 Good afternoon everyone. Happy New Year and welcome back to campus. I hope that you all had an enjoyable winter break Thank you all for being here today. My name is Anne Mitchell, and I am the director for health services We are all well aware of the opioid epidemic and how it is plaguing our nation It's dangerous full-blown and does not discriminate It can affect people of all walks of life and any age More than 130 people in the United States die each day from an accidental opioid overdose in Rhode Island alone 323 individuals lost their lives in 2017 This issue has become a public health National crisis with devastating consequences. We need to be proactive in our efforts to combat this crisis The training you are receiving today is an important step for the Roger Williams community That's you and I to demonstrate our commitment to doing something about the growing epidemic Roger Williams University is taking the lead on addressing this crisis by supporting campus-wide training on Opioid overdose prevention and making naloxone more readily available throughout campus. I Would like to personally thank President Workman and Dr. John King for supporting this initiative a Special thank you to student-led groups the John Jay society and health and wellness Educators for their efforts in bringing overdose intervention training to this campus and Thank all of you for participating in this program. I am pleased to introduce our guest speaker Michelle McKenzie is a public health researcher at the Miriam Hospital Brown Alpert Medical School Her focus for the last 12 years has been on opioid overdose prevention She is co-founder of Pony preventing overdose and naloxone intervention which began in 2006 Last year Pony distributed more than 6,500 naloxone kits to Rhode Islanders She sits on the governor's overdose prevention task force and co-chairs the naloxone work group Please join me in welcoming Michelle. Thank you so much. So wait you guys can hear me. Yeah, okay Thank you so much and it has been a pleasure I've got to spend the day here and it has been really great and I Appreciated so much the students who attended this morning session And I am delighted to be here this afternoon. So what I'm gonna do today is Provide in a background of the issue of opioid addiction and opioid overdose death here in Rhode Island Focus more on what's happening in Rhode Island But I can say that this is really a problem across the country And I'd like to also point out that while I'm gonna be focusing on focusing on opioids because in fact that is as Anne said is what is causing really a Crisis of fatalities in our country right now it is a bigger issue of addiction and Particularly alcohol plays an important role in that other substances play an important role and for the first time really in the history of our country for the last two years the CDC has Has found that we are our life expectancy in this country has shortened Not by a lot. Thank goodness a couple of months But in fact because of the diseases of addiction and suicide what they're calling the diseases of despair We're actually having shorter lives as a result of that So this is it's so important that college campuses take this on you know head on and that is so it It's great to be part of the work that you're here doing here at Roger Williams University So I'm gonna give again where I'm gonna be focusing on opioids We're gonna give a background and then also and we're gonna do a sort of more hands-on how to prevent Recognize an intervene and I have naloxone kits available today for anyone who would like it Okay So there have been multiple waves of the epidemic that really began in the mid 90s with increased prescribing of prescription opioids for acute and chronic pain and I I'm not going to get into the details of that because there's a there's a lot of factors that were involved with that but basically beginning in 9596 in response to real concerns by folks who were suffering with cancer and end of life that there needed to be more aggressive treatment of pain for folks in these specific conditions there was You know the insurance companies the doctors etc and the pharmaceutical companies importantly people came together and said okay we're gonna more aggressively treat pain the Method by which it was chosen to do that is prescription opioids and one of the things that really fueled that was Purdue Pharma in 96 very aggressively marketed oxycontin and Marketed it in a way to say that it was good for everyday pain now opioids play a very important role in Managing pain. There is no question about that But they it does not meant to treat everyday pain and so Oxycontin really had Was did unprecedented marketing of this product that and contain in along with policies that were I'll just say that they're Part of it was a siloed our siloed medical system sort of not Physicians not being trained in addiction medicine not understanding the consequences of Opioid use disorder or opioid addiction The really the look for the magic bullet, right? We were that's kind of we're used to that We are looking for the magic bullet and so that was what Opioid pain relievers were perceived to be and so there was a whole cell adoption of using Prescription or opioids to treat pain for basically about 15 years from the mid 90s to to mid-2000s Into 2000s and what we saw was that as the increase of prescription Oh, if there was an increase in prescription opioids We also saw an increase of fatalities with the same slope Of people who were dying having non-fatal overdoses and fatal overdoses from prescription opioids It took a while for the medical establishment to recognize that there were these Unintended unintended