 Hello, everybody. Thank you so much for joining today. We're just going to give it a minute to let people fill in. Looks like we have a good crowd, so I will begin. Thank you everyone for joining today. I'm Ariel pallets. I'm the executive director of the office of the city of City of City. We are at a nightlife at the mayor's office of media and entertainment. If you're not aware of our office yet. We are a dedicated non enforcement liaison between the city and the nightlife industry and community. We provide resources and information and support. To help navigate and resolve issues with city agencies. approach, which is multi-agency support for hospitality. We assist with quality of life complaints between venues and neighbors through our free mend mediation program. We have free mental health support and affordable, mental health support through elevate mental health program and a few other things. If you're not familiar, please follow us at NYC Nightlife Gov and get on our newsletter. The purpose of this webinar today is to bring you resources and training as part of the city's harm reduction efforts to combat the growing opioid overdose epidemic in our city. As you likely know, there is a fentanyl crisis and fentanyl continues to drive overdose deaths in New York and was involved in 68% of overdose deaths in 2019. The city's new harm reduction approach to addressing these issues recognizes real-world human behavior and is working to help support these issues. We know the stigma of substance use in nightlife can be particularly challenging and there may be some hesitation to have Narcan at your establishments, but this program is legal and supported by the city. We know that substance use is a part of life in many different settings at all times of day and night and may be present in a variety of work settings and gathering places. This is not just a nightlife issue. We know that more than two thirds of overdoses happen in private homes and less than 1% of overdoses happen in venues, but when it does happen in venues, it is so important to be prepared. We want nightlife venues to be a place where people are looking out for each other and see venues as partners in helping to combat the crisis. This is about bringing lifesaving harm reduction tools and resources to all of you in the nightlife community. We've been partnering with the health department on the Narcan Behind Every Bar Awareness Campaign and encourage venues and staff in security how to use Naloxone and get a free overdose rescue kit by mail, which we're doing today. Every venue and promoter is encouraged to have at least a few Narcan kits on hand in case of an overdose and we equate it much like having a CPR kit or a first aid kit or even the free condoms that New York City distributes. Harm reduction tools can help venues to prepare and to promote public health. Today you will learn how to become a certified opioid overdose responder and we'll receive your kit by mail. While the focus of today's presentation is on Narcan training, I also wanna highlight that there is a growing use of fentanyl test strips, which are a public health tool that allow people who do use drugs to test for the presence of fentanyl in other substances. Venues and promoters can distribute fentanyl test strips if they're comfortable doing so for patrons to use at home or off-premise. In New York state drug checking tools such as fentanyl test strips are not included in the definition of drug paraphernalia and therefore are permissible. For today's webinar, we have a presentation by my magnificent colleague at the health department, Yarlix Estrada. She is a special projects coordinator for rapid assessment and response RAR in the Bureau of Alcohol and Drug Use Prevention, Care and Treatment. After her presentation, we will have time for Q&A. So if you are having questions throughout the presentation, please use the Q&A feature in the Zoom to let us know what your questions are throughout and then we'll get to them either in the middle or towards the end depending on where it makes sense. So this is also being recorded and streaming on Facebook so you can feel free to let people know if they haven't registered, they can go to the office of Nightlife Facebook to watch it now or later. So with that said, thank you all again for coming. Although it is not a mandate, our goal is to have Narakhan kids behind every bar because bars and clubs can save lives with Narakhan. And now I would like to turn it over to Yarlix. Take it away, thank you. Thanks Ariel and thanks for putting on this webinar and connecting us so that we can provide this training. So hi everyone, like Ariel mentioned, my name is Yarlix, I use her pronouns. I work for the New York City Department of Health but prior to working here, I worked in Nightlife with DanceSafe and with other Nightlife organizations doing harm reduction work at festivals and at raves. So I have that background as well. And in the Department of Health, I work leading the drug checking work. So I run a drug checking pilot with machines that can test for the presence of certain drugs in those substances. And I also support with the fentanyl test of distribution pilot that we're currently piloting within the department. So I'm gonna be doing a presentation on the lock zone. And there will be opportunities for folks to ask questions. So if there's anything that you are curious about or if questions come up as I'm going through this presentation, feel free to ask. And the framing of this is overdose prevention during the COVID-19 pandemic. Obviously, lots of things have changed because of COVID. And so as I'm going through these slides, I'm also going to be talking about how some things may be adjusted because of the pandemic or some considerations that we may not have talked about prior to the pandemic. Okay. And I just wanna provide a content advisory that I'm gonna be talking about the overdoses that have happened in our city. I'm gonna be talking about different topics that are difficult sometimes to sit with. And so I just wanna acknowledge that, that it can be emotional, depending on your personal experience or your lived experience. Also just acknowledging that the overdose crisis as well as the COVID-19 pandemic have shown us how the structural racism impacts our city, how it impacts our country, how it's prevalent in our city, in our country, as well as the racial inequities that exist and continue to thrive in both our cities and in the country. And so, if you need to take some time to step out of the training or if after the presentation, you also need to take some time to take care of yourself. I encourage that, we encourage that just because this is work that is difficult and content that is difficult to sit with. Okay, so things that I'm going to, things I'm gonna talk about today is how overdose is affecting New Yorkers, understanding opioid overdose and naloxone, also the steps for responding to an opioid overdose as well as naloxone access. And then I'll also be talking about COVID-19 specific guidances throughout the presentation, throughout the training, since some things have changed a bit since COVID. Okay, so a few key terms. The first is opioids. When I talk about opioids, I mean pain relievers that include opioid analgesics, so including like prescription painkillers as well as drugs like heroin and fentanyl. And when I talk about fentanyl, fentanyl is a potent, fast-acting opiate. When I'm talking about fentanyl, generally I'm talking about non-pharmaceutical fentanyl, meaning there is fentanyl that's found inside of hospitals, but, and it's typically prescribed to people that are going through surgery, people that are recovering from cancer or that have cancer and are going through cancer treatment. But typically when we talk about fentanyl, we're talking about non-pharmaceutical fentanyl, although naloxone can reverse both pharmaceutical and non-pharmaceutical fentanyl. And lastly, naloxone, we'll be talking about a lot as well, which is this training with a safe medication that can reverse the effects of opioids and prevent fatal