All right, well, thank you all for joining us today for the Naloxone training with Deborah Antwick, our ORN consultant. Deb, if you could hit the next slide, please. Yep. There you go. So the Opioid Response Network is SAMHSA funded. We exist to help states, organizations, really anybody that reaches out to us to provide free training and technical assistance in response to the opioid and stimulant use crisis. So we do provide evidence-based prevention, treatment, and recovery. That's kind of what we tend to focus on within the areas of opioid and stimulant use disorders. Next slide, please. So we do provide locally experienced consultants in those areas. Again, we accept free requests for training and education, and each state territory has a designated team. So I, myself, am based in Tulsa, Oklahoma. I oversee our five-state region, which includes Oklahoma, Arkansas, Texas, New Mexico, and Louisiana. And then I have team members that also help to respond to requests in those states as well. And this is how you can get in touch with us. As I mentioned at the beginning, I am very familiar with you all at Resonance being on the board. So Katie and Michelle also know how to get in touch with me if you all need it. But I will pop our address into the chat, and feel free to look around at the other trainings that we offer. And we can also customize what you all need, depending on what is happening. So I'm now going to introduce our consultant, Deborah Antick. She has 10-plus years embedded in recovery and mental health spaces, which include roles in the courts, training recovery and mental health professionals across Texas, working directly with justice-involved formerly incarcerated veterans and youth, including those in behavioral health settings. Deborah Antick is a recovery support peer specialist and trainer of recovery support peer specialists. She is a certified family partner and a licensed drug offender educator, harm reductionist, and MAP mood advocate. So with that, I will turn it over to Deb. Thank you, Victoria. So hi, everybody. I'm going to go ahead and put this up here really quick. Like I said, as people are coming into the room, I want to be able to answer any questions that you guys have. And I want to make sure that we do that within our timeframe. So if you want to ask something anonymously, I'll keep it on the chat so that if you have a question, I always tell people, ask, because you might have a question that somebody else also has, but they're not going to ask it. And if somebody doesn't ask, that's information that I might have that I can share with y'all that I can't unless I know that you want to know it. So OK, this is what we're going to be talking about today, the pharmacology of opioids, overdose itself, naloxone pharmacology, how to use naloxone or Narcan. We're also seeing it come out as some other brand names, including, this is a new one, Cloxado. So yes, Victoria's like, yeah, she got it right. And then just kind of looking at also aftercare. If you've pulled somebody out in an overdose, great. But what do you do then? So we're just going to jump right into it. If we need to go back to any slides, we can. That's not a problem at all. So basically, what we're looking at with opioids, and I just would like to see kind of a show of hands. And I know a lot of people aren't on camera, but are you guys working with overdose a lot where y'all are? Okay, Rachel's shaking her head no, so I'm going to go off of that. So I'm just going to go through this in a very informative way then. So expecting kind of that y'all know zero. I'm going to kind of approach it that way, okay? So opioids, and you will hear opiate and opioid, they all are referring to the same thing. So natural opiates, which whenever we used to differentiate, opiate was the natural form. Opioid was synthetic, but now we just use opioids for all, okay, derived from the poppy. And natural opioids will include things like morphine, codeine, things that because they are natural, they have that kind of ceiling, because coming from a natural source, it can only go up to a certain point. Now semi-synthetic, this is where we really are going to start getting into what we're seeing a lot of, which is fentanyl. Semi-synthetic is heroin, hydrocodone, oxycodone, buprenorphine, and buprenorphine we're going to talk a little bit more about because it does also have that ceiling of not being able to overdose. And then you've got the synthetic on the other end, the completely other direction, methadone and fentanyl. So fentanyl, one of the things that I really want to start off with in this training is we are seeing fentanyl in all street drugs now. So another thing that I do that Victoria might not even know about is I specialize in fentanyl. I study fentanyl. I embed in communities to learn about how fentanyl is impacting their community. And so I am out of Austin, and what we are seeing is like seven out of 10 street drugs have fentanyl in them if they are not 100% fentanyl. So we are seeing this in the way of press. So we just had a huge, we called it the bad batch. A bad batch came through Austin. There were 80 overdoses, 10 deaths. I spoke with Phil Owens, runs an opioid work group in Austin, and I had a conversation with him. That was cocaine. It was people buying cocaine, not knowing they were getting fentanyl at all, which is why there was such a high rate of overdose. Because these were people that had not been exposed to opioids, especially in this way, that were just using their street drug, which they thought was cocaine, but also included fentanyl. So we are seeing a lot of that right now, is fentanyl just being in everything. If it's not something else like Adderall, Oxycodone, Percs, Percocets are really big, especially with youth, is they'll be buying a Perc off the street and they will not know that it is 100% fentanyl. So we're seeing fentanyl pressed to look like everything else that is out there right now. We started seeing