consequences as a result of using opioids so much for acute and chronic pain And I'm going to take it just a moment to explain Opioids work are folks familiar with opioids. What are some examples of opioids? Vicodin, that's a good example. It's another Percocet Oxycontin morphine morphine has been around forever Opium opium heroin. These are all examples of well heroin's not prescription opium. Well heroin used to be available actually In the early 1900s not prescribed, but it was available legally So There was what opioids do is they attach to the opioid receptors in the body So everybody has naturally occurring opioids And so they attach to the opioid receptors and they do what they do they In one part of the central nervous system that they work on is the limbic system So people that which causes feelings of relaxation and contentment. So in addition to doing Treating and working on the brainstem and treating pain. There's also this other feeling It's the dating and it's also can be euphoric And while the vast majority of people who use prescription opioids will not have a problem with it, right? That's that's real most people who use it won't have a problem but if you think about that in mid 1990s where there were very few people who were being exposed to prescription opioids at all So the number I will say heroin particularly in Rhode Island has been around forever, right? So we've had a problem with here and but we're starting out with prescription opioids now So there was this there the number of people who had access to prescription opioids was low So while it is true that the vast majority of people won't have a problem with prescription opioids People who are at risk of developing a problem the more people who are exposed to it the more people Who are also at risk, right? So and when you have exponential growth of the access to prescription opioids not only through Be it being prescribed. So we're seeing it, you know, we particularly this time for it being prescribed for any kind of acute pain broken arm Surgery, of course Having your teeth extracted etc etc being prescribed both from emergency rooms and from urgent care centers Being widely used for chronic pain for which it's not really meant to be used for And we saw that what it was doing is people would take home their prescriptions their opioid prescriptions And it would be in the cabinet and then many more people had access to it Because if you think about it if I'm being prescribed something that is good for me, you know, it's supposed to be good for me I don't have to worry about it because these warnings were not happening then then why would it be for good for you, right? And so it is was the case that people shared their medication But also that people that they didn't necessarily share it but that it was accessed from their Bathroom cabinets, so we had not only all of the prescribing that was happening But all of the folks who ads had access to those prescription opioids that were in people's homes so by the late 2000 2010 around 2010 2012 that particularly by 2012 here in Rhode Island There was this recognition of the unintended consequences of having all of these prescription opioids out in the world and so there was a Real focus to start raining that in But one of the things when I talked about that we all that what opioids do is they attach to the opioid receptors A thing that happens and if this happens with alcohol and it happens with opioids if you use opioids over time you actually change the neurotransmitters in the brain and So you develop a tolerance or dependence to opioids. Let me ask have anybody has anybody seen those commercials those truth commercials Right, and so do you know what the tagline at the end is I think dependence in five days Those come or so that's of course individual It's not going to be the same for everybody, but it is true that if you use an opioid for an extended period of time Your brain chemistry changes and you need that opioid if you start taking if you just all of a sudden stop taking it Since your receptors are like wait, where is that? I need that opioid if you're gonna get sick So my mom had a surgery she had to take She had it was a big surgery. She had scoliosis and had a titanium rod in her back She had to be on Oxycontin for Weeks and so if she had stopped that Oxycontin all at once She would have gotten sick because she had developed a tolerance to it And that is just a physiological thing that happens when you take opioids over a long period of time but she was able to Taper or we went in conjunction with her physician who took her off a little bit at a time And so she did not experience Withdrawal symptoms so withdrawal is when you If you stop you've developed a Dependence or tolerance and you stop all at once you're gonna get really sick. Who has Anybody heard of withdrawal? So what does it do? What is it busy? What are symptoms of withdrawal? Exactly all of those things. It's like a super intense flu Is there no think about this so people here's the setting right people have been Particularly folks on chronic medication. They're treating their chronic pain They've been on opioids for ever how long maybe months maybe longer and now there's a really intense scrutiny On people getting too much prescription opioids, right? So one of the consequences is that They're Honestly, we're still struggling with this right now Not having a super well thought-out plan about how are we gonna address it for people who are struggling with Dependence and maybe addiction if we take those medications away, what's gonna happen? Exactly right. That's exactly right. So people will first look to Get other prescription opioids either from