overdose. So all the drugs here at the top, the opioids can be reversed by naloxone. So now I'm gonna talk about how overdoses are affecting New Yorkers. So here you can see the unintentional drug poisoning deaths which are overdoses that have happened in the city from 2010 until 2020. And as you can see, the number has been steadily rising. When we see this shift from 2016 to 2017, that's when fentanyl was introduced or reintroduced because it was briefly introduced into the drug market in the early 2000s, but it was reintroduced in a more sustained and intense way in that period. And we see the increase in overdoses in that time. And then we also continue to see an increase that again is a sharp increase from 2019 to 2020, which there are a lot of factors for why this happened. A couple of them are COVID. So a lot of the people losing access to services, a lot of folks who are in sustained recovery or maybe have had better success with managing their use because they have relationships or people that they rely on a lot of social structures that during the pandemic fell apart. And also because the drug supply already unstable because of the increase in fentanyl became much more destabilized because of lack of certain substances that were available to produce those drugs, as well as the variability of the fentanyl that was continuing to be in the drug supply. And of course, like I mentioned earlier with the structural racism and the racial inequalities, that was just exacerbated. So a lot of the neighborhoods that we know have been historically disinvested from that have higher incidences of poverty, of food deserts, of issues like that, were disproportionately impacted in the overdose epidemic as it continued in 2020. So in 2020, someone died of a drug overdose in New York City every five hours. This number has continued to increase from 2020 to 2021, but because of delays at the corner's office, at the office of the people who process deaths, we don't have those final numbers just yet. We're still working on those. And here it shows the rates of overdose deaths by neighborhood of residents in 2020 where the darkest areas are the areas that have the highest rates and the lighter colors are the areas that have lighter, less deaths. And so we see here a high concentration of overdose deaths in the Bronx, including Crotona-Trimont, Highbridge-Morsignia, Hunts Point-Mott Haven, as well as East Harlem, and as well as Stapleton St. George in St. Nyland. And in 2020, the Bronx had both the highest rate as well as the highest number of overdose deaths. So if you see here on the left, the rate is the number of people who died divided by the population. And the Bronx still has the highest number. And as well as on the right, you can see the number of drug overdose deaths, just the sheer number. And the Bronx also had the highest number of deaths. The rate was followed by St. Nyland and Manhattan. And then here, the number was followed by Brooklyn, but Brooklyn has a larger population. So that's why the rate is less on this side. And heroin or fentanyl were involved in nearly all opioid overdose deaths in 2020. So as you can see here, 85% of deaths had any opioid involved. 80% of deaths had either heroin or fentanyl involved. 48% of opioid overdose deaths in 2020 had cocaine involved. 19% of overdose deaths had benzodiazepines like Xanax or clonopin involved. 14% had methadone involved and 16% had opioid analgesics involved. So opioid analgesics being like percocet, oxycodone substances like that. And fentanyl is the most common substance involved in drug overdose deaths with 77% of drug overdose deaths involved with over 77% of drug overdose deaths that involved fentanyl in 2020. So as we've been seeing since 2017, fentanyl has been the substance that is driving a lot of these overdose deaths because it's such a powerful substance that sometimes, well, in all cases, people are not able to reliably dose themselves because the amount of fentanyl inside of a bag can be different bag to bag. Also the strength of the different kinds of fentanyl because there's many different kinds of fentanyl which we call fentanyl analogs can vary in potency. So even if somebody uses a consistent amount, if they get car fentanyl versus just regular fentanyl, then they're at a high risk of overdose for that reason. So this is what I mentioned earlier with non-pharmaceutical fentanyl and the New York City drug supply. So as I mentioned, non-pharmaceutical fentanyl is the type of fentanyl that is made in clandestine labs. They're not produced by pharmaceutical sources. So they're not patches, they're not lollipops that you can get at pharmacies that some people get prescribed because of pain management or because of cancer treatment. And fentanyl is 50 to 100 times stronger than morphine and 30 to 50 times stronger than heroin. And typically when we talk about fentanyl, we mean fentanyl hydrochloride which is the main kind of fentanyl that we see in the drug supply. But there's also different types of fentanyl analogs like acetyl fentanyl, parafloral fentanyl, car fentanyl and these different kinds of fentanyl each have their own particular risk profile that is similar to fentanyl but some of them can be a little weaker, some of them can be a little stronger, some of them can be a lot stronger. And so that's just something to keep in mind that that is currently happening in the supply. Over time we see waves of particular kinds of fentanyl. Consistently we see fentanyl hydrochloride which is what we're referencing here. And unfortunately in the beginning we were seeing a lot of fentanyl that was being found in heroin. And that's how a lot of folks started having the overdose deaths. But at this point we're finding fentanyl in heroin and cocaine and crack and counterfeit pills. And so examples of counterfeit pills include pressed Xanax pills, pressed oxycodone pills, pressed percocet pills. And there have been some reports of there being pressed Adderall pills and then finding fentanyl in those as well. Fentanyl has also been found in ketamine and methamphetamine and also other drugs that are bought on the street or online that may contain non-pharmaceutical fentanyl. And the fentanyl could be cut in or pressed prior to purchase. And it's also possible that there's cross-contamination. So in some of these situations that we have heard of happening or that we have mortality data for, it seems like these pills were pressed, for example, like a fake percocet, right? Because it's an opioid. And so instead of using actual percocet because they can't get it from a pharmacy, then they put a small amount of fentanyl with other binding agents and sell it as that. But there's no way to reliably tell the strength of that because it's been pressed with a substance that we don't have the information for how to dose properly. But in other cases, such as with cocaine, with crack, with ketamine, with methamphetamine, it's possible that it's cross-contamination. So for example, if there's a dealer that sells both heroin that they cut with fentanyl and they also sell cocaine, even if they leave miniscule amounts of fentanyl from the last measurement that they did for the heroin, that small amount, if they put the cocaine on that and measure it out and put it in the baggie, that could be enough to cause an overdose. So that's just something to be aware of that fentanyl is not only being found just in opioids like heroin, but it's also being found in other substances that are not opioids, which can be dangerous for folks that don't have a tolerance to opioids. And this is just a point of clarification that I hope folks know or maybe are aware of now that there is no risk of overdose from touching fentanyl. Fentanyl does not cause overdose by touching it, you can't touch it with your skin. There are fentanyl patches and those are made to be absorbed by the skin. So that's the specific purpose of those patches. Whereas if we touch powder fentanyl, it's not gonna cause an overdose. The only way that fentanyl can cause an overdose for people is if they ingest it, whether it be orally