose

D. Information for Certificate Holders

E. Tips for Preventing Opioid Overdose (optional)

F. Suggested Resources for Family & Friends (optional)

ORP Core Curriculum

WHAT IS AN OPIOID?Core Curriculum: Section A

ORP Core Curriculum

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Opioids

An opioid is any drug that contains opium (or its derivative).

Opioids can be:

• Natural or synthetic

• Prescription medications or illegal drugs

• Pills, capsules, powder or liquid

• Swallowed, smoked, snorted or injected

ORP Core Curriculum

About Opioids

Opioids:

• Manage pain, suppress coughs and treat opioid use disorders (addictions)

• Cause feelings of euphoria, contentment and/or detachment

• Have effects lasting from 3 to 24 hours

In excessive amounts, opioids can suppress a person’s urge to breathe.

ORP Core Curriculum

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Examples of Prescription Opioids

Generic Name Brand Name

Oxycodone Oxycontin, Percocet, Roxicodone

Oxymorphone Opana

Hydrocodone Vicodin, Lorcet, Zohydro, Zortab

Hydromorphone Dilaudid

Morphine

Meperidene Demerol

Codeine Tylenol 3 & 4

Buprenorphine Suboxone, Subutex, Zubsolv

Methadone

Fentanyl Duragesic

ORP Core Curriculum

Examples of Illicit Opioids

• Heroin

• Non‐pharmaceutical fentanyl– Illicitly produced, synthetic drug

– Pill form packaged to look like prescription medications

– Powder form looks similar to heroin

Fentanyl + heroin can be a deadly combination.

Fentanyl may be hundreds of times more potent than

heroin.

ORP Core Curriculum

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RECOGNIZING AN OPIOID OVERDOSE

Core Curriculum: Section B

ORP Core Curriculum

What is an Opioid Overdose?

Opioid overdose happens when a toxic amount of an opioid—alone or mixed with other opioid(s), drugs and/or substances—overwhelms the body’s ability to handle it.

Many opioid‐related overdoses result from

mixing prescription painkillers or heroin

with benzodiazepines (benzos), cocaine and/or alcohol.

ORP Core Curriculum

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What Leads to Overdose Death?

Respiratory failure

Lack of oxygen in the blood

Vital organs like heart and brain start to fail

Unconsciousness, coma, death

ORP Core Curriculum

Signs & Symptoms of Opioid Overdose

• Loud snoring or gurgling noises

• Body very limp

• Unresponsive

• Skin pale/gray, clammy

• Lips/fingertips turn blue(ish)

• Pulse slow or erratic

• Breathing very slow, shallow, or not at all

• Unconscious

ORP Core Curriculum

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RESPONDING TO AN OPIOID OVERDOSE

Core Curriculum: Section C

ORP Core Curriculum

Responding to an Opioid Overdose

1. Rouse & Stimulate

2. Call 911

3. Give Naloxone

4. Further Resuscitation

5. Care for the Person

ORP Core Curriculum

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Step 1: Rouse & Stimulate

• Noise – Shake person’s shoulders and yell:

“[Name!] Are you all right? Wake up!”

• Pain – If no answer, do a sternum rub:

Make a fist & rub your knuckles firmly up and down the breastbone.

ORP Core Curriculum

Sternum Rub

ORP Core Curriculum

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Step 2: Call 911

Get emergency medical help for

someone experiencing an overdose!

Why?

• Naloxone is only temporary.

• Person may:– have complications or other health problems

– need more naloxone

• May be a non‐opioid overdose situation.

ORP Core Curriculum

Call 911: What to Say

• Tell 911 operator:

–Where you are

–What you observe (e.g., person is turning blue, won’t wake up, making gurgling noises)

• Tell emergency responder onsite:

– Drugs/substances the person used

– Naloxone administered – how much & when

ORP Core Curriculum

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Step 3: Give Naloxone

ORP Core Curriculum

What is Naloxone?

Naloxone is a medicine that reverses opioid overdose by restoring breathing.