it to begin with in methamphetamine and cocaine, but now we're really seeing it across the board. So what are your effects of opioids? I'm also going to speak to fentanyl in addition to this, because fentanyl is its own animal. Going back to synthetics, whenever I said a natural form, it kind of has that ceiling of how much of that high you're going to get. With a synthetic, like fentanyl, because of it being synthesized, I think that's the right way to say that, you can really go very, very high with the effect, especially with overdose. So the effects, the short-term effects, are getting that rush, that very warm feeling, that flushing, and even this overwhelming sense of euphoria with some individuals that will respond to opioids in that way. And then some people will get sick. I had fentanyl in my drip before I got my epidural with my son, and it made me throw up immediately. So some people will have a very adverse reaction to opioids. Other people have told me that when they met heroin, they felt like their life was complete. So that heaviness, the heaviness in the extremities, the drowsiness that you will see after someone uses their drug, you'll see nodding, looking like someone is falling asleep. And what it also is doing, opioids are going to repress, right? They're repressing all the bodily functions, including pain, which is why we use opioids for pain management. So slowing heart rate, slowing breathing, and then whenever you get into the long-term, the chronic effects can be tolerance and dependence. And we do see this in pain management, people using opioids exactly as prescribed, where you will get a very fast and high tolerance and dependence. And I'll talk about that more later, but other things that happen physiologically in the body, constipation, so everything in digestion will just start to slow down. That's why you'll have people a lot of times complain about being constipated, and that's why their digestive system has started to slow down as well. So lung problems, breathing, it's suppressing everything, remember? So you'll get lung problems. Also, people will start to get heart problems, that endocarditis, such a hard word for me. Endo means heart, right? So having issues with the heart, especially with long-term use, okay? Mental health, imbalances, depression, anxiety, I've had some people talk about panic, which is why they will continue to use, because if they try and stop, then the body goes out of stasis, right? So they will start having those things coming back up again, depression, anxiety, which is part of that cycle of use, okay? They're using to not have those things happen, just like we see people using to not get sick with withdrawals. And so we'll talk about that too. You start to see things like sexual dysfunction, again, just repressing different things within the body. Hyperalgesia, and then consequences of IV use, this one, you'll start to see collapsing of veins. You know, whenever you hear of people that have used street drugs for a long time, where they are, they can't find a vein because their veins have collapsed, they're needing to inject in different places, not being able to find a vein for IVs and things like that. And then, especially with some of the things we are seeing in fentanyl, things like sepsis, HIV, hep C, that's from sharing needles, that's from dirty needles. And so I do want to talk just quickly, because I don't know that we'll get to it again in another point. So I'm going to talk about it now, is what we're also seeing is xylosine, which is where you see those very, very, very graphic, horrendous sores and wounds that do not heal, that start from an infection, like from use with dirty needles. You know, it might start as something very small, but with xylosine, we are seeing very, very big wounds that are just not healing. Okay. So, but since we're talking about overdose, here's some increased risks. We're seeing a lot at, you know, that tolerance going up, needing more over time, and then for longer acting, for longer periods of time, or long acting opioids. So a lot of times, whenever we're seeing someone moving into like wanting to use medication, one of the, like methadone or suboxone, buprenorphine, which I talked about a second ago, is it really a lot of that depends on how much have they been using and how long have they been using. Okay. That's going to have a big role in, and also in overdose itself. So also polysubstance use, concurrent, we see a lot of benzos along with opioids. And what do benzos do? What does alcohol do? They're both sedative. They're both going to be lowering, right? Lowering pain, lowering bodily function. And that's one that we see a lot of together is alcohol, benzos, and opioids, okay? And when someone is using those three over time, your organs are affected, then you've also got the liver being affected. So you've got heart, lungs, liver, all being affected over time. And also another thing that I want to talk about with extended use over time is just that wearing down of the immune system. Again, somebody gets a small, like a cut even, not even having to do with use, but something like a cut that's not going to heal as quickly because you're wearing the body down over time. So we also see co-occurring mental health issues. Like I was talking about a couple of slides before with the anxiety and depression, okay? So we see a lot of co-occurring, and you might see mental health issues as one of the reasons that someone is using, starts using to begin with, right, coping, being able to escape, being able to, you know, put it off till later. And then any illicit substance due to that increased risk of fentanyl contamination. Anything that we're seeing that is a street drug, you're increasing your risk of being exposed to fentanyl, a person that is using street drugs, okay? They are increasing their opportunity for opioid overdose. And then a history of opioid use and being released from incarceration or controlled