 All right, folks, any questions or comments about what we've discussed already? No questions? Go ahead, for naloxone. So, you know, it costs money, right? So, Charles will get into the cost of these medications, but if people are on Medicaid or Medicare or even private insurance, very minimal cost, very minimal. Like, some of the ones that he'll talk about are covered by Medicaid, and a lot of our folks are on Medicaid, a lot of us, a lot of our folks are, so a lot of this is on the Texas Medicaid formulae. So, you can go in and access it, yes. Yeah, Texas is a little slow on the uptake. We're working on it. So, right now, the Texas Pharmacy Association, what is it a private? So, H.E.B. is getting ready to come on board. And so, honestly, H.E.B. will be our biggest distributor in the state of Texas. And that's interesting you say that, because I was telling Mark last week in my neighborhood in Austin, I just, last Sunday, I just said, well, let me try this. I went to Walgreens and had some difficulty because they didn't know about it, and I went to local H.E.B. and they're like, oh, yeah, yeah, they don't care. We're looking really forward to it. We already have it here and we're going to be getting more, but we're going to be getting more education about it. So, I think it depends on the region. And I think it's moving that direction. It just hasn't made all the way around yet. That's a good question. The officer? They are. And so, and so, one of the things that we, I've worked with a lot of law enforcement around this, and as I'm sure you're aware, a lot of law enforcement around the country have this medication in their first eight hits. A lot of them. Yeah. Yeah. Many, many, many, many, many. I've trained a lot of law enforcement. They're not on mics, so you have to repeat the question. Oh, this is a lot more work than what you've done to us. So the question was, is law enforcement carrying the medication for emergency purposes? Oftentimes, as we know when 911 is called, officers show up on the scene. And so, in many parts, almost the whole East Coast right now, if you're a police officer on the East Coast, you're carrying naloxone. Yeah. You're looking at me like you don't believe me. You don't believe me? Yeah, I'm going to tell you, you will lose this bet. Yeah. Where are you going to get the officers? Who? Officers or regular people? Officers. You're going to have to work with your police force in order to access it if they want it. They don't, nobody has to have it. It's not mandated. It should be. But you have to work with your particular medical director and your chief in order to get this. This has become such a large national initiative by law enforcement that I can't understand why everybody wouldn't be doing it. And there's been about 1200 rescues just by law enforcement nationally with Narcan. Charles will tell you some stories about some things. You know, I worked in the Northeast and I'm going to tell you that it has changed the dynamic of community policing in some communities. I'll give it to you when you're okay. Yeah. And don't tell the cops, but if anybody needs naloxone, I will send it anywhere in the state of Texas. Just don't tell the cops. And if you have something you don't want, we will come get it in the state of Texas. Kind of work. It's legal. So I can't. So I just very quickly. Um, you know, Charles and I have been doing this around the state over the last number of months over the last couple years. And I can't begin to tell you how important and influential like not only this work has become, I think for people to be able to do some really effective work, people that watch that video last night on Fox 29 here in San Antonio and saw what CHCS is doing would be rather impressed about how they're engaged and with the community and the lives that have been saved. Charles and I first started doing this and CHCS was our first real training to providers and we gave them I guess around 300 or 400 doses of naloxone and they have done an amazing job with putting protocols into place and all that. I am a very fortunate guy to be able to travel around the state of Texas with Charles. He's become my brother. And you know, when you're away from family, um, having somebody close to you that not only has your back in your work, but in your personal life is critically important. So I'll let Charles take you through the interesting stuff of the training. Thank you, Mark. Thank you, Mark. We've been told to stand a little closer here. So if I'm not loud enough, somebody raise your hand in the back if you haven't trouble hearing me, okay? I just wanted to have a few announcements before we get going once. How many of you like to drink water? Yeah, a lot of hands. How many of you's heard of clean water? One hand. Okay, I'm gonna read this to you. 50% of profits support recovery from alcohol and drug addiction. Clean cause water. Look forward in your grocery store. If you don't have it, ask the manager to get it. Go online. Go online. You can get it online. Mark shared some stories. There's folks that are struggling with addiction, wanting to live in stable, sober living environments. And these folks have been really, really good about helping folks do that and other things. So the other thing market calendars, August the 31st is International Overdose Awareness Day on the south steps of the capital. We're gonna have the third annual International Overdose Awareness Day. Mark talked about the Peterson brothers. They're gonna be providing entertainment. You should Google those guys. There's some up and coming little blues specialists, really great musicians. This is real good. We've had folks that show up to have lost loved ones to overdose and honor those folks. So come check it out. There's handouts over here. Scare me. It's gonna be on one of our slides. Stimulate call 911 airway. It's really, really good handout. Something good to sit and have discussions with your clients, your family members, or whoever and use these as handouts after you've had that discussion with folks. Okay, so what we're gonna do on this next little part is we're gonna kind of start talking about the causes of overdose and basically how to recognize, respond and evaluate. Okay, so what are opioids? Okay, heroin, morphine, delotted oxycontin, oxycodone. Mark talked a little bit about the 5% of the world's population, 80 to 90% of the opioid consumption. I watched something on TV the other day and it said there were enough opioids being prescribed at one point here in the last few years that every American in the whole country could have a whole prescription sitting in their counter. Okay, so now locks on North Canada is what we're talking about that reverses opioid overdose. It only works on opioid. It does not work on soma, Xanax, benzos, alcohol, it doesn't work for any of those things. It only works to reverse overdose from opioid. Okay, folks have asked us that question quite a bit. Are all opioids created equal? In some ways, yep. Some ways or not. Okay, they all come from the opium poppy plant, or they are created to be like the ones that come to synthetics that come from the opioid poppy plant. Okay, they all work on the same part of the brain to cause the overdose. And we're going to talk about this more in detail. Basically, opioid overdose is caused because from respiratory depression. Opioid sets on a brain cell can't breathe. And the person that do too much opioids stop breathing die. Okay, so they all have the same effect on the same part of the brain. And they cause the overdose in the same way. Okay, if too much is used. So how are they different? They're different in the variations of strength. And what's really important here is their difference in how long they last. Okay, and this is going to be really important, especially when you're talking, talking