friends or family then maybe from the street But honestly heroin was cheaper, right and heroin was more potent And so there was sort of by 2012 in this state what we saw So what this graph shows us is that by 2012 in this state We actually had a shift that gray line was the fatalities Related to prescription opioids and we see that leveling off and decreasing But the yellow line is from illicit opioids and in 2012 illicit opioids were heroin And there was a very dramatic increase in overdose deaths and in part the reason for that is that when people shift from Using a prescription medication where they know exactly what the dose is They know exactly what they're getting to the illicit market where there's no information about what you're getting and to Confirmed that even more is that even by 2012 and most certainly by 2015 our illicit Drug supply was really radically changing. So there had been examples of fentanyl. So who's her a fentanyl? Okay, what is it? You all raised your hand somebody knows this It's it's a strong okay. This is a chlorate. So fentanyl is a very strong medic pain medication It's used in very specific circumstances And it is true. There's absolutely pharmaceutical grade grade fentanyl and it has been used, you know diverted For a long time too, but the fentanyl that I'm talking about here is actually completely synthetic fentanyl that is Created abroad and enters the drug supply stream. It is it's all illicit. So these are made and Not made at the pharmacy So it's not so it's not a fentanyl that you know what the dose is that you know what you're getting So both the heroin and the fentanyl is being manufactured illicitly and entering the drug supply So by 2015 by the final quarter of 2015 what we'd see we saw was a shift from most Overdoses being attributable to heroin They're now attributable to fentanyl and we've been in that Wave if you will that wave of the crisis for the last several years So we now have a super saturated opioid drug supply of fentanyl There's barely any heroin and part of the reason that that's the case is that Economically, it's just doesn't make as much sense heroin has to be grown the poppy seeds have to be grown Harvested produced Fentanyl is 50 times more potent than heroin. So you need much less of the drug so for it truly for supply-side reasons that is the manufacturers said okay, there's we have this huge market and There is a drug that is more potent cheaper to make and easier to get into the country And so we now have really the opioid supply is completely saturated now This is not happening in all geographic regions the West Coast for instance is not being as impacted by fentanyl as we are But along the Northeast Corridor and the Appalachian we have been completely saturated So and mentioned this earlier What I hope was the height of the Fatalities and that we are on a downward a permanent downward trend was in 2016 We lost 336 people to overdose in Rhode Island. So that's almost a person a day And there had been a as you saw in the earlier graph There had been just increasing every year the number of people who died from overdose in 2017 for the first time in over a decade. We actually saw a slight decrease It certainly certainly has not enough, but we are seeing At least the correct trend is to be going down in 2018 We don't have all the numbers yet, but it looks like that we will we will have fewer than 323 deaths. We are just not exactly sure how many but expecting again a slight decrease So this graph just or just this map just shows that there's literally not a city or town in Rhode Island That hasn't been impacted by this epidemic Everyone has lost every city in town in the country state rather has lost someone and If this is this is the number of people who died Non-fatal overdoses are actually exponentially larger than this and certainly again is an issue in every city in town Okay so You know how I mentioned that we're in the third wave of the epidemic So the first being sort of the increased use of prescription opioids and shifting to Elicit that the beginning it was heroin and now it's fentanyl we may be in the fourth wave So what we saw in 2017 and we don't have the numbers for 2018 yet was there was a 30% increase in cocaine overdoses Fatalities where there was no other opioid with the cocaine except for fentanyl So the thought was that is that there are Drugs are being contaminated with fentanyl unknown by perhaps even the dealer and definitely the user and so Of course people who have a tolerance for fentanyl because they regularly use the Use opioids from the illicit drug opioids play they have okay They have a tolerance for fentanyl people who do not have a tolerance and have take a substance that is not You know, they think you're taking cocaine or methamphetamine or molly or ecstasy And it has fentanyl in it They are at very high risk of overdose because their body does not have tolerance For the opioid for the fentanyl that is in that substance So that is there's a lot of focus now on Stimulants and the possibility of them being contaminated with fentanyl But but I want to point out that almost all fatalities have multiple drugs in their system one of the Risk factor for having an overdose is using Mixing drugs and if you think about it opioids slow your breathing down And if you take another drug that's a downer like Benzodiazepines and alcohol or alcohol or and alcohol you're having a multiplying effect on your breathing on your on your respiratory system But even if you take a stimulants that opioids and stimulants that overwhelms the body and Increases the risk of overdose So this graph just shows the degree to which fentanyl and this is again that the year