environments. This is where you see somebody that has been in county, right? They've been in county, they've been incarcerated, or they've been in treatment. Maybe they've been even in, hospitalized for mental health. So what happens when that happens? And I mean, and I'll ask you guys, does anybody know, if you've been using this much, and then you get put behind a door where you don't have access to your street drugs anymore, what is going to happen to the body physiologically? Anybody can unmute and tell me, if you know. Rachel, do you know? I feel like you might, but I don't want to put you on the spot. Withdrawal. Withdrawal. And what else? Rachel's like, I'm not going to answer. She put her, she put her mic, okay. Withdrawal, as well as tolerance has gone down, right? With use, tolerance goes up. If somebody's put behind a door where they don't have access to their street drugs anymore, that tolerance is going to start going down. So when somebody gets, when that door opens and they're back out and they have access to drugs again, the more likely what they're going to do, their tolerance is here, but they're going to use the amount that they used last. So this little window, this little amount can make a huge difference because their tolerance has gone down. That's what happened to Amy Winehouse. She was in treatment. She had not been using heroin. And when she went back to use, she used the same size shot that she had used the last time, but her tolerance had gone way down and that's what killed her, okay? So that's what we'll see a lot of is somebody, we see this a lot with pregnancy. This is something to also be aware of, that women will stop using opioids when they are pregnant. And then a few months after delivery, we will not always, but sometimes we'll see them go back to use. And this is one of the top killers of women that have been using, stopped using, and then went back to use. Do you see they go back and use the same amount, overdose and die. And so this is also something to watch out with, with pregnancy. So I think I might've talked about this a little bit already, but opioids and benzodiazepines, again, whenever this is kind of also looking at that bigger picture, you guys, if someone is having anxiety, if someone is already using benzos and they're starting to top out with what their dose is, what their doctor might be prescribing them, or if they're getting them off the street and they've got kind of topped out with benzos, they're going to, they're going to look for, for the next step. A lot of times that is opioids or they'll start using together, excuse me, at the same time. So that combination with opioids causes increased risk of that respiratory depression. Okay. Excuse me. And death. So Victoria told you guys, I'm a licensed drug offender educator. I've had so many people tell me, Deb, my best friend died right next to me. I thought they'd passed out from drinking. They'd overdosed. It looks the same. If someone passes out from, sometimes you will hear that heavy snore, that kind of, that kind of snorty sound whenever someone is passing out from drinking because the breathing is being suppressed a little bit. You'll also hear that with overdoses is, and then it just looks like they've gone to sleep until this happened. I can't remember where, but there was like a football game. It was a big story where there were like three or four people that were partying in a backyard and the guy that owned the house went inside and the next day he came outside and two of his friends were still in the backyard and they had overdosed. They'd gotten street drugs and it was fentanyl. So this is the kind of thing, even just, even just talking about like checking in on friends, you know, the things that people don't think about doing with alcohol is going to be something very different with opioids, especially if you, if they know that they're using opioids. Okay. Again, with fentanyl, sometimes we just don't know. But the risk of overdose death with opioids and benzos can be much higher, 10 times higher. Fentanyl being in that mix, you guys, I mean, that makes it much higher. I mean, much higher, okay? And then can potential effects of opioids be a way to make the opioid dose feel stronger? Okay, so people say all the time, like, you know, think of people that use drugs as not very smart. People that use drugs are very smart. They know exactly how to make that dose last as long as it possibly can. That's why you see benzos along with opioids a lot, okay? So let's talk about naloxone. What does naloxone do? If you think about opioid receptors, so we have opioid receptors all over our body. Everybody does. And so an opioid receptor, I just kind of look at it like a little ice cream cone, okay? It's an easy way to think of a receptor. So an opioid receptor is going to have an affinity for opioids, which means it kind of is like, hey, over here, come over here, opioid. And an opioid is sticky to that receptor. So I always look at it like, here's your ice cream scoop going onto that ice cream cone, which is the receptor. So an antagonist is going, naloxone is an antagonist. It has got a higher affinity for that receptor. It's a little stickier, okay? So an antagonist is going to block that receptor. It's going to, and what it's going to do, and I'll give you an example of this in a second, but I want to kind of get through this slide first. It's just going to, it's going to knock off that opioid and it's going to sit on that receptor so that nothing can get into that receptor, okay? It is going to stay on that receptor for about 30. Now we're looking at, especially with fentanyl, about 30 to 90 minutes, okay? So what has it done? If opioids in the body and opioids are sitting on that receptor, naloxone comes in and it's like, get out of here, blocks it completely, okay? So the way that we see naloxone, really the way that you guys are probably going to see it most is going to be, and we're going to get to