through their nose, through their injection, through some kind of mucosal insertion into the body. Okay, so I'm just gonna pause here and check if there's any questions. You can put questions in the chat or you can put it in the Q&A, no questions yet. Okay, cool. But yeah, if you have any questions, feel free to share and I'm happy to pause and answer them, but I'm gonna keep on since I don't see any questions. Okay, so now I'm going to explain what an opioid overdose looks like, and how to identify them. So this is how opioids work. So we all have opioid receptors in our brain. It's just like part of our brain. And the opioids that we sometimes consume, such as if we have a surgery and they prescribe it to us at a hospital or if somebody uses opioids from the illicit drug supply, opioids can provide relief from pain. They can also relieve withdrawal if people have a dependence on opioids. They can also produce feelings of happiness or feelings of comfort, but there are side effects. And the side effects of opioids include constipation, nausea, drowsiness and respiratory depression. And respiratory depression is how the overdose has happened. So the process of overdose can happen over the course of minutes to hours. And a lot of this depends on which substance it's happening with and the intensity or the strength of that substance as well as how much of that substance was consumed. So first it starts in the brain. So the quantity or the strength of opioids gradually suppress the involuntary drive to breathe. So if somebody's using, let's say heroin for example, their breathing might go from 20 breaths per minute to 15, like in an hour. And then in another hour it might drop down to 10. And then in another hour it might drop down to five. And that's when it gets dangerous. The breathing slows down and eventually the breathing gets so slow that there is not enough oxygen circulating through the body and then the heart stops which leads to a fatal overdose. And the reason why it says that this can happen through a course of minutes to hours is because again, it depends on the substance. So here it says it's rare for someone to die immediately from an overdose. When people survive it's because someone was there to respond. And so that's why it's so important for us to recognize signs of overdose, to be able to respond when we might suspect that this is happening. Back when we only had heroin to worry about to respond during an overdose and overdose could happen over the course of several hours. So somebody might be taking heroin for some time and maybe be in the state of an overdose after four hours of use. Whereas now with fentanyl, especially when there may be stronger kinds of fentanyl or somebody may have used a large amount this overdose can happen in just a few minutes. And because of that, it's important to have a faster response time because the window that somebody could fall into a fatal overdose decreases. And so it's important to be able to respond and help that person breathe again. So here are some common risk factors of overdose. The first is changes in tolerance. And so if somebody is someone who uses opioids regularly and then they take a break, their tolerance has gone from, let's say they use like three bags a day and then they stop using for a while, let's say because they went to jail or maybe they went to treatment or just decided to take a break or decided to stop using. If they were to start using again and they start out with three bags a day again, they will likely end up in an overdose because they don't have that tolerance that they usually have. Another risk factor is mixing drugs. So sometimes certain substances can exacerbate the risk of overdose. So for example, combining opioids with benzodiazepines like Xanax, like two depressants in some circumstances, combining opioids with cocaine because it puts a lot of stress on both your respiratory system and your circulatory system because they're drugs that act in two different directions. And generally just depressant with depressant is something that puts someone in a high risk of overdose. Also the drug quality. So if somebody finds a substance that is adulterated and they may not know, this is something that can cause a risk of overdose. So if somebody purchases methamphetamine or cocaine or ketamine and they don't know that there's fentanyl in it, whether it be likely because of cross contamination, then they're at very high risk of overdose if they don't have naloxone around them with someone that can administer it to them if that were to happen. Also previous non-fatal overdose is one of the top indicators that someone might have an overdose again. And lastly, using a loan. So if somebody uses a loan, then there's not a possibility for another person to respond unless they use a resource like the Never Use a Loan Hotline, which is a hotline that if you are going to use a loan, you can call this number that has an operator and they will hang out with you on the phone. And if you say like, okay, if I don't talk to you in five minutes, please call an ambulance and they don't answer in five minutes and they'll go ahead and start that process. And they have successfully reversed overdoses using that system. And the use of any opioids can put someone at risk. And so just recognizing in New York City over 85% of opioids that have been lab tested has been found with fentanyl in them. And because there's no clear way to dose the substance, that puts people at risk whenever they use them unless it comes from a pharmaceutical source. And even then, if you take too much percocet, like if you take 10 pills at once, you know, you can still overdose. So dosage is also important, knowing how to dose properly. Okay, so I'm gonna talk about risk reduction practices that people can do if they can do it when possible. And so the first is in changes in tolerance is be careful if you take a break or you miss doses. If you use drugs, use less, you know, like go slow, do a test shot just to see how strong it is. Maybe it's a lot stronger than you expected and you don't need to take as much because it's so strong. Something else that folks can do if they are using drugs is to make an overdose safety plan. And so in general, this is like if you're gonna use drugs with friends or if you know, someone who's gonna use drugs talk through what do we do if someone were to have an overdose? And it's an uncomfortable and potentially intense conversation but there have been stories of people that have chosen to not respond to an overdose because they're afraid that if they call 911 they're gonna get arrested or they just freeze up and they don't know what to do and they end up leaving. And so being able to talk about, in this circumstance, like call 911 and leave or give me naloxone and then leave or stay and notify my mom or things like that. So just having an overdose safety plan is helpful. Buy from people that you trust and ask about changes in product and also talk with others about quality. And this is mixed, I have mixed feelings about this risk reduction practice because realistically, yes, people that have reliable supply tends to be generally reliable but a lot of folks that have bought ketamine or cocaine or different substances that have had overdoses we're not expecting there to be cross-determination because sometimes the dealers themselves don't know where it's coming from. And so when possible, it's always important to use with someone or use something like the hotline, have naloxone with you. And if you can have access to fentanyl test strips testing your drugs for fentanyl if you're not trying to use fentanyl. But talking with others about the drug quality they may be asking like, do you sell opioids? Do you sell other drugs that might have fentanyl in them? That could be a way to mitigate that risk. Also, like I mentioned earlier use with someone else and take turns or use an ever use alone hotline that I mentioned earlier and this is the number that you can call if you are gonna use alone or if you know someone who uses and might use alone then they can use