to clients and talking to family members. And when I've talked about talking to family members and clients, I'm talking about anybody, you know, I'll tell a little story where there was a friend that lived with a grandmother and the grandmother got education and nor can and when somebody went out at the house and grandma ended up giving Narcan so anyone can can use this medication folks Senate bill 1462 allows for that. Okay. Narcan is a short acting medication. So that's why it's going to be really important whenever you're talking to folks and educating them about how long these opioids last. That's going to be very important. So methadone 24 to 32 hours. Oxycontin 12 hours. heroin, morphine, the codeine, demoral, your average in three to four hours. Okay. And when we're talking about fentanyl here, I was talking to gentlemen and I said break, we're talking about the fentanyl patch can last up to three days. Okay. But just straight fentanyl across two hours, we're talking about pharmaceutical fentanyl here. Okay, because later on, we're going to be talking about fentanyl is being produced in the clandestine lavatories. Mark talked a little bit about it. The hundred pounds of pure fentanyl that was seized. That's not the fentanyl patch of the pharmaceutical. This was fentanyl that was made in in laboratories. Okay. You may want to write this down. I know some of you said you from the south. So you may understand it. It's called a naked truth. Mark said death by fentanyl. And Mark said if you're from the east coast, that means the naked truth. Okay. So naked truth. It's a it's on YouTube now on our station at home. It's channel 1206 I saw it was a it was on again the other night. And it it's a lady goes into into Mexico and she's interviewing some of the cartels that are manufacturing some of these drugs. And she was particularly asking this guy about fentanyl. He said he paid someone from Columbia $50,000 to come in and show him how to make it. And she said how much of the heroin going into United States? Or you guys put in fentanyl and he said all of it. And it kind of long story short, he talked about competition. If this guy's putting fentanyl in his heroin to make it a little stronger, they're going to want to buy his and not mine. So therefore I have to put some in mine when he puts a little more to make his better. I have to compete. And that's what we're seeing. That's part of what we're seeing. So, you know, that's part of what's driving this thing. So and remember when we talk about durations of effects, just because demoral may last two or four hours if a drug users using these drugs, the biggest fear for a drug user is what? Withdrawal. Hope your drug user does not want withdrawal is not a pleasant situation. Okay, so the last thing someone wants to do is go into withdrawal. So even though the duration of the drug may be six to eight hours, that doesn't mean the person is going to wait six to eight hours before they use again. What happens is they keep using it keeps building up in the system. And that's where you go and you start increasing the risk for overdose as well. Why do people use opiates? Mark talked a little bit about it. They work. Basically, pain relief before you where are they coming from? And again, this epidemic is being fueled by prescription drugs. But what we're seeing is we're seeing an uptick. You know, law enforcement's response to this has been work on shutting some of the pill mills down. You know, there was a difference in scheduling for hydrocodone went from schedule three to schedule two back in October 2014. So all those things are effective things. There's a prescription drug monitoring program. There's a drug take back program. But I'm here to tell you not a prescription drug take back program. Not many opiates are showing up. Okay. But they are somewhat effective. So all those things put together can really make a difference. But most of the drugs that we're seeing coming in or coming from Mexico, South America, Southwest Asia, Southeast Southeast Asia, where I was going with that a while ago, it's like shutting down some of the pill mills. What's happened is what we're seeing is the uptick in heroin use as people that were getting prescription medications for whatever reason, can't obtain those as easily anymore. And they go to street heroin's more available. It's cheaper. It's easier to get. Okay. So we are seeing a rise. What's the different number? What's 60? 6040 6040 some parts of the state. Yeah, still about 60% prescription drug. You know, we've never seen more opioids at a higher purity and a lower cause than we are seeing today. In this country, more available. Yeah. Ever. You had a question? Are you seeing with that arise with the increase in heroin arise in HIV and Hep C? It's a great question. Good question. We're seeing a rise in HIV and Hep C. Remember what what happens is even if someone starts off with the prescription drug use, taking pills, what at least I've seen my experience in working with with users through the years has been people maybe graduate over starting heroin. Eventually, the majority of times people end up using an intervention. And with that usually comes sharing equipment, sharing syringes and increased risk for HIV and Hep C. I mean, Hep C is running rapid in IV drug using community has been for a long time. And so we are seeing an uptick in both HIV and Hepatitis C. Texas is an interesting state where there's very limited if any access to clean injection equipment. And yet we're seeing the number of injectors increase. What's going to happen is we're going to see the number of Hepatitis C and HIV increase, health care costs are going to increase, need for services are going to increase. And we could have spent seven cents on a clean injection equipment. So nobody wakes up in the morning because there's a clean needle and say, Hey, think I'll start shooting dope today. It's not all works. Yeah. And we hear the argument with Narcan some folks that say, Well, if you're going to make Narcan available, won't people use more? Overdose is not a pleasant experience, but I haven't met anybody yet that says I'm going to try to do enough to overdose today because I know you have Narcan. It's just not a pleasant experience. It really isn't. How many? Some of you raised your hands about working in substance abuse treatment. How many licensed counselors in the room? Quite a few? Any LCDCs? Yeah? How many of you remember an LCDC school where they set you down and talk to you about this? They didn't have it? Yeah, you sound like you went through a I can I can relate. Yeah, first test. I took us for KDAC. What? LCDC training school and being ready to start another one and I do teach them about this. Good. Great. That's great. So teaching it in the LCDC training, that's great, because we rarely hear this, folks. The bottom line is what I remember is, you know, you need to get a relapse plan with your client at the beginning of the process when you develop a treatment plan, individualized agreed upon treatment plan, objective strategies, goals with the client that's agreed upon. But nowhere do I remember anybody telling me to talk to your client about using safer if they go back out, talk to your client about not overdosing if they go back out. That was not part of the conversation. We really need to be changing the way we do and things we really, really do. When we have clients come in the door, it'd be really nice to know that they're all going out and they're going to stay clean and sober and hop down the recovery trail is just not happening. Now there's treatment work. Absolutely. I'm not saying it doesn't. But we need to be talking to folks about what happens if it doesn't. We need to keep them alive. I don't know about you folks. I haven't seen any dead people walk in a 12 step