for which we have the latest data is Is is a is that issue 70% of deaths in 2017 were related to fentanyl of overdose deaths Okay So are there any before I get into this are there any questions about sort of the bigger picture? Hey, I was so clear. I'm glad I will say I Towards the end in few more slides. I'm going to show a website website called prevent overdose Ri prevent overdose ri. That's a fantastic website if people are interested in this issue want to know About treatment availability we're about getting the lots on want to know about any Statistics in the state about fatal or non-fatal overdoses What to do in case of an overdose all of that information is on the website and I'll show you a little bit Including the governor's strategic plan Which is to reduce overdose deaths in the state and there's a four prong Strategic plan and one of those prongs is to increase access to naloxone Which you guys are doing today? Another prong is increased access to medication Addiction medication for addiction treatment Accessing recovery and and really working with prescribers and patients to To address safer opioid prescribing Decreasing opioid prescribing And embracing alternatives Alternative pain therapies, etc. So those are the four prongs of the governor's overdose prevention task force Okay, so now is the more hands-on part Are people here interested in getting naloxone? Which let me show you what I have Okay, this is a pony kit. This is the kit. We gave out about 60 over 6,500 of these last year in 2018 And it is comprised of two Intramuscular syringes because this is intramuscularly administered to one CC doses of naloxone and a cheat sheet So everything that I'm going to go over today Is included on this cheat sheet The first which is this slide right here This first section is How to it talks about the risks of Overdose what increases the risk of overdose And then we'll go through the rest of it. So if I could get someone to help me pass these out Okay, and for everyone who received a kit I Need you to fill out Okay, so here's the deal with naloxone naloxone is a prescribed medication I'm able to distribute the naloxone because of the standing order that the prescriber Created the prescriber for the standing order is dr. J. Ritch He's also the prescriber that created the standing order at the pharmacies So the naloxone is available at most pharmacies in the state without a prescription because of the standing order And so you'll see that the label actually is my name because I'm the trainer And So there's there's not anything there's no personal information on there about you But I do need to be able to contact you in case of a medication recall although it's rare It's possible. And so that's what this piece of paper is. So it's just this first section right here the other thing That this does is it helps us track? It helps us track It helps us track I get the demographic information to the state And it helps track where the naloxone trainings are happening and where the naloxone is being Distributed to see if there's a match between what the state is finding in terms of overdoses Okay, so one thing to be aware of so we're going to start with what What puts people at risk of an overdose? So one of the things that I was talking about was that if the person that has never used opioids and they use a drug That has fentanyl in it that puts them at risk of overdoses, right? Because they they have not developed developed the tolerance to fentanyl For people who regularly use opioids who have developed a tolerance their risks are different so Change in our lower tolerance so people you know how I talked about you've developed a tolerance over time Well, actually your tolerance pretty quickly goes back to baseline. So let's say that I have been using heroin for Several weeks months and then I get hospitalized and don't have access to heroin are getting carcerated and I don't have access to heroin or I decide that I want to go into treatment and I Don't go on a medication assisted treatment, but I go cold turkey What's going to happen is that the tolerance in my body is going to go back back to baseline Pretty quickly. And so when I if I return to use Then I cannot use the same amount of drugs that I use before because my body can no longer take that So that idea of knowing your tolerance is really important in terms of overdose risks using alone so The deal with fentanyl is that it works very quickly in the body. So I've been doing this for a while and when When I started doing this in 2006 the drug that we were focusing on was heroin And so if someone is having an overdose from heroin then what their Their body to the point at which from the time they take the dose to the time that they have a Critical reaction in their body could be up to One to three hours like it's not immediate it could be but it worked not very often it usually took time So you actually had a little time to intervene that you maybe even if the person used alone Which it was never recommended, but if they use alone, maybe somebody would find out with fentanyl That's not the case People have seconds to minutes to intervene because fentanyl works so much more quickly in the body and is so much more potent And so using alone There is not going to be time for somebody to find you of changing administration personal health history So people who have chronic conditions Like the impact their respiratory system their liver or their immune system are going to be at Have sort of a Lower baseline as it were a higher baseline. They're going to be more susceptible to overdose And it's this deal with the purity or dose. So fentanyl is Now part a regular part of the drug supply, but