that hotline. And the taking turns part is important because if the substance that y'all are using is strong and you use at the same time and you both overdose at the same time then there's not a lot of helpfulness if you're both out. So having one person use first and waiting a particular period of time whether it be 15 minutes, 30 minutes to see how they react. And then if they're okay then the other person can go. So if there is an emergency someone can respond with maloxone. And lastly, if someone has a dependence on opioids if or when they're ready they can find medication for opioid use disorder such as methadone or buprenorphine if they want to use a supply that's more secure than what's found on the street. Okay, and I'm gonna talk about the words that we use when we talk about folks who use drugs or people that have dependence to drugs because the words that we use matter. And I've been in a lot of settings like obviously the street is the lowest barrier place but also in hospitals and clinics even in professional settings where I've heard people use stigmatizing language and some of these words include addict, substance abuser, junkie, substance abuse, clean doctor shopper replacement or you should or you shouldn't. And it's important to use more compassionate and person-centered language when working with folks use drugs because some people have had the stigma of drug use or of drug dependence for so long that having this accusatory or negative language thrown at them constantly can make them not feel empowered to modify their drug use or do certain practices to change their use or in some circumstances, if you're a provider, for example or if you're someone who works with other people who use drugs, like people may not feel comfortable coming to you and being honest and saying like, hey, like I use fentanyl or I use this substance because they may feel that they're gonna get judged and so I think it's important for us to be open to let folks know that we're there for them in whatever capacity we might be and a lot of that starts with language. So some of the more compassionate and person-centered language includes person who uses or person who injects drugs, people living with a substance use disorder instead of saying abuse, saying substance use or possibly misuse and instead of saying clean because if you're saying clean and you're implying that using drugs makes someone dirty which is not true, you can say someone who is currently abstaining or making changes to their drug use instead of saying doctor, shopper, seeker saying patient, participant or client as well as medication for addiction treatment or medication for opioid use disorder and instead of saying you should or you shouldn't that sounds like a very like demanding kind of action then saying, would you consider or can you try to avoid and then talking about it in that way and some other loaded words are words like relapse and recovery depending on who you ask you'll get a different definition for each one and so we just wanna make space for wherever people are in their process and using words that don't make them feel worse about their situation. Any questions now? Okay, still if there are any questions feel free to put it in the Q and A function or in the chat and I can pause but I don't see questions, I'm gonna keep going. Okay, so now I'm gonna talk about naloxone. So naloxone only functions so naloxone is the same thing as Narcan Narcan is a brand so when I talk about naloxone or Narcan they're interchangeable and naloxone only functions to reverse opioid overdoses so if I was to give it to myself right now this is what it looks like these little sprays if I was to give myself a naloxone right now nothing would happen, it's basically like water it's safe, it has zero effect if opioids are not present. If there are opioids present in my body then it'll block that substance and I'm gonna go through what that process looks like and naloxone is available as a nasal spray or it's also available as an intramuscular injection and the intramuscular injection are these little vials with syringes where people draw up the medication and they give it to them on big muscles so the arm, the thighs, the butt but in New York City through the Department of Health we give out the nasal sprays so they're a lot easier to use. Let's see, there's a question. Can you talk about if there's a way to test pills determine counterfeit pills and where to get free fentanyl test strips? So I will, there's a little section on fentanyl test strips and I will talk about them there there are a way to test them, yes with the fentanyl test strips and at the moment there isn't a way to get free fentanyl test strips we're at capacity in our pilot but we're looking to expand in the coming months so I'll talk a bit more about that later in the presentation but thanks for your question, Jennifer. So with naloxone there are no non-negative effects the only negative effect which is a pretty big negative effect for someone who is dependent on opioids is it could put an opioid dependent person in withdrawal so if someone's having an overdose and there's someone who's dependent on the substance and you give them naloxone, they'll get sick and I'll talk a bit more about what that looks like but they can feel very upset, very irritated, nauseous, uneasy because they've been put straight into withdrawal which is where they are when they don't have the substance that their body is craving and there's another question does naloxone work if the nose is stuffed or if there's not a lot of breathing through the nose? And yeah, Ryan, thanks for your question the naloxone should work because it's absorbed through the cavity of the nose so as long as the liquid makes it in, it'll still work yeah, but I'll walk through what you should do like we should tilt the head back and by tilting the head back that also helps with the entry of the medication into the nasal passageway so I'll explain that in a little bit is there any allergic side effects if we use it by mistake for the person who is not having an overdose with other health issues? Thanks for your question, Edda and no so the safety of the naloxone has been tested with like pregnant people, with other people that are sometimes have adverse reactions to medication and as far as we know there are no negative effects to people that are not having an opioid overdose either so the worst thing that can happen so the way we usually frame it is if you find someone who's not breathing or someone who's exhibiting the signs and symptoms of an overdose, we always encourage people to use it because the worst thing that can happen is nothing like you're just gonna, well I mean if somebody, if I'm like passed out let's say I'm like really drunk and I'm like kind of sleeping but you can't tell if I'm breathing or not and someone like sprays me with naloxone like I'm gonna feel uncomfortable because I've just been sprayed with a bunch of like random liquid in my nose but I'm not gonna have any very bad adverse reaction that we know of, there's nothing beyond like the discomfort of someone like spraying your nose so yeah, it's a safe medication and there's no potential for misuse or dependence and responders have a liability protection in New York state so I'll talk a little bit about what that is but that's called the Good Samaritan law in New York state so there is protection if you're out in the community and you see someone having an overdose and let's say they're not having an overdose and you use it on them, you're still protected by the law because you're acting in good faith to try to help someone that may be experiencing an overdose. Thanks for your questions and if you have more keep them coming I can always pause to check them out, okay. So how does naloxone work? So this is what we talked about before so we all have opioid receptors in our brains and these are the opioids that are on those receptors so they're on the receptors in our brains because they're on the receptors in our brains over time that causes that respiratory depression it causes our breathing