Your protocol for dealing with overdose will vary depending on the physical layout of your site and variables like how far you are from the nearest hospital.

However, the general steps are the same for any overdose event and include first identifying the signs of opioid overdose. When experiencing OD:

• People will sometimes have labored, strangled breathing (frequently called “the death rattle”), if any breath at all.
• In lighter skinned folks, people will exhibit “cyanosis”, in which they will appear pale and their skin, especially their lips and fingernails, may be bluish.
• Cyanosis often causes darker skinned people to appear ashen and their lips and fingernails may appear grey or whitish.
• People may also be cool or clammy to the touch.
• They will be unresponsive and may lose consciousness.
• People may lose muscle control and appear slack.
• People’s pulse may be slow or erratic.
• People’s pupils will be constricted or “pinned”. NOTE: this is always an effect of opioids, but if someone suspects OD and the person’s pupils are not “pinned,” they may be having another kind of medical crisis such as a heart attack or stroke and emergency care must be sought immediately.

After the signs of opioid overdose have been identified, staff and volunteers should contact appropriate emergency medical services.

• Ideally call 911 as soon you recognize the signs of overdose and perform rescue breathing until help arrives.
• Be advised that, owing to the realities of police involvement in overdose situations, there are a variety of things to do to minimize possible conflicts that might interfere with the victim’s treatment while still getting someone help. For instance:
• When calling 911, try to remain as calm as possible and minimize chaos in the environment to minimize the likelihood of the police accompanying emergency medical services.
• Tell the 911 dispatcher that “someone has stopped breathing” and avoid sharing that someone has overdosed to minimize the likelihood that the police will be sent with emergency medical personnel. Emergency medical personnel routinely have and use naloxone for anyone who has stopped breathing when there is not an obvious mechanical cause (such as a drowning victim).

Next, provide rescue breathing:

• Rescue breathing is sometimes called mouth-to-mouth and is used to help provide oxygen to people who have stopped breathing.
• Chest compressions, known as CPR, are for people whose heart has stopped and are not necessary for folks who’ve OD’ed.
• Start rescue breathing as soon as you realize someone has stopped breathing or is breathing erratically.
• First make sure the person’s airway is clear by looking in their mouth and clearing anything that might be in the way such as their tongue or vomit. Occasionally this will be enough to allow the person to breathe without rescue breathing.
• Hold the person’s nose and cover the person’s whole mouth with yours, OR cover their whole nose and mouth with your mouth and exhale into their lungs.
• You can be sure it is working if you feel their chest rise and fall, so it is good to keep a hand lightly placed on the person’s chest during rescue breathing so you can sense that effect.
• Rescue breaths should be provided every 5-6 seconds.
• Slow-but-steady rescue breaths are preferable because, even in the absence of naloxone, you can save someone if you keep breathing for them for as long as they are not breathing, or until emergency services arrive, which may take some time.
• If you have naloxone, administer it after starting rescue breathing.

Next, administer naloxone:

• First, alert the person that you are going to administer naloxone by speaking to them loudly.
• Next, shake them and rub their sternum or under their nose with your knuckles—the pain may arouse them.
• Tell them again you will be administering naloxone.

(Choose which of the following is appropriate based on current inventory and explain)

How to administer naloxone intranasally:

• Make sure that the person is on their back with their head tilted back and remove the cover from the naloxone.
• Place the tip of the nasal administrator in the person’s nostril.
• Grip the nasal administrator with three fingers and squeeze releasing the aerosol naloxone.

OR

How to administer naloxone intramuscularly:

• Get out the naloxone vial(s) and muscle syringes.
• Inject air into the naloxone vial with the syringe.
• Draw up to 6ccs of naloxone into the syringe OR however much is in the vial.
• Choose a large muscle group such as the upper arm, thigh or buttocks.
• Clean the skin if possible, though naloxone needles can go through fabric.
• Inject 1cc at a time, up to a total of 6ccs. If it is in one syringe, simply depress out 1cc at a time. Otherwise, use a new syringe for each additional cc or refill the syringe if necessary.

Note:

• Naloxone works by pushing the opioids off the receptor sites which can make people go into withdrawal, which is why you want to administer it slowly/use as little as possible.
• If people do start breathing naturally and are feeling like they are ill or “dope sick”, that they should be advised they will begin to feel “well” again within about an hour and that they should not use opioids again because the naloxone may not work a second time if they use more opioids.
• Naloxone metabolizes—that is, gets processed—out of the body faster than opioids do, which is why people get well without using again.
• Finally, you must wait with the person at least two hours after administering naloxone to make sure they do not go back into OD again when the naloxone wears off.
• If the person does go back into OD, administer more naloxone and/or perform rescue breathing as necessary.