meeting yet. Yes, ma'am. And access to syringes. There's still a problem in Texas with access and syringes. This lady is shaking her head yes. So I was go ahead. So I will tell you, there's a number of municipalities in the state of Texas. God, this ought to go over big in this room. HB 10 was passed a number of years ago, which allowed people you guys in San Antonio should be intimately aware of this that allowed for municipalities to do syringe exchange. The district attorney here in in San Antonio didn't really like what was happening and kind of close it down and that never came to fruition where people that injected narcotics, I had access to clean injection equipment. Honestly, that though that HB 10 is still on the books. So potentially, you could be doing syringe exchange in San Antonio. And there are some movement in that direction. I will tell you that legislators are not against this per se, right? There's a lot of proof now nationally. Listen, Mitch McConnell is backing the needle exchange. Okay, I mean, people know what Mitch McConnell is right? Okay, maybe not. So here's the thing. Is it moving in the right direction? Yes. Is there still an incredibly lack of access to clean injection equipment in the state of Texas? Yes. We have really, really high rates of hepatitis C in the state really and there's treatment for help see for folks in treatment if you want more information on that, we can give it to you after the training as well. This is where the drugs are coming in. Okay, what do they look like? Mexican black tar heroin pictured here, the brown Mexican brown, more so in the past, we China white we saw on the east coast again, the fentanyl that we're seeing hitting the streets now we're seeing more and more and more of it. You know, I have some of the questions we get asked some time that's quite frequently people have said why would someone want to get up? Why would someone want to use it? They know it's that if it's that's potent, it's killing folks. They don't know what they're getting folks. The drug they may get today looks like the one on the bottom of the white and it's hair mostly heroin. And they'll go back to the same connection or different connection or whatever. And it looks just like the stuff they got last week. But it's got fentanyl in it. And bam, they're out. Fentanyl like hits like a like a train coming down the track. So folks don't know. And again, the cut mark talked a little bit about the cutter a while ago. I don't know how many of you can see this probably can't see that measured in micrograms. Okay, some of the fentanyl think about granules of sugar. Three granules can be lethal. Fentanyl and clandestinal laboratories 100 times more potent than morphine. 50 to 60 times more potent than heroin. We got a Mark Center article yesterday showing up in some crack cocaine. They're actually manufacturing pills that look like Norco or Viking have fentanyl in it. It's crazy. Okay. Fentanyl dose almost invisible. Okay, how does overdose work? talked about the cause. Okay. So there's the opioid. Here's the brain receptor. Basically how it happens. You put opioids in, the opioid lays on the brain receptor, it lays on the brain receptor that tells the body to breathe. So you see folks going into heavy nod, the breathing slows, the more opioids you put in, the heavier it sets on the brain receptor tells the body is slow, slow, slow on the breathing. You do too much. It says stop. The person stops breathing and end up dying. Okay. It fits exactly on on the brain receptor. Who's at risk? The very folks that we are working with some of you that raise your hands, the folks coming out of treatment, those very folks that we do that relapse plan with that we say, Oh, call your sponsor, work the steps, read the literature, go to meetings. Does that stuff work? It does for a small amount of people. We need to be talking to folks and say, when you go back out, what's the plan if you start using again? Okay, if Mark and I talked about the hypothetical of us going out and use again, I may not want to share my drugs with Mark. But I need to tell Mark, when I go over in this room, if I'm not out in two or three minutes, you need to come check on me. We need to be educating clients about that. You need to have a plan with your using friend. If you're living with family or friends, you need to have nor can you need to educate them, the family and tell them how this works. You need to let folks know when you're using and where you're going to be using. Okay, homelessness. Very big increase in risk of overdose, incarceration, folks that have not used in a while whether it be voluntary or involuntary, or at higher risk for overdose. And we'll talk a little bit about tolerance and stuff. So entering and exiting your treatment programs. persons with comorbidities, COPD, asthma. Talk about the story about the lady that goes in has COPD gets some kind of minor minor surgery happens, the doctor gives her a prescription for 30 60 narcos doesn't say anything, no education whatsoever. About overdose. Talk to a gentleman last week that was here. said had a friend went in and got a toothbrush got 60 narcos. No education. Nothing about overdose. Okay, it's crazy. Sure. So one of the things who's working in criminal justice system people are okay. So what just really briefly one of the things that we found really effective. So you come in the lockup, you get an assessment, right? You usually do a pretty good assessment around people's histories, so on and so forth. Opioid use comes up in those assessments oftentimes, right? You flag it. When people are going through their their stint in lockup, they're in jail or in prison. During their later stay, we start to educate them around overdose prevention and education. We actually train them around what an overdose looks like how to respond how you evaluate, they take a test, they get certified in this. When they get ready to leave lock up, they get a certification, right? So they leave lock up with their belongings. They have a certificate that shows they're certified in overdose prevention. They are given a bus pass or whatever in directions to a community health provider. In Austin, it's the Austin Travis County Internal Care. They go to ATCIC, they present their certificate, they are given the lock so good stuff, right? The other good thing about that is is that they get directly connected to services, right out of the joint. We have vast data that shows the quicker we connect with folks out of the joint, less recidivism, less overdose deaths. Very simple and you have you have the resource in your community. Mark talked about many times Center for Healthcare Services way ahead of the game on this stuff folks way ahead of the game. There's been six reversals I think as a result of their work just in the last few months. That's that's a lot. Talking about some of the specialized outreach programs I know in Austin, there's been over 60 reversals in Austin from specialized outreach programs been doing this work again, headed again. So, you know, the folks in the community, the ones that have going to have to be doing this and you are the folks in the community. So people living with HIV, Hep C, running rapid 75% higher risk of overdose than someone that doesn't have it. Yes, ma'am, we're going to talk about that. That's a good that's a really good question if there's somewhere in Texas that that's funding that it's really depending on individuals and agencies and how to be creative and do that. How many of you in here have contracts with Department of State Health Services to do substance abuse treatment? How many of you know that it's been in your statement of works in September the first 2014 that you should have already be doing this with clients? No hands go up. That's what I thought. That went into