About naloxone:

• Wears off in 30 ‐ 90 minutes

• Safe for children and pregnant women

• Delivery: intramuscular, intranasal or intravenous

• No potential for misuse or getting high

• No effect on someone who hasn’t taken opioids

• Side effects are minimal and rare

Naloxone is only effective in reversing opioid overdoses.

ORP Core Curriculum

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How Does Naloxone Work?

• The brain has many receptors for opioids. When too much of an opioid fits on too many receptors, an overdose occurs.

• Naloxone knocks opioids off opioid receptors and binds to receptors for a short time. This blocks the opioids’ effects, quickly restoring breathing.

ORP Core Curriculum

Naloxone Storage & Disposal

Storage• Do not attach naloxone to delivery device until ready to use • Store in original package at room temperature• Avoid exposure to light• Keep in a safe place away from children & pets, but easy to

access in case of emergency

Disposal

• Naloxone devices with syringes: dispose as medical sharps (in a rigid container)

• Other devices: dispose in household trash

ORP Core Curriculum

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Intranasal Naloxone

Amphastar

NARCAN©

ORP Core Curriculum

Instructions: Amphastar Nasal Naloxone

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①Remove caps from needle‐less syringe.

② Screw nasal atomizer into top of syringe.

③ Remove cap from vial of naloxone.

④Gently twist naloxone vial into

syringe until you feel it catch.

ORP Core Curriculum


⑤Tilt the head back (so the naloxone will not run out of the nose).

⑤ Spray one half (1 cc) of the naloxone up each nostril.

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⑦ Allow 1 to 3 minutes for the naloxone to work.

Continue resuscitation as necessary.

⑧ If breathing is not restored after 2 or 3 minutes, give another dose of naloxone. Continue resuscitation as necessary.

⑨ Stay with the person & provide care as directed until medical help arrives.

ORP Core Curriculum

Instructions: NARCAN© Nasal Spray

ORP Core Curriculum

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① Remove NARCAN nasal spray from box. Peel back tab with circle to open.

① Hold NARCAN nasal spray with your thumb on the bottom of the plunger and your first & middle fingers on either side of the nozzle.

ORP Core Curriculum


③ Tilt head back & support person under neck.Gently insert tip of nozzle into nostril, until your fingers on either side of the nozzle are against the bottom of the nose.

④ Press plunger firmly to administer.

ORP Core Curriculum

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⑦ Allow 1 to 3 minutes for the naloxone to work.


⑧ If breathing is not restored after 2 or 3 minutes, give another dose of naloxone.


⑨ Stay with the person & provide care as directed until medical help arrives.

ORP Core Curriculum

Intramuscular (Injectable) Naloxone

ORP Core Curriculum

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Instructions: Injectable Naloxone

① Pop off the flip‐top from naloxone vial.

② Insert needle into vial & draw up 1 cc of naloxone into syringe.

③ Use alcohol wipe to clean injection site: shoulder, thigh, or buttocks.

④ Inject needle straight into muscle (through clothes, if necessary), then push in plunger.

Do not inject naloxone into the person’s heart, chest, or back.

ORP Core Curriculum


Shoulder Thigh Buttocks(upper, outer quadrant)

Where to inject naloxone:

ORP Core Curriculum

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⑤Allow 1 to 3 minutes for the naloxone to work.


⑥If breathing is not restored after 2 or 3 minutes, give another dose of naloxone.


⑦Stay with the person and provide care as directed until medical help arrives.

ORP Core Curriculum

Evzio

ORP Core Curriculum

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Instructions: Evzio

①Pull off the red safety guard.

Note: the red safety guard is made to fit tightly. Pull firmly to remove.

ORP Core Curriculum

Instructions: Evzio

②Place the black end of Evzio against the outer thigh. (Over clothing, if needed.)

Press firmly & hold in place for 5 seconds.

• Evzio makes a distinct sound (click & hiss) when pressed against the thigh. This is normal & means that it is working correctly.

• Keep Evzio firmly pressed on the thigh for 5 seconds after you hear the click & hiss sound.