the thing is is there's not one kind of fentanyl There's multiple they're called analogs and there's identified of more than 50 Fentanyl analogs and basically that means is that the chemical Construction of those all differ slightly and the potency differ So the most potent that we know is car fentanyl, which fortunately we really haven't seen More than once or twice here in Rhode Island is the most potent But even sort of the baseline fentanyl is about 50 times more potent than heroin And so you can imagine that Keeping up with exactly what the purity or dose you can't possibly know what it is because there's no labeling It doesn't have any milligrams of x y and z And so it is variable all the time homelessness of course is is Puts people at risk for a lot of different things, but including as crazy as this sounds Developing a relationship with people are going to new people new Areas it's going to be a different product and they're they may or may not be have the tolerance for that I mean number one is when I talked about mixing drugs and we talked about what we saw that in Fatal fatal overdoses are almost always have multiple drugs in the mix Are there any questions? Okay, so What happens with an overdose is that? The breathing just slows and slows and slows and the body is not getting enough oxygen And so that's what an overdose looks like is that you're not getting enough oxygen so There is slow or no breathing. It can sound like Snoring or girl sounds your change your skin is going to change color. You're going to get blue or ashen fingertips or lips Clammy pale skin and unresponsive so Opioids are sedating and so that is an effect that they have is they kind of put people to sleep and so to determine that a Person is not is asleep versus having an overdose is you can try to wake them up and They don't respond You can do a chest no gear sternum rub, which is where you take your knuckles And you rub it on this chest bone of the person because that your bone on their bone And if they don't respond to that they're in trouble, right? Of course, if they're blue, they're in trouble Okay, so the the first two 911 and administering the locks on or would ideally happen Simultaneously, so if you have two people who are there to intervene in case of an overdose you're going to both Call my one person calls 911 and one person administers naloxone Now I want to show you the different types of naloxone so you In your kit you have intramuscular administration, which is this this It's called dark hand and this is a brand name. This is generic And This is you administer here's a little sample of it You literally administer by putting the nose the nozzle and someone's nostril you have to Turn their head down a little bit like this and push the button and that's that's all there is to the administration of it It's very simple to use The one thing to be aware of is that there's a tiny bit of liquid in here It's really not very much at all So you have to make sure the nozzle is in the nostril so that you don't waste it if you push the button Then it's gone and you have to go this so if you've got two doses of these When you go to the pharmacy and it can be available at the pharmacy through a standing order Then there's two doses and so you would administer the first dose And I'm going to show you how you administer naloxone the Generic naloxone Okay, oh Let me start over I Like everyone to open their pack and what I want you to do is just Take this orange cap take the orange cap and Click it open Do it for both of them because some of them can really stick and if you're in the moment needing to use it You do not want this to stick Okay Now, okay, so this part don't do because you want to keep your naloxone. This is an expired dose You're going to take the orange cap off So because you want to get this is a dose and there's just a little bit of liquid There's one cc of liquid you want to get all of that into the barrel of the syringe You're going to get a little help with that by pulling some air into the barrel the needle Into through the little rubber bit of the bottle and push the air up into the bottle And what you're doing is creating a little compression chamber That's going to aid you in getting all that liquid out of the bottle So once you've done that you're going to pull the tip down and then draw it out Now I'm sure you can't see this from where you're sitting, but there's a little bit of air at the top of my syringe Between there's liquid and then there's a little bit of air I don't care about that because I'm administering not in a vein, but in a muscle and what I'm going to do is I'm going to administer and Right here see if you can fight your muscle in your arm Yeah, you're going to minister the muscle here or you die and You're going to do it through the clothing and so it looks like Okay, you have a jacket on Anybody sitting through here you would just do it right through the jacket not here someone else If you've got somebody who's got on a thicker jacket and you're worried that needle is one inch So if you're worried about it being long enough just do it in their thigh wherever you have access or easy access so you're going to Find the muscle in the upper arm or thigh and then you're going to with force Put it in there because you need the needle to get into the muscle tissue, right? I know that's hard to think about but that's what you need to do and the person is out They're not going to fill it. So they're not care then you're going to push the plunger down Then you're done. So now here's the deal This is now a dirty needle because you've used it on somebody you have it's not a vein But you have used it on somebody so you need to