statements of work September one FY beginning of FY 15. I was still an employee at Department of State Health Services should be in your contracts. Every client coming in for services gets education on overdose prevention and information on access to naloxone at entry and again prior to discharge. And we put it in there like that because we wanted to make sure if they came in and went AMA that they they would get it at least either on the front end the back end or both. So and I'm not up here calling people out saying you should be doing I'm just saying there's the majority of folks what we've seen edgy going through the state doing this work is the majority of folks that have those contracts weren't aware it's in there. Anyway, check it out. And one of the things we talk about how to purchase it I encourage you to get with your DSHS folks and ask them some creative ways on how to purchase this. Many people coming out of jail mark brought up a good point. You know, same way with treatment programs folks, those folks in your programs are the highest risk folks there are for overdose. They're the highest risk folks not on their tolerance going down the strength of the drugs is probably changed since they went out a lot of people go in thinking I can go back out and use the same amount I used for I came in it just doesn't work. Lots of tolerance, the regular use. Folks continue. The next one's a big one mixing drugs. Okay, alcohol, opioids, and benzos is almost equals overdose. Okay, we need to educate folks again. That's another thing that you know that we need to educate clients about persons may be on benzodiazepine maybe for long term use or whatever. And they, you know, have again have a toothache or will for whatever reason go to the doctor get a prescription for opioids and want to have a couple glasses of wine tonight. Those are going to put you at high risk. So educating folks is very important. You know, there's one of the little videos that we show at the end. I don't know if we'll show that one today. But the guy kind of talks about, you know, when it comes to mixing these drugs, you know, one and one doesn't equal to necessarily one and one might equal for when you start mixing them together. And I'm sure everybody's got the prescription that says alcohol may intensify and all this good stuff. Using alone. That's a big one. You know, I have a son is 25 years old and he's lost a couple of friends and and the story was kind of the same. The friends they go to a party and and somebody starts nodding out or looking like they're really high and all that. So the, you know, what are we going to do? We're going to pick them up and put them in the back room, let them sleep it off. They find them dead. Okay, again, a strong education piece. Educate clients if you're at a party and people are using don't put them in a room by theirself. That's the last thing you want to do. You got to stay with the people you got to watch them. Okay. Don't tell them don't use alone. Or if you do let someone know where you're going. The variation the strength of the street drugs we talked a little bit about that. Okay, educating folks tell them to do it. Test shot or whatever. Again, with the fentanyl. It's a very high risk if you don't know what you get. Possible cause what happened? Someone overdose is going to depend on the kind of drug that they use. Okay, so what does overdose look like? Anybody here ever actually witness actual overdose? Yeah, a couple of people. Okay. Remember, people are trying to get their breath turn in blue, purplish. Okay, the loud to call it the death gurgle, real loud snoring, both these folks are trying to breathe. Okay, they can't breathe. They're trying to catch their breath. So it may be the bluish may be underneath the fingernails. Okay. The breathing is slowed down. Lips turning purple. I think it's important to Charles. So most overdoses take one to three hours to occur. So we have time to respond folks. Right. Yeah, what we see on TV is somebody usually see lovers of person sticks kneeling their arm down, they fall over dead. Okay. We're kind of seeing some of that with the fentanyl. But in most cases, we got one, two to three hours. So what does that mean for us? That means we have time for intervention. Okay, we have time to intervene. And we can keep people alive long enough to get them some help. Okay. Yes. Talk about beef and arpey. Suboxone subutex. Yeah, benzos is increased risk. Kind of same concept with the opiates. Yeah, good point. So yeah, you know, and we've seen, seen that, you know, Prince just died from an opioid overdose. So we've definitely seen with with benzos. Yeah, it's like, well, most overdoses actually are in combination. Yeah. I said you're very, very huge increased risk when you start mixing those. Okay. Yes, ma'am. No minimum age for naloxone. Good question. Yes, ma'am. Exactly. So someone can go to pharmacy, pick it up and carry it like an EpiPen for allergy. That that's exactly right. Right. It's legal. So right. Right. That's correct. Yes, anyone, doctors, anyone. I'm a licensed counselor. I can do it. Senate Bill 1462 covers you under that. Okay. That's a good question. Yes. Great question. If it's not an overdose, you give it to him. What happens? The love of my life. I'm gonna tell you her name. Penelope. Four years old. She has my heart. If Penelope comes in my house, which she does all the time, my granddaughter, and she sees my North can laying around and decides to inject it or drink it or whatever. Nothing happens. Zero. It will not hurt Penelope at all. So the only thing this drug can do, folks, is save people's lives. They cannot do any harm. Okay, these are all great questions. Okay. So what are we doing? We see these persons? Okay, they're nodding out. They're doing all this stuff. Blue lips, the death gurgle. Okay, tap them on the shoulder. If you know their name, yell their name, pull their ear, pinch their hand. Okay, you want to do a sternal rub? You can try it on yourself. Put your fist like this, put it right here on your chest bone and rub real hard. Okay, if there if there, there's a fine line between being real high and go and be in an overdose. If they're just real high and you do that sternal rub real hard, they're coming up. Okay, if they're in overdose, they're not going to respond. Okay, so you've seen them, you recognize them, you tap their name, you tap, tap them, you call their name. Okay, you've done the sternal rub, you've determined they're probably in overdose here. So next thing to do is gonna be called 911. What's some of the reasons folks won't call 911? Mark, I sure like you a whole lot, but I don't want to go back to the walls unit. I'm on parole. I don't want to call 911. That's another education piece, folks. You know, I know I worked when I worked at the community based level doing work with active users on the street, we used to talk about that stuff. What's gonna happen if you one of your friends go out? Well, I don't know. I'm on parole. I'm on probation. How about if you call 911, and you stay with the person until you see the lights get there and then you go or whatever just having the conversation means a whole lot. Okay, so start those conversations. The primary barrier folks not calling the spirit of being arrested. Just a little bit information. Mark and I, we were working on some of this legislation stuff in the last session, there was a house bill 225 that had a good Samaritan piece. Okay, and it also had access to naloxone. The good Samaritan piece was going to give immunity to someone more than I was out using illegal drugs. He goes out. I call 911. I don't have to get worried. I have to worry about getting arrested because I was using illegal drugs because I call it an emergency situation. If there was a good Samaritan law, it did not pass. It got