• The needle will inject & then retract. The needle is not visible after use.

ORP Core Curriculum

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Instructions: Evzio

③ Allow 1 to 3 minutes for the naloxone to work. Continue resuscitation as necessary.

③ If breathing is not restored after 2 or 3 minutes, give another dose of naloxone. Continue resuscitation as necessary.

⑤ Stay with the person & provide care as directed until medical help arrives.

Note: individual Evzio device cannot be reused.

ORP Core Curriculum

Practice: Naloxone Devices

• Practice using naloxone devices now.

• When you train people to use naloxone, it’s important to give them a chance to practice using the device (especially if it requires assembly).

Tips:• Injectable naloxone: practice injecting into an

orange.• Amphastar nasal spray: refill the glass vial with

water.• Use expired naloxone for practice kits. Dispose of the

naloxone liquid & refill with water.• Evzio: every package of Evzio includes a training

device and two doses of naloxone. Point out which is the trainer & which is the naloxone.


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Step 4: Further Resuscitation

Assess breathing.

If the person is not breathing, or breath is shallow or short:

– Give rescue breaths

OR– Follow the 911 dispatcher’s instructions

OR– Give CPR (chest compressions + rescue breaths) if you are trained in it

ORP Core Curriculum

Assess Breathing

Look, listen & feel for breath.

If shallow or short breaths, or not breathing start rescue breathing right away

ORP Core Curriculum

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About Rescue Breathing

Rescue breathing is:

• the quickest way to get oxygen into the body

• one of the most important things you can do to prevent someone from dying from an opioid overdose

ORP Core Curriculum

Rescue Breathing Instructions

①Lay the person face‐up on a flat surface.

① Tilt the chin to open the airway.

① Remove anything blocking the airway.

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④Pinch the person’s nose closed.

⑤ Cover the person’s mouth with your mouth. Blow 2 regular breaths (about 1 second each).

ORP Core Curriculum


⑥ Continue breathing.

Give 1 breath every 5 seconds.

ORP Core Curriculum

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Rescue Breathing Demonstration

At least one volunteer should demonstrate rescue breathing now with a mannequin.

Note:

• Seeing & doing things helps people remember them.

• When you do a classroom training, it helps to have a rescue breathing demonstration and practice on a CPR mannequin.


Step 5: Care for the Person

• Stay with the person until medical help arrives.

• If person cannot sit up, put him/her in recovery position.

• Keep person calm.

• Encourage person not to take more opioids.

• If overdose happens again, give another dose of naloxone.

ORP Core Curriculum

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Care for the Person

After receiving naloxone, a person may:

• Feel physically ill or vomit

• Feel withdrawal symptoms (unpleasant but not life‐threatening)

• Become agitated and upset

• Have a seizure (this is rare)

ORP Core Curriculum

Recovery Position

If you have to leave the person (even briefly) put him/her into the recovery position.

This keeps the airway clear and prevents choking or aspiration if vomiting occurs.

ORP Core Curriculum

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Recovery Position

• Face and body turned to one side

• Hand supports head

• Bent knee supports body

ORP Core Curriculum

If You Administer Naloxone…

• Call the Poison Center within 2 hours: 1‐800‐222‐1222

• Or contact the training entity that issued your certificate

ORP Core Curriculum

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INFORMATION FOR CERTIFICATE HOLDERS

Core Curriculum: Section D

ORP Core Curriculum

Good Samaritan Laws in Maryland

These laws are meant to encourage people to:

• call 911 for help when someone overdoses

• administer naloxone

ORP Core Curriculum

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Good Samaritan Laws in Maryland

• A person who helps someone who is overdosing cannot be arrested, charged, or prosecuted for:– Possession of a controlled dangerous substance– Possession or use of drug paraphernalia– Providing alcohol to minors

• Calling 911 in an overdose situation will not affect your parole or probation status.

• You cannot be held liable for a good faith attempt to help someone by administering naloxone.