this slide, but I'd rather just show it to you, like this. This is a full dose of Narcan, okay? And then sometimes you'll see it, this is something that I got, this is how it looks, and it comes with needles and injectables. Most regular people are not going to want to use these, okay? They're going to want to use these because they're much easier, okay? And if you're coming across an overdose, you're going to want to use the easiest thing possible because everything I'm about to tell you is going to fly out of your mind. If you come out into an overdose, it's like, you have to do it the easiest way possible. And so, okay, let me make sure I'm getting through all of this. Duration, yes, no clinical effect. Okay, this is one thing that is important to note. If you administer Narcan, naloxone, to somebody that is not an overdose, it's not going to do anything to them. It'd be basically like spraying water up their nose. So if somebody is overdosing on something else, like cocaine, this is not going to do anything to them because they are not overdosing from an opioid. This only works with opioids, okay? And then safer use than overdose during pregnancy and in children, yes. I mean, kids can, a child can administer Narcan to another child. We're really big right now with really teaching everybody how to use Narcan because we're seeing that a lot of teenagers are really our first responders, okay? If they are at a party and they have Narcan and they can administer it before even calling 911, that person is in a much better situation to survive that overdose. So, all right. Okay, so before using your naloxone, okay, you're going to want to assess the scene, evaluate, call 911, administer, support breathing, and then monitor response. I'm going to go through all of these. So, one thing that we tell people, especially, well, it doesn't matter. I don't want to say especially, because you may or may not expect that that person might've been using a needle. Opioid users look like everybody else a lot of the time. We are trained, our stigma and our bias tells us that an opioid user is somebody in an alleyway that looks dirty, right? That's not the only place people are using opioids. I will tell you that bad batch that came through Austin, we had a lot of people overdosing at work because their tolerance has gone up, they don't want to withdraw, and so they will be using wherever they need to be using. And so that's where we were seeing some overdoses in the workplace. Opioid users don't just look like what we've been trained to think an opioid user looks like, and that's very important. So, if you come across somebody that you think might be overdosing, look around to make sure that there is not a hazardous material, unstable surfaces, or needles. Needles, especially, because if you kneel down to check on somebody and you get stuck with the needle, you don't want that to happen. We just make sure and assess and make sure there's not something around that you could also get hurt from, okay? So, this is one thing, it's very frustrating for those of us that are in the field. This is perpetuated very often with law enforcement. The DEA loves to talk about this. This is not true. Touching fentanyl will not cause an overdose. This is the example I wanna give you guys. So, some people, especially at end of life, people that are dealing with chronic, severe chronic pain, use fentanyl patches, right? The little square patches, those have got a very specific chemical in them that opens up the pores for the person to be able to receive the fentanyl. If you just touched somebody with fentanyl, that is not going to get into their skin and cause them an overdose. The one place where I will say this will be different is if the pores are already open or if somebody gets fentanyl on their hands and touches their face. Little kids can overdose from fentanyl easily, why? Because if they touch something, they're more than likely gonna put their hands in their mouth. Little kids stick their fingers up their nose all the time. And so, thinking about it in that way, but just coming across fentanyl and touching it, you're not going to overdose on it, okay? I'm not gonna even spend time speaking to that because it's just too big of a conversation, but just know that touching fentanyl, you're not going to overdose from fentanyl, okay? So, what you're looking for is someone being unconscious, not being able to arouse them. So, this is some of the things that I've had people ask me. I want to like dispel all of this because we do see people doing this. If you put somebody in a cold shower, that is not going to reverse an overdose. I've had people say, okay, like hitting them, slapping them, trying to wake them up that way. You're not going to pull somebody out of an overdose that way, okay? So, these are the things to do to evaluate if they are actually in an overdose. So, if you take your knuckles like this, and to make, not like this, but like this, and you rub your knuckles. Yes, over there, Dawn's friend. Yes, yes, that guy over there. So, I don't think he's Dawn. So, I hopefully I'm not assuming too much, but so, okay, if you take this and you rub those knuckles on the sternum hard, and again, if you think someone's overdosing, the adrenaline is going to be at 100, okay? So, if you take those knuckles and rub hard on that sternum, it hurts, and you will get a reaction. And the other thing that I will tell you also is if you take your fingernail and put it, dig down into like where that cuticle is, that also hurts a lot. If someone is just passed out from drinking, they'll respond to that, okay? You're going to get some kind of reaction from them. If they are overdosing, they're not going to react at all. So, these are some things that you're looking for in an overdose situation. I always tell people physically, it looks like a drowning. Blue or gray, you know, gray skin tone. With someone with darker skin, it's going to look kind of ashy, okay? Blue