vetoed. Okay, so call 911. Soon as you've done the sternal rub, yell, all this good stuff. Begin rescue breathing. Have you ever done any rescue breathing? Good deal. A few hands went up. I forgot to say, Mark and I, we wasn't aware of this was gonna be a film. So we got kind of excited because last week someone told us we had the perfect faces and bodies for radio. So we said, man, we're gonna be in front of TV now. This is really cool. So anyway, rescue breathing. What you want to do is put the person on her back. Okay, you've already called 911. So when you get him on her back, as gently as possible, use your hand. Put on the forehead under the chin, lifting the head up, making sure you keep the mouth open. Okay, pinch the nose and give two slow really long breaths. And then a breath every five seconds, one 1000, two 1000, three 1000, four 1000, five 1000 another breath. Okay, you want to watch the chest cavity to make sure there's no blockage. Okay, place your ear. See if you can feel air coming in and out or whatever, or watch the chest to make sure that they're there breathing that the air passage is open. Some folks when they went in and overdose may have had food in their mouth. I know some of the dealers when I worked the streets in Austin used to carry the heroin in balloons and they kept them in their mouth. That way if law enforcement came up, they would swallow. They went to jail two hours later to go to the bathroom. They had their dope back. So there was a lot of reasons people had stuff in their mouth, people that injected may have the syringe cap in their mouth. So you want to make sure that that airways opening at the air is getting in. Okay, it's very important. Okay, pinch the nose. We talked about taking a deep breath, the two slow breaths. Now rescue breathing is not hard to do, but it's hard to keep up. So again, educated tell folks if there's more than one of you there, you can swap off. Care for opioid overdose. And this is important folks. Even if you don't have Narcan. This education is important to give the folks because you can keep someone alive long enough for medical emergency care to get there. Okay, rescue breathing alone can keep them alive. Okay, so the real cure for opioid heroin overdose is air oxygen. If you have to leave the person for any reason, remember you have them on their back. You want to put them in the recovery position of the rescue position we call it on their side arm over and leg over. Okay, if you leave them on their back, and they vomit, they could vomit, choke on it and die. Now lock song. Yeah. The other thing it's important to get medical attention there in particular with some of the new synthetic opioids that are coming into place. I don't know if long for have you guys seen any of the w 18s and all here is there been any arrest with the new synthetic w 18 here? You know, you know of any. So the reason I say this that what what's happened is people are getting chest rigidity syndrome would chest right. And if we don't get medical attention there, even doing rescue breathing may not be enough. So what happens is that this stuff is so powerful that it almost anesthetizes your lungs where it won't receive air, right? Gotta get medical attention there. You just have to have very good. I'm glad Mark brought that up. We're talking to gentlemen from CDC last week that was telling me about the chest rigidity syndrome where someone was trying to put the nasal norcan up someone's nose and they couldn't it wouldn't go up because of the chest rigidity because of the kind of drugs that they'd use it was so potent. And he said being creative that instead of pinching the nose and trying to push air in the mouth, they put the medicine in the nose and covered the guy's mouth and blew up the nose and got it in. So it's like, man, I don't know if I thought of that. But yeah, very good point. So we're going to talk a little bit about the norcan and now lock song. Okay. Remember, it works for opioids. Thank you, Mark. It's an antidote for any opioid. Got a high penalty. It's set on the brain. Now, here is the important part. I talked about the duration of how long some of those drugs were oxycontin 12 hours heroin 68 hours. Okay, methadone 2432 hours. So remember, that's how long those drugs are sitting on that brain receptor and telling the body telling the brain receptor not to breathe. Okay, nor can 30 to 90 minutes, folks, short acting. Guess what the first thing someone's going to want to do when you give them nor can they're going from overdose to withdrawal. You just save their life, but they're not going to want to hug and kiss you because you ain't gonna be their friend. Okay, don't let them use again. And we're going to talk a little bit a bit more about that. So the opiates have said on the brain receptor, what nor can does it comes in, it kicks the opioid off the receptor tells the body you can breathe again. Okay, that's what it does. Very, very short action 30 to 90 minutes. This is one form of the nasal. And it kind of looks like this at birth. And then when it's assembled, it looks like this from Mountside Medical. And this has got an atomizer. Okay. And the atomizer screws on looks like this. One thing that's important. The atomizer is meant to insert the nose to inject. If you have this type of nasal nor can and you don't have the atomizer, it will still work without the atomizer. Okay. So that's important. And it screws on atomizer screws on like this. The medication is in a vial. Looks like this. It's a little glass vial. And it also screws in. Okay, one CC each nostril. Happen one nostril, happen the other. Okay, we'll talk about cost, and how you can get this stuff here in a minute. The newest on the market. This one has four milligrams. Adapt is the pharmaceutical company. Okay, and inserted in the nostril, just one nostril and pushed all of the medicine in. Okay, any questions on those two? It will work for the opioid. Good question. If they're mixing opioid and stimulants would still work. It will work for opioid. It will do nothing for the stimulus. You know, it's pretty hard to overdose on stimulus, to be quite honest. Yeah, it's much less likely to overdose on a stimulants. However, people think that a stimulant and so we'll probably show them that move. People think stimulants and depressants even things off and they don't. Yeah, that's not the way it works. You know, and you tell I know you, when I worked with active ease, a lot of them would, you know, hey, if I'm doing methamphetamine, maybe I need to try some diluted to kind of even it out. And it doesn't quite work that way. But folks will tell you that. The next one, I call this one the Cadillac model when we get to the prices. You guys know what I'm talking about. This is the drug company Kaleo K a l e o. Okay. Great company. This one is a trainer. It says on top of this, it says trainer. This medication comes in. I think I have a box comes in a box. It looks like this. Okay. The box has two doses of medicine. The medicine is LSU colors, of course. Okay, everybody's a tiger fan, right? Except more. Two doses of medicine that comes with a trainer and the trainer talks to you. Maybe you can hear this. Life's safe. Okay. FZO. About Kaleo. That's the one everybody kind of wants because they're kind of cute. Like you were talking about the EpiPen model. Yes, ma'am. Good question. Question is, which one should the pharmacies have? Do they have all three? It's going to depend on the pharmacy. And to be quite frank, if you have insurance, it's going to depend on the insurance company. I sat and looked up my insurance last week and looked and they cover the one that I'm about to talk about. And then I went to HEB and they had the nasal. They didn't have the one that my insurance comes. So again, I think that's going to be conversations that