treat it like a dirty needle so what you're going to do is you're going to put it to the side and Then you're going to continue administering to the person who's had the overdose then when rescue comes You can give them the needle or you can dispose of it wherever you dispose of needles on campus Worst case scenario is that you can put it in a hard plastic container like a soda bottle And dispose of in the trash, right? But this you want to make sure that you dispose of it properly, right? Okay, so you've called 911 you've administered naloxone now the person may wake up Right, that's a possibility. They may wake up after one dose and if they wake up they're going to be They could be a variety of things every single time they're going to be disoriented because they were passed out So when they come to they're not going to know what happened to them you have to explain you had an overdose I gave me naloxone rescue is on the way You they they could wake up and be alert Very often if it's a fentanyl overdose, they will not be alert They're going to be groggy and really out of it So they'll be kind of a way you'll see they get color to their face They're breathing more normally, but they're still really not with it if that's the case You'll see on your little cheat sheet that there it has the recovery position, which is a person on their side And the reason that you do this is because if they vomit which they could well do Because when you have given them naloxone and they come to and you've taken those opioids off this receptor because that's what naloxone does The person could if if they are dependent on opioids will experience withdrawal So they could vomit both during the overdose And more likely after the after they come to from the overdose after you've given them naloxone Okay So rescue breathing So remember this is why I told you the person needs oxygen So if you know rescue breathing and if you feel comfortable doing rescue breathing Then you can give them breaths. So you call 911 you've given them naloxone and you can give them rescue breaths And a way a handy-dandy thing to have for that which I am sorry that can't include in our packs because we don't have the money to pay for it But is this breathing mask? It's a one-way valve right here. You put this over the victim's mouth And then you can breathe through it. So basically who knows CPR Okay, so one of the many people here tell me how to do rescue breathing And okay, exactly right. So you're doing one breath every five seconds We went you how you want to prepare the head and this is also in your cheat sheet You basically want to lay the person flat Tilt their head back because you want the airway to be straight. So you're thinking I'm breathing for them I need my breath to get into their lungs So you do a couple of breaths to start off with you have to pinch those Because if you breathe into their mouth without pinching the nose the air is going to come out the nose So you tilt the head back pitch the nose Open your mouth to make sure nothing's in there. You put your your mouth over there There's give a couple of breaths. What you're looking for is the rise and fall of their chest That means your breath is getting into their lungs Once you see that then you're going to get one breath every five seconds and you're going to do that for three minutes If you do not feel comfortable giving rescue breaths Don't wait three minutes so that second administration Happens two to three minutes after the first so if you're giving rescue breaths Let your oxygen do some work and go ahead and wait the three minutes But if you are not able to do that a couple minutes later Give them the second dose of naloxone and then so you would do 911 naloxone Rex rescue breathing two to three minutes later more naloxone rescue breathing until EMTs arrive and they take over for you, right? So does that make sense? That's right. So here's the deal. That's thank you for saying that So if they wake up your job your job is done, but they need medical attention, right? So they don't so there's a couple of things one is they actually can go back into overdose because what happens naloxone Goes into the opioid receptors it kicks the opioids out and that's what causes the withdrawal But it only lasts in the body 30 to 90 minutes And so the other the opioids that kicked out don't disappear They are waiting around to reattach to the opioid receptor now as the naloxone dissipates So are the opioids so the vast majority of time the person will will have some relief from their withdrawal But they won't go back into overdose, but if it's a long-acting opioid like methadone for instance It is possible that they go into an overdose again So medical help is really important not only that There are multiple consequences to an overdose not just death So it's possible for instance I talked to physicians that say that the main reason people are intubated is because they overdose So the whole thing a person if someone hasn't had oxygen for long enough They are susceptible to a variety of problems including brain damage, etc. So having medical attention is critically important So this is administering naloxone, which we showed So this as via This is a brand product. The thing is is that it there's not a whole lot of it in Rhode Island because it's about $4,000 for two doses and there's not many insurance companies that cover it Understandably they are talking about reducing the price of that. We'll see if that happens This is the generic intranasal this this right here, and then this is the brand name which we talked about Okay, we talked about rescue breathing. So all of this is in your the cheat sheet. I was telling you about