lips, under the fingernails, blue as well, okay? So, that slowed or shallow breath or not breathing at all, okay? That sound, that kind of like, you know, what they refer to in movies as the death rattle, that kind of gurgly sounding breathing, that's also something that you might hear. And then another big indicator along with all those other things, opening the eye. If the pupil is just like a pinpoint, you're looking more than likely at an overdose, okay? So, this is one of the very big things to know when calling 911, even if naloxone reverses your overdose, if the body has still got opioids present, remember I told you naloxone says, oh, let me sit on that receptor, I'm going to knock that opioid off, I'm going to sit on it, that is creating a barrier. But if naloxone dissipates within 30 minutes and opioids are still present in the body, they go right back onto that receptor. So, it's very important to call 911 before doing anything else, why? Because that means you are getting EMS in route, okay? So, even if naloxone is reversed, it can dissipate within 30 to 90 minutes. And we are seeing, I will give you a very real example. A very dear friend of mine, I was working with her son as his recovery support care specialist, he was trying to get into treatment. He'd been in county, he got out, we were trying to get him into a treatment center, we were taking him the very next day, so he did what a lot of people do, they go out to the street for that one last shot, that one last use before going into treatment. He went out to the street, he thought he got heroin, it also had fentanyl in it, he went home and used in the bathroom, which is where many people will use. And when they use and fall out, they'll lean against the door. So, it's hard to get that door open. His girlfriend administered three of these, this is a full dose. So, six of these little guys, he still died. He still died, his toxicology came back, it was fentanyl mixed with heroin, okay? So, we are seeing multiple doses needed to reverse overdoses because of fentanyl, okay? So, that's why it's really important to get EMS headed your way, because if you've used all your Narcan and EMS has Narcan, they will come and if that person has gone back into an overdose, then they will administer it on scene, okay? So, this is the language that you want to use when you are calling 911. Describing a medical emergency often triggers EMS response. What you are calling about, how do you know how many to use? Dawn, I'll tell you in just a second, okay? We're gonna get to that part. So, good question, thank you for asking. Dispatchers can only follow, and I will tell you this is the truth because my daughter is a 911 call taker and her boyfriend is a dispatcher. So, I am telling you this from direct knowledge. Dispatchers can only follow the information given by the caller and are trained to err on the side of caution. Therefore, mentioning drug overdose will often trigger a full call out, meaning police, fire, and EMS. Now, in the state of Texas, we do have the Good Samaritan Law, and we also are seeing that people that do not call in the case of an overdose can be held responsible as contributing to a death, okay? Texas is very, very hard on the criminal aspect of it, unfortunately. So, but describing a medical emergency will often only trigger EMS, which is who you want, right? You want EMS there. Reporting that a person's breathing has slowed or stopped, this is the correct language to use. They are unresponsive. That is the truth. And tell them exactly where you are, okay? I cannot tell you how many times someone has said, looked, and not known exactly where they are. It causes so many problems from EMS and dispatch, okay? If you know exactly where you are, that's a very important piece. And stating that the person is unresponsive, okay? And this is the sad part of it. This is also the bias and the stigma, is that sometimes whenever you call and say someone is overdosing, it actually will make the call move to the bottom. It is not being acknowledged as an emergency medical response needed on scene. Unfortunately, in some areas, that's what happens. PD goes slower, and it's just a fact. So here's some different types administration. So Narcan, the one I showed you in hand, that's the top. This is the most often, okay? We are really moving to the nasal because if you know how to use, if you know how to use Flonase, I always tell people, if you know how to use Flonase, you know how to use Narcan, okay? So the internasal prefilled atomizer, I got one of those when I was trained in 2016. I've only seen the one that I received when I was trained. So this is something you're not gonna see very often. It's very clunky. It's difficult. It's pieces that have to be put together. Again, we've really moved to the nasal. You will see the intramuscular, the two vials. Again, even though it's two, this is one dose. Just like even though it's two, this is one dose, okay? So, and then the intramuscular prefilled syringe, you are not really gonna see those very often at all. This is one that, again, I got whenever I received my training. And this actually is, I'm only showing it to you because, and I can't, I don't have my trainer with me. It physically tells you what to do. It says, do this, do this, do this. This little thing talks. It's crazy, but it's also about $3,000, which is why we don't see these anymore, okay? So the ones that you're really gonna see are these and these, okay? So the One Step Nasal Spray, this is a four milligram, a single dose. We're also seeing it in six milligrams, but what you're probably gonna see is this. So no, you do not, this is one thing I wanna tell you guys. Don't spray this to test it because you just wasted a dose. You just wasted half a dose, okay? This is ready to administer as is. There's no pumping, there's no priming. You will lay the person on their back and tilt their head back, just like when you're giving CPR. You're gonna make