to slow down so we're breathing less frequently per hour and then let's say this person's having an overdose so we give them the naloxone and the medication makes it into their nasal passageway and then the naloxone comes and it knocks off the opioids that are on the opioid receptor and so it was once the opioid that let's say heroin was once on the receptor and then the naloxone comes, knocks it off and now naloxone is on the receptor. So that person was potentially having respiratory depression now breeze in because that respiratory depression has stopped for that time and it usually takes between two to eight minutes to restore breathing. So that's how long it takes for the naloxone to work and this isn't an important detail that naloxone is not a permanent, you know, substance it's not a permanent drug it lasts for 30 to 90 minutes. So if you give naloxone to someone it is possible that they can fall back into their overdose after those 30 to 90 minutes and so because of that it's important for either somebody to be there with them to make sure they're okay to make sure that they don't use again or to call an ambulance and make sure that they go and get some additional support at the hospital and get checked out. So now I'm going to talk about how we respond to an opioid overdose and just one guidance comment is part of responding to an overdose will involve a brief period of being less than six feet from another person. This involves like giving the person the dose if the person doesn't start breathing after we give them the initial doses mouth to mouth as advised. So, you know, these are just situations where if the person has COVID it can cause transmission and so their care should be taken to avoid any unnecessary contact if you don't have to or if you have your mask that can be additional protection and it's always important to wash your hands or use alcohol-based hand sanitizer before and after responding to an overdose. Okay, I see another question. Can you give someone a second dose if needed? Yeah, thanks for your question, Ryan, absolutely. In the explanation that I'm about to give now I'll talk about what the timeline is like how long you should wait before giving a second dose but there are circumstances where if somebody use a stronger drug like fentanyl or might have consumed a stronger analogue of fentanyl they might need more than one dose for sure. And the blue bags that we give y'all that ones that will mail out if you don't already have one they have two naloxone doses, two of these in there. So you can ask for several kits if you think you might need several kits. That's a good question. So here are the signs of an opioid overdose. The first and one of the more obvious signs is someone who has slow or stopped breathing. Another sign is that someone is unconscious or unresponsive. Another is if someone has blue or gray or white lips or nails. And the reason why somebody might have this around their lips or nails is because if they've consumed an opioid and that opioid is causing respiratory depression that means that oxygen is not circulating in the body as it should and eventually they'll start to get pale. And you can sometimes notice that that paleness depending on the color of their skin. So for some people that are more light skin, light, more white it might be more blue. And for folks that have darker complexion it might look more gray around the mouth and as well as the nails. Like normally if we press our fingernails it might turn pink or purple. And when we don't have that blood circulating through our fingers properly then it might be more blue or gray or white also depending on our skin complexion. Another sign is snoring or gurgling sounds. So if somebody is having difficulty breathing because there's not enough air coming into the body it might sound like snoring. And also muscle stiffness or rigidity of somebody consumed fentanyl. That's one of the signs for someone that has specifically used fentanyl. And so some of this muscle stiffness is like tightness in the chest. They might like have some spasming. Also lock jaw is a sign that they have consumed fentanyl. And Catherine I think it's fine for me to send the PowerPoint I will double check with the team and I send PowerPoint and I will let you all know. And if I can then I'll definitely send it out to y'all. So these are the signs and symptoms of an overdose. I'd say generally the most important thing to look out for is if the person is unconscious and not breathing. At that point I would definitely give them naloxone because again there's no harm in it besides just some discomfort of having some like water straight up your nose but there's no potential negative reactions that we know of or that can happen and people have used a lot of naloxone. So I think we would have heard of some of those other potential effects by now. Okay, so these are the steps. This is what you do if you think that you're finding someone that is having an overdose. The first thing is to shout from a distance. So be like, hey, are you okay? You know like calling out the person and then tell them that you're gonna call 911 if they don't respond. If they don't respond, if they're still not answering or not making any seeming like awareness that you're around then we encourage folks to do a sternal rub. And so a sternal rub is when you take your fist and you take your knuckles of your fist and you rub it really hard against the person's chest because it hurts. And so if the person, let's say is like very drunk after a night out and decided to take a nap on a bus bench, the likelihood of them waking up if you do a sternal rub is pretty high. I mean, they'll probably be breathing. So you probably shouldn't give them naloxone if they're breathing, but if they're snoring and you're concerned, you can do a sternal rub and see if they wake up. So you will apply some pressure and you'll do that into their breastbone. And just as a reminder, you always wanna perform that order. So shouting at a distance, if you wanna come close and be like, hey, tap the person, you can do that. And then do the sternal rub before administering naloxone. And all the naloxone kits come with non latex gloves. So if you don't feel comfortable touching the person with your bare hands, you can put on those gloves. So someone may be high, but not yet overdosing. So if someone responds to shouting or the sternal rub, even verbally, try to keep them alert and monitor them closely. So there may be someone who is maybe in the process of going into an overdose and you found them before they've gotten to that point. And so if that's what's expected, an overdose is still possible, especially if you found them and they may like, if you decide to leave, they could be in like an actual overdose in like 20 minutes or something. So in that case, keep naloxone nearby. If you have your kit, keep it with you and stay with them or ensure that they will not be alone. So if you're concerned about someone, maybe call 911 or find someone that can be with them so that if they were to fall deeper into their overdose, then someone can help them. But again, when in doubt, call 911 for medical help so that someone can be there to support them. So if there's no response from the sternal rub, so you've like gone to the person, you've yelled at them, you've done their sternal rub, they're still not responding, they're still unconscious. Then at that point, you wanna call 911. And when you call 911, you wanna give the dispatcher the address and the specific location of where you're at at that time. And you wanna tell them what you see. And in that case, for example, you'll say like the person is not breathing, the person is turning blue or gray, the person is unconscious, they're not responsive. And we wanna do that because we wanna protect the person. We don't want to mention any potentially incriminating information on the phone call if we can help it. So it's better just to say like, I found someone they're not breathing, this is what they look like. Hurry up. And the reasons why we call 911 is because it may, despite