See: Code of Maryland, Criminal Procedure Article , §1–210, and Health General §13‐3110

ORP Core Curriculum

How to Get Naloxone

By successfully completing a Maryland Overdose Response Program training, you are entitled to receive a certificate.

How to get naloxone:• Show your certificate to a physician or advanced practice

nurse to get a prescription for naloxone. OR

• Take your certificate to a participating pharmacy to get naloxone through a standing order.

You may also be able to get naloxone directly from a training entity.

For a list of pharmacies that stock naloxone, go to www.bha.dhmh.maryland.gov/naloxone

ORP Core Curriculum

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Certificate Holder Responsibilities

• Administer naloxone in accordance with training procedures.

• Make a good faith effort to get emergency medical help for the person experiencing an opioid overdose.

• Contact the Poison Center or training entity after administering naloxone.

• Note:– Certificates are valid for 2 years.

– An entity may charge you a reasonable fee to replace a lost certificate.

ORP Core Curriculum

Suspending or Revoking Certificate

DHMH may suspend or revoke a certificate if:

What can you do?

• A certificate holder improperly uses or administers naloxone.OR

• DHMH determines it’s necessary in order to protect public health or safety.

• File an appeal.OR

• Write to DHMH requesting reinstatement of your certificate once you’ve corrected the problem.

• The training entity does not meet DHMH requirements.OR

• The training entity issues someone an invalid certificate.

Apply for a valid certificate after completing training at an authorized entity. (Ask DHMH for a list of approved entities.)

ORP Core Curriculum

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TIPS FOR PREVENTING OPIOID OVERDOSE

Core Curriculum: Section E

ORP Core Curriculum

Activity

Brainstorming Prevention Tips


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Opioid Overdose Prevention Tips

For everyone:

• Keep medicine in a safe place, like a locked cabinet. (Naloxone should be kept readily available.)

• Properly dispose of expired or unwanted medications.

• Only take medicine prescribed for you.

• Take medicine only as directed.

• Never share prescription drugs with others.

• If you have breathing problems (like asthma or sleep apnea), check with your doctor before taking opioids.

• Never mix pain medication with alcohol, benzos, sleeping pills, muscle relaxants, anti‐nausea drugs, other opioids, or illegal drugs.

ORP Core Curriculum

Opioid Overdose Prevention Tips

If you use drugs:

• Do not use alone.

• Make an overdose prevention plan. Share it with someone you trust to give you naloxone if needed.

• If you have not used opioids in a few days, your tolerance will be lower and your risk for overdose greater. Use less opioids than you normally would.

• You are at greater risk for overdose if you have overdosed before.

• Always keep naloxone on hand. Tell others where it is.

• Get treatment for drug dependence or addiction.

• Seek professional help if you are depressed.

• Call a crisis hotline (phone #) or 911.

ORP Core Curriculum

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How NOT to Respond to an Overdose

Anecdotal Remedy Possible Consequences

Use ice to cool down body Slowed heart rate, arrythmia

Put person in bath or shower Drowning

Hit, slap, or burn fingers or feet Bruising, broken bones,

infection, amputation

Give drink or induce vomiting Choking

Inject person with cocaine, salt

water, milk, or epinephrine

High blood pressure, infection

While well‐intentioned, these methods waste valuable time that would be better spent on rescue breathing, administering naloxone, and calling 911.

ORP Core Curriculum ‐Optional

TAILORING THE TRAINING Part III


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Overview: Tailoring the Training

A. What content is required by law?

B. Training structure1. Quick trainings (10 minutes)

2. Classroom‐style training (1 hour)

C. Audience1. General public

2. People who use drugs

3. Family & friends

4. Patients of opioid treatment programs

5. Others


What Content is Required by Law or Regulations?

This content is required to certify someone as an overdose responder under the Maryland Overdose Response Program:

1. Signs & symptoms of opioid overdose2. How to respond to an overdose, including:

a. How to administer naloxoneb. Proper rescue breathing techniquec. The importance of contacting emergency medical services

(911)d. How to care for someone after administering naloxone

3. How to get & fill a prescription for naloxone

DHMH may change this list.