sure that the airway is not constricted in any way. And then you're gonna do one dose in one nostril, okay? I actually was doing this for a group of young boys and a kid said, do you spray it on their face? No, I'm just not sticking this up my nose right now, okay? So it goes, but I will for you guys. It goes in the nostril as far up as it can because you really wanna administer it around here, okay? If it's kind of down here, you're wanting it to get as far up that nostril as it can and then you push the plunger. So up into the nostril, push the plunger. You have given a half of a dose, okay? And then you give that dose and this is, I always tell people this is gonna be the longest two minutes of your life. You wait two minutes to see if that first dose is gonna do its job and then you administer the second dose. And you, so this is a half dose, two minutes, wait, watch and then second dose, other nostril, okay? When you have done that, you have administered a dose of Narcan. If it has not done anything and you have additional doses on hand, waiting two minutes and then same exact thing, one side, wait another two minutes, on the other side. Doing that process until you have used all of your Narcan. Okay? Now, whenever, and I wanna speak to this really quick because you're not really gonna see these again. This one, I don't even know why it's, why is it doing that? You're not really gonna see. This one, I will say the places that you would administer an injectable is the shoulder, just where you'd get a shot, okay? Shoulder, the upper thigh or the back end. Anywhere you're gonna have that tissue that that would go into. This is not needing to go into a vein. This is just going into a muscle, okay? And then the pre-filled, I'm just not gonna talk about that because you're just not gonna see it. And then after you have administered the Narcan, this is the important piece, you guys, rescue breathing. If the person, if the Narcan has had no effect, at least give rescue breathing until EMS arrives, right? Because you called EMS before doing anything else. Now, in the case that that, if you did it the other way and you administered the Narcan and then called EMS, they might be there in the amount of time that it took you to administer that Narcan. That's why calling EMS first is the most important thing. And then just your administering rescue breathing. Why? Why are you gonna, even if they're not conscious, why are you supporting their breathing with CPR? You're getting oxygen to the brain. Because if you're not doing that, they are having no oxygen to the brain. That's a really, really important piece. Whenever we're seeing so many doses of Narcan being needed. Okay? So this is how you monitor them. Once, okay, this is another important piece to know is that when you, if you are pulling somebody out of an overdose, what is going to happen to their body whenever that Narcan knocks that opioid off and sits on that receptor? You are putting that individual into immediate withdrawal. Immediate withdrawal. Which means they might come out fighting. They might come out puking. They might come out very disoriented. Another thing too, is if you can get a person up and walking around safely, once you've administered your Narcan, your Naloxone, do that. Because that's gonna get that moving around in their system faster. Okay? You're gonna wanna kind of keep them alert, talking to them. And this is something, I know a guy that was pulled out of an overdose eight different times. He was like, they might ask you, where am I? What is happening? Tell them. Be as honest with them as you can. Because you, I mean, and then you say, you were overdosing. You were overdosing. We're getting you out of an overdose. Because it's terrifying to come out of an overdose and have no idea what is happening to you. At least talking to them might start to kind of engage them a little bit. So they're not freaking out so bad. The other thing to know is if somebody is getting pulled out of an overdose, that withdrawal is very, very painful for them. They were just in a state of euphoria, and you just put them into an immediate state of sudden and intense pain. So they are, a lot of times, if they have it right there, they're gonna pick up and try and use again. And so that's something that a lot of people won't talk about because they just don't know. And so making sure that they don't have that, that's why you've also taken away anything that might be laying around, pills, needles, anything that might still be an opioid that they can pick up and put back in their mouth, okay? So once breathing returns, monitoring them closely. If they're breathing but unresponsive, this is the position that you wanna have them in, the recovery position, on their side with the hand underneath, the arm out, and then the knee on the ground. Provide support and reassurance if opioid withdrawal causes agitation or confusion. It's gonna cause many different things. It might be confusion. It might be agitation. Again, they might be physically sick. A patient should be transported to the ER and monitoring for at least four hours after naloxone dose. This is important, them getting that extra step of getting them to the hospital because, and we've seen a lot of people say, You would not really believe that that could happen, that they could be so close to death's door and then get pulled out right away. I've had people ask me, oh, is this like that scene in Pulp Fiction, whenever they give her the big dose of adrenaline and she's like, and comes out like that? No, this is not the same thing. But that response, the way that someone gets pulled out might be similar to that, where you're like, oh my God, I can't believe this person is physically up, walking around, able to talk to me. If they can do that, they can go find drugs again. So this is the very important piece is getting them to the hospital, having them be monitored. I mean, they can leave the ER on their own, they