everything that's happening in that moment, it may not be an overdose, it could be something else, it could be a heart attack, it can be someone that's gone unconscious for different reason. There could be other potential medical complications that can come from having the overdose. Like someone may be having an overdose, but may eventually have seizures or may have more complicated issues that can lead to more dangerous reactions, that it would be good to have a trained medical professional present to handle. And another reason is because more overdoses and naloxone may be needed. So if you, for example, have just a kit, just one kit, and that kit just has two doses, it would be helpful to have EMS come and if they needed more doses, then you have that help coming. So now I'm going to talk a bit about the Good Samaritan Law, the 9-11 Good Samaritan Law. And this is a law, a New York state law that offers some protection to the overdose victim, as well as to those who call 9-11, and you have protection from the prosecutor. And the protections that it provides is for drugs up until A2 felony offense, which is a possession of up to eight ounces of illegal substances of narcotics. So I'll give an example afterwards, but that alcohol for underage drinkers, cannabis of any amount, paraphernalia offenses, and for the sharing of drugs. And in New York state, sharing constitutes a sales offense. And so if you're selling drugs to someone that's still considered sharing, so it's protected in that way. Is the Good Samaritan Law only in New York state? So this specific law and the context of this law, the boundaries of this law that I'm explaining now is only in New York state. Different states also have the Good Samaritan Law, but they have different stipulations. So they may not provide as much coverage or they may provide different kinds of like types of protections or non-protections for certain people. Some states I think don't have Good Samaritan Laws, but a lot of states do. New York state definitely does. But that's something you can search online if you're curious for other jurisdictions or other states. So I'll give an example of here, the law. So let's say I'm someone that I'm like, I'm with a friend and I have like two ounces of cocaine on me and I also have like, I don't know, we don't criminalize paraphernalia here, but because syringes just got decriminalized. But let's say I had, I just sold a friend cocaine and I had two ounces of cocaine on me and I also had my like 16 year old sister who's drinking alcohol. Actually, no, that doesn't count because it's the person who calls and the person who's having the overdose. So let's not talk about my sister. But in this situation, if I were to call and say, my friend's having an overdose and like, please help, if the police show up in that situation and they find me with my two ounces and they know that I sold the drugs to my friend, I would still be protected and I wouldn't be prosecuted for being president because I called 911 in an emergency situation in good faith that there would be help from my friend so that they wouldn't die. So that's a situation where I would be protected. And this, if I was a 16 year old that was drinking and I called 911 to help someone who's overdosing, then that's another situation where the Good Samaritan Law would provide protections. However, there are some situations where the Good Samaritan Law does not provide protections. For example, it does not provide explicit legal protections for people who are on parole or probation violations, violations for open warrants, issues related to immigration and for child welfare. So, everybody has a unique situation. Everybody has their own situations personally that they may be working through. And so if these issues here may apply to you, then think about that in an overdose safety planning situation. Like if I'm someone who's undocumented, maybe I can call from someone else's phone or maybe I can have my friend call, my friend who was documented, who was a citizen because we don't want someone who wants to act in good faith to potentially go to prison or get deported because they fall under these circumstances. So just think about other ways to help someone out in that situation that may not involve incriminating oneself. Okay, so here's more overdose response planning. With overdose response planning, this is what I mentioned. So an individual response plan acknowledges a difficulty of calling 911 and allows for the person to respond to the overdose while taking care of themselves. So like I mentioned before, there's many reasons why somebody may not want to call 911. One of these reasons is previous experiencing reversing overdoses without medical intervention. There's also the stigma attached to drug use. And so if somebody does say like, oh my God, this person's having an overdose, that can lead to a situation where the police can show up and it can make the situation a lot more complicated. Also fear for personal safety in a situation like that, the potential impact on other legal matters as well as the criminalization and policies around drug use and also NYPD overdose response squads. So there have been situations where someone says somebody had an overdose and these overdose response squads that are from NYPD come and start to harass people. They start to ask questions, doing investigations that sometimes could feel very uncomfortable for the person that made the call. And so we understand that there are circumstances in which somebody does not want to call 911. And so if possible, call and don't say words like drugs or overdoses or things like that, but also just consider who's in the room and what folks might be in a situation to call if 911 needs to be called and these potential situations happen. Okay, so prior to talking about the policies we were talking about, we called them out. You said we're gonna call 911. We did the sternal rub, we called 911. And now we're going to give the naloxone. So then naloxone comes packaged in these little plastic packages. So you wanna peel back the package and then you wanna place it. So when you place it, you wanna push the person's forehead back, tilt their chin up, that way their nose is already at an incline and if you give them liquid, it's gonna likely travel back. And you wanna place the naloxone in their nose. And usually when you hold it, it's good to hold it from the side as opposed to, in the center there's a plunger and the plunger is really sensitive. So you wanna hold it from the side until you've placed it where it needs to be placed while holding the person's head back. And then once you're ready, then you press because if you press the plunger too early, you can waste the dose and then you may not have another one. So always make sure that you press the plunger like you can see here once you're ready because it's a little trigger. So you can accidentally lose the dose if you press it too early when it's not pressed, when it's not placed. So you wanna wait two minutes and after two minutes, if the person still hasn't woken up, then you wanna give them the second dose that's in the bag. So that's what we mentioned earlier that it is okay to give the person a second dose. And in some situations, you may have to give more than two doses. So in the case that someone becomes responsive, they wake up, they might be confused or afraid. Some of them may have just been in this really deep experience and they're in their overdose by losing consciousness. And when they wake up, they may be confused or afraid and not realizing what had just happened as well as they could potentially be sick, they might be in withdrawal. And so you wanna explain to them that they overdosed and you also, if they're in withdrawal, you wanna explain to them how naloxone works. So you wanna reassure them that the naloxone wears off in 30 to 90 minutes. And because of that, you don't want them to use more drugs or more opioids because that can increase the risk for another overdose. And then you also wanna talk out with the person, the benefits of receiving follow-up medical