we're encouraging you to start having with your local pharmacies on if you want some, nor can what which ones are they going to carry which ones do you want? And we'll talk about pricing to that's going to probably have some to do with. So that's a really good question. Okay, the injectable intramuscular comes in a vial one CC already measured out. Okay, also comes in a bottle with 10 CC actually get 10 doses out of this. The syringe that we recommend to be used with the with the intramuscular. I call it kind of the animal syringe in the region. I call it that one that you can find them in feed stores or online. But this has a really long needle. Okay, that will reach the muscle. There's been some concern folks say, Well, if we leave these around drug users will use this I worked with active users for a lot of years. I never met anybody that used illicit drugs with a needle this big. I'm not saying it hasn't happened. I haven't seen it. Okay, take the take the needle, put it into the bottle, draw up one C on CC, hit him in the arm, the thigh or the booty. Okay. Now, doing education with drug users are with folks that may have a syringe is not this type of this long intramuscular. Lot lot of users use you 100 insulin syringe. I have a really short needle. If it can hit him in the tongue, inject in the tongue. Yes, my oh my god, that hurts. They're gonna be alive folk. They're gonna be happy to be pretty happy their sons or daughters or brothers or sisters be really happy they have that sore tongue. I'm here to tell you. Okay, do not put the cap back on. And we're being filmed. So I'm putting it on because we're gonna use it for training again. But it's not recommended to put the cap back on. Okay, dispose of it in a sharps container. Okay, anybody have any questions on any of the types? We're gonna talk about pricing. Oh, everybody needs to have a t shirt like this, right? We went, we went what was in some burger joint last week. I don't remember what city was in Houston, maybe? Or Dallas, Houston, and the barbecue place. Keep calm and eat our barbecue or whatever. I'm like, Hey, look, and they got the naloxone shirt, but it replaced barbecue. And they probably came first. But anyway, we like this. No effect other than opiates. Can't hurt you. It's not a scheduled drug. It has no potential for abuse. To be quite honest, it would be nice one day that it's not even a prescription. But so that everybody understands because I know people have come up and asked questions. Open script means you can go in a drugstore and get it without going to the doctor. We were riding around. We did the training in Dallas. And we passed by drugstore and it was like flu shots here. And it reminded me of it. It's like, okay, I can get flu medications as prescription. I normally have to go to my doctor to get it. But because there's an open script, I can go to Walgreens or CVS and get it. Same thing at naloxone. Open script, the script's there. You just go get it. Okay. And some instances, if someone has done enough opiates or with some of the stronger opiates we're seeing on the street, it may take more than one shot of Narcan. That's why it's important to stay with the person. Remember, you recognize sternal rub, call 911 rescue breathing, then the two big breaths, give Narcan and go back to rescue breathing. Okay, you may have to give takes three to five minutes for the Narcan to start working, folks. It's important. Three to five minutes. So if you give Narcan and they don't come out of it 10 seconds because it hadn't started working three to five minutes for it to start working. Okay, last 30 or 90 minutes. You continue to give breath. Absolutely. Good question. Remember, you've called 911, you got medical intervention coming. Okay. It's not a pleasant situation for somebody waking up. So again, another reason you want to stay with them, they wake up and they see you there. They see a mess there. They remember these these folks are going from overdose into total withdrawal. Okay. So it can be it can be a pretty traumatic deal for someone. Here's a couple of videos if you want to write this down. The first one is www.get now locks on now.org. You can go to this link. You can go through a series of questions, take a test and you complete it will actually spit out a certificate you can print out a certificate saying you've completed the training. Okay, this is the one mark was referring to folks being incarcerated go in they take this test to get the little certificate and they get the voucher. They go to communities for recovery or Austin Travis County integral care here would be Center for Healthcare Services or whoever you can work with. The other link is www.prescribe to prevent.org. This link has some really good videos one we're probably going to be showing you here in a second. And also if you're a medical professional doctor, a PA nurse, you can go here and take a little test and questions asking you can actually get free CEU. Okay. Great videos on here to show family members after you've had that discussion with them. You know, I'm not recommending or suggesting that you just get the person and sit them in the room and say here we're going to put this video on so you'll learn all about overdose prevention. And have a nice evening. Yes, ma'am. Yes, ma'am there's several videos on there and we're going to be showing one. But there's there's videos on there. But again, I encourage you to have conversations with your clients or family members or whatever and then David also show the video. Yeah, so we're going to talk about how can we access this stuff? Okay. One philanthropy if you can find some some folks that just want to, you know, make their mark in the world and make this a better place to live keep people alive. That's a real good way to do it. Medicaid reimbursement mark touched on this. All of this is on Medicaid formulary. However, this one is not preferred. It's non preferred. Now, if any of you familiar with Medicaid plans, there are certain instances where you can do single case agreements and other stuff and talk to your Medicaid plan if you can work something out where they'll pay for whichever one that's fine have that conversation with your Medicaid plan but the inter muscular and the nasal are on the formulary as preferred. Okay, federal funding block grant dollars can be used to purchase naloxone. If you're receiving block grant dollars, have those conversations with your funders. Okay, how do I purchase naloxone? There's been conversations with the state on providers purchasing this and I was told that it needed to be a line item. Start having conversations about how to make it a line item. We need to start problem solving figuring out how to do this folks. Pharmaceutical donations. Kaleo talked a little bit about have been very, very generous to mark and I we've been able to distribute quite a bit of medication in state of Texas. A lot of lives have been saved. And Kaleo's played a huge part in that. But the block grant dollars started having those conversations. Currently have Texas standing orders. Now locks on train overdose responder enrollment forms. There are forms that if you're going to be working with folks, information can be gathered. So many specialized programs we talked about that are working with folks on the streets or in certain settings that ask information doesn't ask for name, but just demographic stuff on who's being reversed so we can collect data. Okay, adapt has a record of use form the nasal. Any questions so far? Yes, ma'am. Okay, if they're mixing anything, let's say if they're taking Xanax and narcos and nicotine, I think you mentioned our alcohol, you give Narcan, it will reverse what the opioids doing, but it won't do anything for the rest. So the main contributor to respiratory depression is going to be the opioid, right? Even