the recovery position and this is the This is the website that I was telling you to prevent overdose ri There has there's a lot of great resources here. So the other thing that I want to tell you about The other thing that I want to tell you about is That the naloxone needs to be stored at room temperature, which is basically 60 to 90 degrees So you don't want to keep it outside. So you don't want to keep it in your car I keep my naloxone in my purse all the time So basically keep it to 69 to 90 degrees So that is so how do people feel like they could use their naloxone? So what I want to give you the opportunity to do is that if you are not used to if you've never had diabetes or had Apparently had diabetes or had some reason to handle needles before I welcome you to come draw up the naloxone You in the vibe from these vials right here just to get some muscle memory for that I Otherwise I want to like make sure that everybody I need a sheet of paper from everybody who Took a kit of naloxone And the last thing that we're going to do is on the back of that sheet of paper. There's a little quiz Yes, you take the orange tip part off exactly right Yes for the medicine when you're getting ready to use it Yeah, but for now leave it on I'll look to see if I have another one here. It's okay. It's actually okay, but um Yeah, no, of course, that's fine It's fine, but just remember that it's still good You know that it's that even though the caps off that it is that's still usable Do you know I mean this naloxone is as good until February 2020 So it if you have expired naloxone and for any reason let's say it's 2021 and all you have is this kit of naloxone still use it at last past its expiration date if it's been stored room temperature it has It if it's exposed to extreme temperatures. It's going to lose some of its potency. So Thank you for saying that That's right. Thank you so much for saying that So if you know CPR, so here's the deal if you what happens is when somebody's had an overdose there They need breath and so if you can get to them right away, that's what they need is bread But ultimately they could have a cardiac arrest right because that's the one of the consequences of not breathing for For too long So if the person has had a cardiac arrest then you know CPR you definitely want to use CPR So you would check for their pulse and you would administer CPR and integrate rescue breathing If you don't know CPR Donna can tell you how to learn it So that so you would start off administering the Narcan first So if you come upon somebody So this is a really good question So there's a couple of things one is is if it's not an opioid overdose, right? then you right Naloxone is not going to help them right CPR if they're having a cardiac arrest CPR will help them and if you come On somebody and you're not sure the The best the best trained you could be would be to have your naloxone No CPR check them for a pulse, etc. If you were But given the amount to which we have opioid overdoses in our You know, I hopefully on campus, but more broadly and certainly in Rhode Island Administering the laksa is a safe thing to do because if it's not Opioid overdose, you're not going to hurt them and if it is an opioid overdose you're giving them critically important medicine So what Right, so what if you come on someone who is unconscious and they're and they're exhibiting not breathing Then treating they're not so giving the naloxone calling 9-1-1 Obviously first is important giving them naloxone Intramuscularly or even intranasally because it doesn't they don't have to breathe it in absorbs through the mucus membrane Then you can address, you know at doing CPR and rescue breathing, etc If you assess that they have if you know CPR and says that they're having you've checked for the pulse and they don't have a heartbeat So let's do the quits on the back So what is the first question? Are there any of those sheets left? These sheets Wow, yeah, okay Okay So what are what are ways what puts people at higher risk of overdose of opioid overdose? Mixing drugs absolutely. What else? Using alone fatal overdose Tolerance being aware of tolerance. What are two signs of opioid overdose? Yes, excellent very good. So they were not responsive Girdling slower now breathing and losing color blue pale lips So you see that number three has ABC or D Assuming that you're not doing a CPR or just focusing on rescue breathing now ABC or D is the most correct response See, that's right And where do you administer naloxone if you're doing an intramuscular injection? Where do you do the injection? Arm of thyroid and how long do you wait to give a second dose? Two to three minutes and then six number six. What is the order of intervention? Say nine, okay If at all possible nine one one administering naloxone at the same time But if you're alone nine one one naloxone and rescue breathing and then a B or C is the recovery position See great. Okay No, it doesn't matter Doesn't matter where you administer the second dose if you get Narcan though if you have the intranasal This You should give it in the second nostril. So first dose in one nostril second dose in the second nostril Yeah, so does anyone want to practice? It would the naloxone would bind with will bind with the opioid receptors It'll do that regardless of the whether person has opioids in those receptors or not And if there's no opioids present, you won't feel anything because there's nothing they are except you're naturally occurring opioids So it doesn't do anything. It doesn't help but it doesn't hurt Come on. Nobody wants to try wants to practice everybody here. Good Okay, well, thank you very much and come down and practice