care. So just acknowledging that they might fall into an overdose again in 30 to 90 minutes or even if they don't, they may feel tempted to use again because they feel sick. And so sending them to seek medical attention could be a way to mitigate another overdose from happening. If the person declines medical attention, make sure that someone stays with them for at least three hours after that event. It's important for that person to not be alone because as I mentioned, they could be at an increased risk of overdose again. If they use or if what they have is still in their system and could lead them to another overdose once a naloxone wears off. And once you've given the person the first breath, I'm sorry, the first dose of naloxone and they're still not breathing, it's important to give the person rescue breaths or CPR if you know how. So for the rescue breaths, you wanna, after they give them the naloxone, you wanna do the same thing, tilt their chin up, press their forehead back. And then inside of the blue kits that we give y'all, there are face masks, face shields. So you can put the face shield on the person's face if you don't wanna have like contact with their saliva and you can give them rescue breaths. And for that, you wanna put your mouth over their mouth and then you wanna watch their chest rising just to make sure that the breaths are going in. If you start noticing that their stomach is rising then raise their razor chin up a little bit higher because that means that the breath is going into the wrong place. But you wanna give them a breath every 15, two breaths every 15 seconds. And if you give them a second dose and you wanna continue giving them the rescue breaths until there's more support. And as I mentioned, the naloxone kit has a face shield. If something happens that you don't feel comfortable being there anymore, that you feel like you have to leave or you don't wanna give them rescue breaths, then it's important to put the person in the recovery position. And this is what the recovery position looks like. So you wanna have one leg out and straight, one arm out and straight and one leg that's bent in and another arm that's bent in. That way it's kind of like a kickstand that's holding the person. And this is a supportive position because if the person wakes up and starts to vomit and they're like laying flat on their back, they're probably gonna vomit and swallow it and potentially choke on it. If they're on the recovery position on their side, they'll vomit onto the floor and there's less of a risk of choking. So just another COVID-19 guidance, the recovery position and the rescue breathing may increase the risk of exposure to COVID-19. But if both of these are done correctly, they can save a life. And so just acknowledging that in the age of COVID, if the person has COVID and you give them mouth to mouth, there is a potential risk that you might catch it. But there's gloves and there's a face shield. And it's important to wash your hands and face for at least 20 seconds after responding to a potential overdose. So I'm gonna cover some things to consider. So these are the things that we talked about. So the first thing you wanna do, the first element of overdose response is monitoring, assessing and communicate. So seeing what's going on, seeing how you're gonna respond and then trying to communicate with the person. If you don't respond, then you wanna call 911 and create a response area. So where you're gonna be responding to support the person with naloxone. And then you administer the naloxone and then you engage the person that's experiencing the emergency. If you've called 911 or since you've called 911, then you want to also engage with the MS and potentially with NYPD and tell them what happened. So tell them that you found this person, they weren't breathing. You had naloxone on you or maybe they had naloxone on them and you used it. And maybe tell them like how much naloxone was dispersed in that time. If you use one dose, if you use two dose, if you use more than two doses. And then you wanna follow up and report. So we have, when we do the distribution of naloxone, we have individual kits. So these are kits that you can have just for yourself or your friends, your family. And we also distribute shared access or communal naloxone kits. And these are kits that can be used by trained responders to respond to an onsite overdose. Usually they're conveniently located and accessible for staff. So for example, near a first aid kit or if you work at a bar in a nightlife place, you can have them behind the bar for easy access. So yeah, just if any of y'all are here from like business or an organization, you can have as many communal kits as you'd like and you can keep them in a place that your staff knows that it's there. So if an overdose were to happen, then you can respond. And there is New York State Liability Protection for having these communal kits on staff, onsite at your business or your organization. So this is what I mentioned before. We do, we currently have fentanyl test strip distribution. I wonder if I can, no, I can't right now. Okay, you put that in the chat really quick. So in the chat, I'm putting, oh, thank you. They've put it in the chat for me. We have the brochure and we also have this poster that's a bit easier to follow. So feel free to check out the poster as well. So I'm sure y'all have heard of fentanyl test strips. Fentanyl test strips are cool because they're preventative measure. Obviously naloxone is extremely important and extremely helpful, but it is a reactionary method, a tool that if somebody's already having an overdose, then we use it to respond with fentanyl test strips. We use it before you use the drugs by checking your drugs and then you can tell if your drug has fentanyl in it. They're little strips. They are little strips that the packaging looks like this. So they're very small, like a sheet of thin paper. And then the strips themselves are very small and they can tell you if there's a positive yes or a negative no result of fentanyl in your drug. However, it does not tell you how much fentanyl there is or how strong it is. So it has its limitations. And fentanyl test strips can help prevent overdose if they're used correctly and with other risk reduction practices like having naloxone, going slow, having a test shot, using a little bit to see how strong the drug is, using with other people, things like that. And so the brochures in the chat, also the poster that I just sent, if y'all want to read the instructions, there are some instructions on how to use fentanyl test strips out there that are not correct. There's been fentanyl test strips were not originally used for the purpose of testing drugs. They were used for your analysis. And so over time we've learned a lot about how to use them properly. And so our instructions take a lot of that and take consideration. And we've also worked with our partners at DanceSafe and Bunk Police to have similar instructions. And fentanyl test strips can be purchased through an organization called DOS Test, also with Bunk Police or with DanceSafe. And so I would recommend these three organizations if you're buying fentanyl test strips just for yourself and you don't need them in bulk. If you do need them in bulk because you're ordering them as an organization, I would encourage you to reach out to BTNX. And BTNX can help you order them in bulk. And if you tell them that you're doing it for harm reduction purposes, then they'll give you a discount. But just to answer the previous question, we currently have a pilot that's going on and what we're finding is that the demand for fentanyl test strips greatly exceeds the amount that we currently have available to purchase and to send out. We're hoping that over time we can buy more and we can support more organizations and more programs in this pilot. For now, we don't have enough supply. Unfortunately, we're distributing to about 40 organizations. And the supply is just running very quickly as you can imagine. But if you're a nightlife organization and you're interested in