though some of the other drugs the gentleman was talking about benzos and alcohol work on the same part of central nervous system, what it's going to do is it's going to kick the opioid off, which will allow you to start breathing again. Here's a story I'm going to share I shared with this gentleman in the audience a while ago and this is a story it was told to us. It's like, okay, I'll use myself an example. I have insurance. Okay. And I'm going to talk about the price of this but I can go in with my insurance. I can purchase this for $10 the one CC. Okay, that's my copay or whatever they call it. Alright, I have a cousin that's using opioids. Living with his roommate. And I know my cousin that's using even if he had $10 in his pocket, he's probably not going to go buy a norcan with it. He's struggling with addiction issues or whatever the case may be. I can purchase this naloxone. I can go give it to my cousin's roommate and educate him and tell him if my cousin goes out, please administer this to him. So there's ways that we can figure out how to get this in the hands of folks. Now the cost okay, the cost of this about $28 for CC if you're buying it out of pocket. Okay, most of this stuff is recommended to get at least two doses. The nasals are sold in a minimum of two doses for the reason I talked about sometimes you have to give someone more than one dose. Okay, so about $28 a dose for one CC out of pocket that that four milligram two doses about 150 bucks. Okay, like a lot of things, demand and supply and demand the price of this medication is skyrocket or spokes especially on the East Coast working with the former pseudicles try to bring the cost down. The nasal mountain side medical two doses somewhere around 6575 bucks. Kaleo out of pocket about $4,000. Again, these folks have been very, very generous with the patient assistance program. Okay, with insurance, about 20 bucks. I heard a sigh of relief. Again, that's between your and your insurance company and the drug, you know, is the insurance company gonna want to pay for something that costs this much versus pay for that. But I wanted to say with these two here law enforcement, there is a program for law enforcement, where you will receive these. If you want that information, I can get it to you. So law enforcement is usually provided either free medication or a very, very reduced rate of these two in particular. Any other questions about the pricing or how to get it? Yes, ma'am, then I'll come to you. $28 for the for the intramuscular and the 4,000 and the 75 and 65 is someone with no no insurance, no coverage whatsoever. That's walk in and out of pocket. With insurance is gonna it's gonna be whatever your insurance covers if they covered if it's on the formula, I have the health select or whatever and it covers the the intramuscular. It's okay. There it goes, man. Everything we made today is down the drain. So this for me was 10 bucks with insurance. If I wouldn't have insurance, it'd been about $2830. Yes, ma'am. Good question. Is there a difference in the reaction type? No, there's a different kind of in the formulation. And you know, some folks have come up and said, Well, I have that the intramuscular and I use it as nasal, you probably don't want to do that. It's got a different formulation. But the response is going to be the same. It's all going to work the same way I talked about. It's going to get in, you know, the act. Obviously, the nasal is going to go in and work on the mucous membrane. Folks that say, Do they have to be breathing? It's like, No, they're not breathing. But it gets absorbed through the mucous membrane, but they all work the same. They go in and it knocks the opioid off the receptor and gives the person a chance to breathe. It's safe for pregnant women. I know one thing that's not safe for pregnant women. Over there. Not good for the baby either. Yeah, folks have asked that. I don't know that there's been a lot of studies. But what we know is if the if if the mom's going into an overdose, her and the baby could both going to die. Bottom line. And this has been used on pregnant women. And there's been no reports of it having adverse effect. And the lock zone is given to newborns often that are in situations where opioids are used. Someone actively using it may have been I was saying that someone actively using may not go in and purchase it. A chest rigidity. Well that the chest rigidity things for the drugs Mark was talking about the real, real strong drug we're seeing mostly on the East Coast now that comes in and they get they get rock solid. People do rescue breathing and it won't let it in. It's just like solid here. So people are being creative. The guy that I talked to last week from CDC said somebody had the chest rigidity syndrome and the guy was trying to do rescue breathing and he would blow into the mouth and it wouldn't go in. And he started freaking out. He didn't know what to do. And all he had was nasal Narcan. So he shot the nasal Narcan and the person's nose and it started running out. It wasn't going in. He's like, Now what do I do? I'm supposed to be blowing in the mouth and holding the nose, right? But I'm blowing the mouth. I can't get air in. So he kind of freaked out. And he said he put the medicine in the nostrils and he put his hand over the person's mouth and blew up their nose. And it blew through. And the person started a few minutes later, first started breathing again. But I said, Well, I don't know if I would have thought of that. It's why it's really important to get medical attention. Yeah, it's really, really important because, you know, there may be something that that else is going on that medical people need to be there. The majority over 85% of all rescues are done by laypeople, meaning other people, friends, family members, people that are not trained medical providers. And so that's how easy this medication is to administer. Another good education piece, you know, because we when we start thinking overdoses like who's going to save these people, the police, EMS, not let you folks in the audience, the people you work with, or you folks sitting in these audience, you don't necessarily have to be a professional to use this anybody can use it. Uh, how many folks working criminal justice? Part of you? Do you folks want to see something with got folks coming out of jail, or around overdose prevention or overall pain medications and, and other opioids. It's a video that goes through all of that. And what it looks like, it's like 1050, not even 15 minutes. Which one? Make a choice, folks. Okay, coming out of jail, raise your hand. Okay, we'll show the other one. Nobody wants to go to jail today. I don't blame you. And on this presentation, one of the last slides we have is that little scare me handout. And it's also got a place on the side you could actually add local resources. And if anybody wants this presentation, we have a few business cards up here. If you want our information, please come get them and come join us August 31, folks in Austin, if you get a chance. Or if you want to hold your own event here, we'll be glad to help. Can we dim the lights? Or is that against the movie rule? To severe pain, some common opioid pain medications include hydrocodone, which includes brand names like Lorset and Vicodin, oxycodone, which include brand names like Percocet. There are also longer acting opioid medications like oxycontin, MS content, methadone. And there's one in a patch called fentanyl or dirgeizic. Opioid medications can cause a number of side effects. In the short term, we often see nausea. Longer term, we see constipation as a common side effect. Some people will also have some sedation or sleepiness. Fewer people will have itching or rash. Those need to be brought to the attention of your physician immediately. There's