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Quick Trainings

• 10 minutes

• Suggested materials– One‐page handout with key info– Practice kits

• Teaching tips– Start with what people know: ask questions and add or correct

info as needed (e.g., “What are some signs of an opioid overdose?”)

– Let people practice assembling and using the naloxone device– Ask people to teach you

• When? Where?


Classroom‐Style Trainings

• About 60 minutes• Suggested materials

– Mannequin to demonstrate rescue breathing– Practice kits – One‐page handout with key info– ORP applications & certificates

• Teaching tips– Aim to engage participants (ask questions and have them participate)

– Don’t assume that the information is new to people

• Logistics– Helpful to have a 2nd person to help with paperwork


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Tailoring to the Audience

When planning, consider your audience.

• What do they likely know already?

• What will likely be new to them?

• What will their concerns likely be?

Make educated guesses, but remember that you may be wrong!


Tailoring to the Audience

• Consider space in pharmacy:

– Can people overhear the training?

–Will the person feel comfortable?

• How much time is needed?

• How much time can you give?


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All Audiences

• Remember that the training may bring up painful memories or difficult emotions. Be sensitive to that and respectful of participants.

• Model respectful language.

• Prepare based on educated guesses, but don’t make assumptions about individuals.


PRACTICE TEACHPart IV


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Activity: Practice Teach

ORP Training of Trainers ‐Optional

MARYLAND OVERDOSE RESPONSE PROGRAM: KEY ELEMENTS

Part V


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ORP Law and Regulations

ORP = Maryland Overdose Response Program

• Law: Article‐Health‐General, Title 13, Subtitle

31, Annotated Code Maryland, §§13‐3101 –

3109

• Regulations: COMAR 10.47.08.01‐.11 (3/3/14)


Becoming an entity

• Entity application form

• Identify supervisor

• Supervisory agreement

• Dispensing protocols

• Data collection and reporting

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Key Elements: ORP Certification

• Trainee Application Form – completed by trainee, kept on file by entities

• Certificate – awarded to trainees who successfully complete the training

– Certificate holder can show it to any authorized prescriber for a naloxone prescription

– Certificate holder can show it to obtain naloxone at any pharmacy in Maryland without a prescription

• Certificate log –maintained by authorized training entity


Naloxone Dispensing

• Store and dispense naloxone according to existing protocols

• Using the standing order:

– Keep copy of standing order on file

– Place copy with patient records

– Reference standing order guidance document


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Pharmacy Barriers

• Reimbursement for training

• Reimbursement for naloxone and atomizer

• Time and space for training

• Liability concerns

• Others?

WRAP‐UPPart VI


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Learning Objectives

Can you do the following?

• Identify 5 signs and symptoms of opioid overdose

• List 5 key steps to respond to an opioid overdose

• Identify 5 ways to prevent opioid overdoses

• Explain the following key elements of the Maryland Overdose Response Program (ORP):

– How to issue certificates

– How to dispense under the statewide standing order

• Explain Good Samaritan protections

• Identify 3 ways to tailor overdose response training


Additional Resources

• Guide to Developing & Managing Overdose Prevention & Take‐Home

Naloxone Projects (Harm Reduction Coalition)

http://harmreduction.org/issues/overdose‐prevention/tools‐best‐

practices/manuals‐best‐practice/

• Naloxone Access: A Practical Guideline for Pharmacists

https://cpnp.org/_docs/guideline/naloxone/naloxone‐access.pdf

• SAMHSA‐sponsored CE training for pharmacists:

http://www.powerpak.com/course/preamble/112666

• Prescribetoprevent.org


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ORP website

http://bha.dhmh.maryland.gov/NALOXONE


Erin E. Haas, MPH

Local Programs Manager, Overdose Prevention

Maryland DHMH/ Behavioral Health Administration

Office: 410‐402‐8574

[email protected]


Documents

Training of Trainers...ORP Training of Trainers 6/7/2016 6 Language •Research demonstrates that the language we use about drug use can affect our attitudes toward people who use