having fentanyl test strips at your organization and have the capacity to do light reporting, and the reporting is like how many test strips did you distribute this month? How many test strips do you have in stock and how many do you need? Feel free to email me. And when we start to look for organizations to do distribution again, if we're able to get more strips, like a higher capacity for strips, then we'll keep you in mind and reach out to you once we're ready to expand. Okay, so I'm gonna talk about naloxone access. So congrats, you've completed the majority of the training. If you would like to receive a naloxone kit by mail, then you can go to this link right here and you can put a request in. You can put the address, the number of kits that you want, and then we'll mail them over to you. But because of the volume of requests that we get, we ask for you to allow 10 business days for the requested kit to arrive in the mail. And if you need the naloxone to arrive sooner, then you can go on nyc.... Yeah, Ryan, the Office of Nightlife just put the link in the chat. Let me know if you'll have any issues opening it and we can put it in the chat again. But if you need access to naloxone sooner, then visit nyc.gov slash naloxone and you can find naloxone within your community. So as part of the naloxone distribution that we do, we have over 400 organizations that are registered as opioid overdose prevention programs and those opioid overdose prevention programs also have naloxone on site. So you can go to any of these... Oh, I see, it got sent to me. They didn't get sent to y'all. I'll put it in the chat now. Could y'all see it now? Okay, cool. But yeah, so there are organizations around the city. There may be one near your house or maybe one near your organization where you work, where they have naloxone on site. And so if you wanna receive it like today or tomorrow, you can go on this website and it'll show a map of all the places in the city that are distributing naloxone. But if you don't mind waiting 10 days, then we can mail it to you. And as I mentioned before, these are the things that are found inside of your overdose rescue kit. So there's a blue bag that it comes in. There's this instruction sheet that goes over everything that I went over with y'all today. It comes with two doses of naloxone. It comes with a blue card. And in that blue card, if you're using it for yourself, you can put your name. It just is basically verifying that you have been through this training. And if you're leaving the kit at an organization or bar or business, then you can just put the name of that bar or business on the blue card. And it includes some gloves and it also includes the face shield that I mentioned that you can use if you have to give someone rescue breaths. And like I mentioned, once you receive your kit, you wanna add your name and the date. You wanna review, you wanna keep your blue card in your kit so you don't have to keep it in your wallet. You can keep it in the kit and review the instruction insert in the kits on the response steps. In case, I forget things in 10 days. So when you get your kit, you can review it just to make sure that you remember some of the things that we talked about today. And after you use your naloxone, we encourage you to submit an anonymous report as soon as possible. This helps us just to understand what happened to know that it was used and also to help you figure out how to get a new kit. Also, it's important to get a refill if you've used one or more doses of the naloxone. So for example, if you have a kit that has two, but you use just one, it's important to get a new kit because you never know if you might need two doses. It's important to always have at least two doses. You also wanna get a refill if your kit is lost, if you don't have it anymore, if it's damaged or if it's stolen. And lastly, you wanna make sure that you refill your naloxone if it's expired or near expiration date. So on the back of your kit, in the back of the dose of naloxone, it'll have the expiration date. So if it's expired for about six months after it's expired, it's still effective. It's just not as effective. So we encourage you to replace it just to make sure that it's effective enough in the case of an overdose. So in summary, naloxone is a safe medication that can reverse the effects of an opioid overdose. It only works to reverse opioid overdoses. It doesn't cause any other harm if you use it on someone. It's important to look for the signs and symptoms of overdose, of opioid overdose, like we talked about before, unresponsive, not breathing, turning blue. Then you wanna check for responsiveness, shout, do a sternal rub, call 911, give the person naloxone, do rescue breathing if you have to. And then these are the other pieces of providing support. So getting medical help, giving rescue breathing and putting the person in recovery position so that if they wake up and they have to vomit, then they won't choke on it themselves. And lastly, to report and to refill. And so the upcoming naloxone trainings can be found on our webpage. You can go on nyc.gov slash naloxone and you can see all of the, so this is like a training that I did just with an office of nightlife that they scheduled, but we have standing trainings every month. And so you can go on there and see the trainings and you can attend those again if you want to, or you can share them with colleagues that wanna get trained. And if you want us to host a training, whether it's online or in purpose, in purpose, in person, feel free to email us at this email and then we can coordinate that. I think for in-person trainings, we require at least like 15 people to be present. So if less than 15 people register, we might not take it. It's other 10 or 15, but feel free to reach out if you wanna host a training for your organization. And now I'm gonna go through the questions and here's my email in case you need anything. If we don't use the link, are we sent the kit automatically? No, we don't know where you, we don't know who you are or where you live. So there's no way for us to send you a kit. So if you want a kit, you need to use the link. And the other question is, isn't mouth to mouth resuscitation as part of CPR controversial by many leading health organizations? I don't know what other leading health organizations are saying. In the particular case of an opioid overdose, the whole reason why the person may be dying is because they can't breathe because they're in respiratory depression and oxygen is not circulating through their system. And so because of that, it's important to provide rescue breaths because if oxygen doesn't get to the brain at all, in let's say four minutes, then the person is gonna die. And if it takes four minutes for the ambulance to arrive, then it's really critical for the person who's responding to this overdose to be able to give rescue breaths. So there is some sort of oxygen coming into the body until the ambulance or some other EMS can come and support that person. But yeah, thank you all so much for being part of this training. If you have any other questions for the folks who have asked questions, if you have follow-up questions, feel free to ask and I'm happy to answer them. And yeah, thanks for having me. And again, feel free to email me if you all have follow-up questions about anything harm reduction related. And I'm happy to answer them. Thank you so much, Yadda-Leeks. We are so, so grateful for this really important and compassionate presentation. If anyone has any other questions or concerns regarding anything else, nightlife related, please reach out to the Office of Nightlife. We are here to support the industry and we will be hosting other nightlife-specific Narcan trainings as well as others. So please follow us on our social, sign up for our newsletter. And we will continue to work together to bring New York and nightlife back and wishing everyone safe and happy travels in your day. And thank you all so much again for joining and we'll see you again really soon. Be well. Thank you so much again, Yadda-Leeks. Bye.