a couple of things that are really important that you need to know about this medication. If your doctor wants to go up on your dose, be real careful with that. You know, especially the first couple of days, if you jump into a dose that's too hot, it can cause that respiratory secretion to and can cause overdose. The most serious risk for taking opioid medications is the risk for overdose. If you take more than your body can handle for whatever reason, it can depress the breathing centers of the brain and you could actually stop breathing. What would put you at more risk for an unintentional overdose would be starting a new opiate medication or switching to a newer, especially a long acting version. Other conditions might be certain medical conditions like chronic lung disease or kidney problems or liver problems. Your body adjusts to opioid medications and develops a tolerance over time. Taking these medications, you need more of a medication to achieve the same pain relief result. It's very important that if for some reason you're off of your pain medication for a period of time, like you're in the hospital or you're ill and can't eat or drink very much, that you not go back to your previous level of use. As that tolerance has gone down, your body will be more sensitive to the medication and you'll be more at risk for an overdose. If your pain is not adequately controlled by your current medicine dose, it's important that you stay in close contact with your physician so that he or she can help you adjust your medications. Particularly with long acting opiates like methadone or Oxy Contin, increasing pills even by one pill can put you at increased risk for overdose. Other substances can combine with the opiates to make you more at risk of an overdose as well. If you take certain medications, especially like Valium or Ativan, alcohol or recreational drugs, even at low levels of use, taking them along with opiates can increase your risk for overdose death. This is a lot boxed for my medications. I have two young grandchildren. That is a lot of the medicine I have, so there won't ever be that chance of getting into the wrong hands. Good noon. It's really good to see you again. And I know we're working really hard with you to manage your pain as you go through this. We've increased the pain medicine a bit. So I want to talk to you today about one of the scarier things that can happen rarely, but sometimes with these medicines, which is an overdose. So I'm going to teach you how to recognize one and what to do. Do you have any idea what an overdose might look like? They can't wake up? You've got the most important part. When people overdose, they're breathing, they stop. I'm not hearing anything. I don't see the chest going up and down. So I don't think they're breathing. They're breathing maybe really slow. They may be snoring in a strange kind of way or gasping. They may begin to turn a little blue around their fingernails and around their lips. These are all signs to be watching out for. But the key point is that you can't wake them up. They take my knuckles and rub them up and down on your breastbone like that. It hurts. Right. So if somebody sleeps through that, whatever's going on, it's an emergency. And what do you do in an emergency? You call 911. Right. And it's very important to say that the person's not breathing or struggling to breathe and they'll make that their top priority in coming. And so now, if they're having trouble breathing or they're not breathing, then we're going to breathe for them. I'm going to open up his airway by tilting his head back. Check in the mouth and make sure there's nothing in there. I'm going to hold his nose and then I'm going to make a seal over his mouth with mine and start with two quick breaths and then one breath every five seconds. 1001, 1002, 1003, 1004. Okay. Want to give it a try? Sir, I'm ready. Nothing's happening. We're opening up the airway. That's great. Hold in the nose. Tight seal over the mouth. His chest is going up. That air's getting in there. 1001, 1002, 1003, 1004. Excellent. Now you're going to keep that up until you get to your next step or he tells you to stop or the EMS folks come. Now you've got the ambulance on the way. You've given your friends some oxygen. Now we're going to talk about a medicine called Naloxone or Narcanth. This is a life-saving medicine that just blocks the effects of whatever opiates are in the brain. It can be injected into somebody that's having an opioid overdose and within minutes they're going to wake up when we talk to them. Now it doesn't block the effects of alcohol or other tranquilizer somebody might have taken. It does block the opiate, which is what makes people stop breathing. Very safe medicine if I give it to somebody that's unconscious for some other reason. It does absolutely no harm. Naloxone comes in a couple different ways. There's a whole dose right here. Now this is what we expect you to get but sometimes pharmacies have a larger bile of it and we'll say on here just give one cc. It's the same dose. Here's your Naloxone. Here's your needle. Have a good fight. Grab off of the Naloxone. Take the cap off the needle. Put the needle into the deepest part of the liquid. Hold the plunger up. Push a little air out but air is not dangerous to inject into the muscle. And it wants to go right into the arm or into the leg. Whenever this person's unconscious they're not going to feel a thing. Perfect. Now don't put a cap back on the needle because that's a really easy way to get a needle stick. Keep doing the rescue breathing because you need to keep that oxygen flowing. That's what's really keeping them alive while you're waiting for the ambulance while you're waiting for this to work. Now just in case this one dose doesn't work we're going to give you a second dose to have on hand. If in three to five minutes they haven't begun to rouse and to breathe you can go ahead and give them a second dose. I'm also going to show you how to use the intramasal form of Naloxone. This starts up the nose instead of being injected. It takes effect even if the person's not breathing because it's absorbed through the nose. So the box like this comes with the tube and this is the medicine and it's got a little nasal applicator. So I'm going to put it together, pull up that cap, pull out the southern yellow one, pull out the red top. I'm going to drop it in this tube gently and then turn it very gently until it's just barely tight. That means it's ready to go. Now we'll take the nasal applicator and hold on to these plastic wings here. One side is about half of the medicine. The other side precise about it. But you want to get all the medicine in there. You want to try it? Sure. One nostril. Half of the other nostril. Then you'll go back to your rescue breathing while you wait for it to take effect. There's two doses just in case that first one doesn't work. Rescue position is on one side, usually the left side with a left arm above the head. This helps them to breathe more clearly. This is the position that you want to keep the person until EMS arrives. Even if you get the Naloxone and the person who has overdosed becomes conscious, it's still important to get EMS to the scene as soon as possible. The opiate that had been in their system relieving their pain is no longer working. Therefore, they might have pain. They could have some symptoms of opiate withdrawal and they may be very uncomfortable. You think it can teach us at home? Great. Do you feel comfortable teaching your mother and sister about it? I feel much more reassured that I can go home and tell my family how to respond, what to do in the worst case scenario. And if folks want flyers for overdose awareness day, they're up on the table here by the camera, please take some, put them in your office. Thank you.