might go out and use again, but at least you're using, you're doing the whole thing, all the steps to make sure that you are supporting them coming out of that overdose. So that's what aftercare is. So referrals to care that, you've pulled them out of the overdose, that's incredible that you've been able to do that. You've gotten them to the ER. And then what happens so often, people just walk out of the ER. This is part of that continuum of care, right? Like the, and this is something that an RSPS and a recovery coach does, if you have peer support is those referrals. You know, your organization might help with those referrals, the, you know, what we call the warm handoff. Someone that is, because we do know that if somebody has that little window, excuse me, where they are interested in seeking treatment, those windows close fast. I have myself been a person on the phone all day trying to find treatment, trying to find a bed for somebody else. Could you imagine being that person just came out of an overdose that is just kind of given a list and said, good luck. This is where we can support that, that movement towards treatment, referrals, helping them understand what medications are available. You know, MAT and MOOD, methadone, suboxone, or also buprenorphine, that's the, suboxone is just the brand name, but helping them understand what, and this is something I want to say about fentanyl. We are seeing many, many, many, many, many, many, many, more people needing to utilize medication because they cannot get off of fentanyl on their own. Fentanyl again is a very different animal. I've had people tell me, you know, it calls to me in a different way than heroin ever did. We're seeing people where their drug of, they're not, they're not accidentally using fentanyl. Fentanyl is their DOC. Fentanyl is their drug of choice they are seeking when they go to the street. I have heard from people that sell drugs that they test their drugs for fentanyl so that they are able to keep the pure fentanyl for their clients that are seeking fentanyl. So like I said, the game has changed with fentanyl, okay? I have one individual that said, Deb, I broke through suboxone right away. So we're seeing people that are using suboxone or buprenorphine and fentanyl at the same time using suboxone because suboxone does have that blockade that they can't overdose. Now, is that the perfect scenario? No, it's not. But we are seeing people that are using fentanyl, using suboxone just so that they don't die. It's not like, oh, we're helping them to use fentanyl. They're using it and trying to just be able to... Because fentanyl has got... So other referrals, individual or group therapy, residential treatment, community resources, SAMHSA's findtreatment.gov. And these sometimes are not alone. They're like over each other, right? So being able to prescribe naloxone, training family and friends how to use it. We give naloxone away, and I will train anybody how to use it. You guys are gonna have access to this recording. So now you can train anybody how to use it. And when to prescribe naloxone, anyone using prescription or illicit opioids, especially high-dose and or long-acting opioids like fentanyl, okay? Concurrent benzo, alcohol, and other sedative use. So polysubstance use, using more than one substance at a time. And again, we see benzos and heroin, benzos and fentanyl a lot. COPD, sleep apnea, reduced liver or kidney function. Anything that is gonna be any kind of... Anything that's suppressing breathing. Sleep apnea, COPD, those are things that are going to be issues with breathing. And then anyone that's 65 or over, anyone that's got a compromised immune system, and then co-occurring with mental illness. Any illicit substance due to increased risk of fentanyl contamination. So that means anything being used at the same time or being used any kind of street use that's gonna be referring to that. History of opioid use and being released from incarceration or controlled environments. Like I talked about, getting out of county, getting out of prison, getting out of treatment, and going back to the street and use. That tolerance that was so high has gone down over time. And then they go and use that same size dose that they were using before they went in. Okay, let us see. Stigma, everything about the language that we are using matters, okay? Using the words. And this is also, it kind of also matters where you're speaking. If someone is using this language, like you see this language a lot in rooms, right? AA, NA rooms. If you go in saying person with substance use disorder, they're gonna look at you like you just grew another head. But like for us, when we're working in the field, instead of saying alcoholic or addict, we're using a person with a mental health disorder, a substance use disorder. We're using that person-centered language, right? Instead of saying dirty or clean, UA, positive or negative drug test. We hear this all the time, staying clean, especially with people who are using any substance. And again, alcohol is a substance, that they're maintaining recovery. They're maintaining sobriety. Former addict or alcoholic, a person in recovery. Do you see how these words hit differently? Drug abuse, someone that has been, has used drugs. A person with a former, a person who has formerly used drugs. Drug abuse or drug use or dependence. Do you see how these words are just different? This is a big one. And this is a really big one with stigma in the ER, drug seeking. You can change somebody's life by writing drug seeking on a chart. Because that chart will follow them. They might've been requesting medication. So these are things to really be thinking about whenever we are talking about people who use drugs. And there, I mean, that's a whole training on its own, but for now, and I know we're getting super close to the end, but does anybody have a question before we show the survey? Does anyone have a question that I did not address in this training regarding opioids, naloxone, anything? I wanna be able to speak to it. I think just Dawn had a question in the chat. How do you, thank you very much. How do you know how many to use until they wake up? I mean, if you have naloxone and usually you will have used all of it that you can. We are seeing up to like six. So six of these. So meaning three doses, right? Four doses. Usually you'll go through all of your doses before you know an EMS should have gotten there. Do you see what I'm saying? You can administer as much Narcan as you have, I guess is really the answer to that question. Does that answer your question, Dawn? Okay, feel free to put more questions in the chat or raise your hand via Zoom. Yeah, if you have a question, come up. Katie, what have you got? What's your question? So I was curious about, I've heard it recommended that you carry naloxone with you in different places just so that it's on hand. If you leave this in your vehicle during high heat, does that deteriorate the potency of- That's a great question. It only depletes it. And also that made me think of another question. It'll only deplete it by like 10%. I'd rather have Narcan that had been sitting in my car all summer and administer it and possibly reverse an overdose than not. Do you see what I'm saying? It doesn't deplete. It will still be usable 100%. And then another question I get is what about when it expires? You can use Narcan way past the expiration date. If you have Narcan, use it, okay? Even if it's two or three years expired, it still is potent and it does not change chemically. What do you know about over-the-counter enhancers at stores? Leon, some of which that voids. Okay. Please, Leon, will you unmute and talk to me? Can you speak to an example of what you're saying right now? I know we've had some recent training that talk a lot about those different over-the-counter stuff you get at like convenience stores and all that that have the THC and then also now we're starting to get into some opiate type additives to that. Okay. Are you talking about things like, I mean, like in the old days it was like Spice or K2? Yeah. They're getting like the mushrooms and stuff like that now. They're also have- Yeah. Opiates in it. Okay. So that will usually be, so, okay. That's a really good question. So that's gonna be more in street drugs where you're not quite seeing opioids in packaged things that you can purchase. I'm trying to think of how else I can answer that question that's gonna be beneficial. The THC, so one thing I will tell you, so this is all street, okay? This is, we're also, we're starting to see fentanyl in vapes. The one thing I will tell you about that is the little plate in a vape burns really, really hot and it burns up fentanyl. So we'll see residue of fentanyl, but it's not something that we're seeing affect people in the way of overdoses. Do you, is that kind of answering your question? Are you, Kaylee, are you saying Tatiana and Zaza as like names of- Those were the things that they were, that Leon's referring to in the Phenibut, or Phenibut, maybe I'm not saying it right. It's a synthetic depressant that's sold over the counters that they told us that Narcan does not work on. Okay, so, okay, thank you for additionally- It's Tiana, not Tatiana, I'm so sorry. No, that's okay. I mean, that honestly, I just was like, they weren't hitting me, but you saying that, there are, yes, thank you guys for clarifying. We are seeing some things that if it is not an opioid, it is not, naloxone is not going to be effective against it. Just like we're starting to see derivatives of things like xylosine, nitrosines, that Narcan will not be effective against because they're not opioids. They're hitting on different receptors. And so that is a very valid question. And if someone is overdosing, like I said, if you give this to somebody that is overdosing on something other than an opioid, it will have no effect. Does that answer your question, Leon? Yes, but what we've been told is they're adding that stuff to fentanyl and it's preventing even an opioid overdose because it's not allowing the naloxone to work. It's like a blocker. Okay, so based on my knowledge of how opioids work, I do not feel that that is correct information because, yeah, I just, and I've not heard anything like that. I'd really be curious what the training was around, and maybe we can talk like after the recording is done. I'm just, because I don't know of anything. And like I said, I get information from a ton of different places about that, where something is being added to something that is sold over the counter that would be a blocker. So that's new and interesting information to me. So let's put a pin on that for a second, Leon. Did anyone have anything else, like any other questions that I can answer? I know we're a little bit over. And Victoria, she dropped in the chat, but I'm going to put also, I always forget about this last slide. This is for the survey, but I want to be able to make sure that I, hmm, okay, okay. So anybody else with any questions? Okay, Victoria, do you want to speak to the survey really quickly? And then maybe we can go ahead and stop the recording. Yes, this just helps us with our grant. You all know how that works with our grant awards. So if you could please take a quick moment to fill out the survey. I did pop the link in the chat. You're welcome to also use your mobile device and use the QR code. So we will get this training uploaded on our learning management system, and I'll send out that link. That'll probably take us a little bit. So just expect to see that. Hopefully the end of this week, it might possibly be next week. When I send that out, I will also include the slides so you guys have that as well. And with that, I will stop our recording.

Opioid Response Network

training

technical assistance

opioid crisis

stimulant use

naloxone

overdose

rescue breathing

person-centered language

naloxone administration