Heroin addiction and prescription opioid abuse are persistent national problems that reach deep into communities across New York and heavily affect young adults. NYS has been awarded $8.1 million in federal funds to help prevent heroin use, prescription drug abuse, and opioid overdose among adolescents and young adults across the State, while also increasing awareness about the dangers of these drugs. The Combat Heroin campaign was launched in September 2014 to educate New Yorkers about the risks of heroin and prescription opioid use, the warning signs of addiction, and provide resources to help. Emergency medical personnel, health care professionals, and patients are being trained in the use of the opioid antagonist naloxone to reverse and prevent opioid overdose. Schools and school districts are now permitted to become Opioid Training Programs and train volunteer personnel. This program will provide education on opioids and the current epidemic as well as training for school personnel on administering naloxone for opioid overdose.

Resource:Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014Morbidity and Mortality Weekly Report (MMWR)-June 19,2015 / 64(23);631-635http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm?s_cid=mm6423a2_w

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This training program is a collaborative effort between the New York State Education

Department and the New York State Department of Health utilizing resources provided

by other collaborative partners noted in the next slide. Completion of this training,

100% accuracy on the post-test and the skills check for administering naloxone will

allow school personnel to administer life-saving medication naloxone in school.

Although the certificate of completion is valid for two years, NYSED strongly encourages

review annually to ensure both understanding and skills in opioid overdose response

that are current and timely. Additional information on training and implementing an

opioid overdose prevention program is available on the NYSED Opioid Overdose

Prevention Guidance Document available on the NYSED website. In addition, useful

resources you can view and print can be found in the upper right corner of this webinar.

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As part of a coordinated State effort, the NYS Department of Health, the NYS Office of

Alcohol Substance Abuse Services (OASAS) and the Harm Reduction Coalition have

been working collaboratively with the NYS Education Department on statewide

communications and training for schools in combating heroin and supporting opioid

prevention education including supporting schools in the ongoing modernization of

local level health education curriculum, development of a school/community toolkit,

and additional resources in this webinar. We would like to gratefully acknowledge the

wealth of resources shared by these collaborating agencies used in the creation of this

presentation.

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The goal of this presentation is to provide school responders with training to recognize

a suspected opioid overdoses, and to take appropriate action by administering

naloxone when needed. The objectives are listed on this slide. A “Terms to Know”

resource sheet is located in the resource tab above. Click it at any time to review a term

which is unfamiliar to you.

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Heroin and prescription drug misuse occurs in all social, economic, geographic and cultural groups. Overdose among those who use illicit opioids such as heroin and among those who misuse medications such as oxycodone, hydrocodone, and morphine is rising, largely due to increased use of prescribed opioids for treatment of pain. Children, as young as 12, are using prescription drugs to get high. Prescription drugs are easier to access because they can be taken from a home medicine cabinet and young people may believe they are safer than illicit drugs because they are manufactured by a pharmaceutical company. According to the Centers for Disease Control and Prevention (CDC), an average of 120 people die every day from an accidental or intentional drug overdose in the U.S. Roughly 80% of these deaths were accidental, and more than 16,000 involved prescription opioids, compared to 8,260 attributed to heroin. Evidence indicates some people who use prescription opioids have switched to heroin in recent years as it is often cheaper and easier to get. This has caused an increase in heroin deaths. In 2014, there were more than 118,000 admissions into New York State-certified treatment programs for heroin and prescription opioid abuse – a 17.8 % increase over 2009. The largest increase in opioid admissions during that time was patients ages 18 to 34.

Resource: https://www.governor.ny.gov/news/governor-cuomo-announces-8-million-combat-heroin-and-prescription-drug-abuse-among-young-adults

Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) 14-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. page 4. accessed 6/29/15 http://store.samhsa.gov/shin/content//SMA14-4742/Overdose_Toolkit.pdf

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This chart shows the total number of US overdose deaths involving heroin. From 2001 to 2013 there was a 5-fold increase in the total number of deaths.

Resource:National Overdose Deaths—Number of Deaths from Heroin, National Institute on Drug Abuse (NIH), Revised February 2015http://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

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This chart shows the total number of US overdose deaths involving opioid pain relievers. From 2001 to 2013 there was a 3-fold increase in the total number of deaths.

Source:National Overdose Deaths—Number of Deaths from Rx Opioid Pain Relievers, National Institute on Drug Abuse (NIH), Revised February 2015 http://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

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As seen in this infographic, heroin use is part of a larger substance abuse problem.

Resource:National Survey on Drug Use and Health (NSDUH), 2011-2013.http://www.cdc.gov/vitalsigns/heroin/infographic.html#use

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Federal, state and local government as well as private organizations are attacking this issue from many angles. The main goals are shared on this slide. Opioid use and overdose is a community problem which will require a community solution.

Resource:CDC Vital Signs http://www.cdc.gov/vitalsigns/heroin/index.html July 2015

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Most overdoses are not instantaneous and are preventable, especially if witnesses have had appropriate training and are prepared to respond in a safe and effective manner. In school, staff may find the victim or be the first person on the scene. The chance of surviving an overdose, like that of surviving a heart attack, depends greatly on how fast one receives medical assistance. With training on risk factors, signs of overdose and the appropriate responses including contacting EMS, providing resuscitation and/or administration of naloxone, volunteer school personnel are well-positioned to assist in an opioid emergency. School staff are also in a positon to educate students on the dangers of prescription drug misuse and refer concerns regarding students to appropriate school administrators or assistance teams.

Resource:Sharon Stancliff, MD*, Steven Kipnis, MD, FACP, Fasam, Robert Killar, CASAC*This workbook is adapted from a presentation by Dr. Sharon Stancliff’s program – “Get the SKOOP: Skills and Knowledge on Overdose Prevention”. Dr. Stancliff is the Medical Director of the Harm Reduction Coalition in New York City.

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New laws in NYS now allow schools to institute Opioid Overdose Prevention Programs and train volunteer school personnel to administer a life-saving medication called naloxone. The applicable laws and regulations will be reviewed in the next slides. It is the responsibility of licensed individuals to understand their scope of practice and the school or school district to create district policy and procedures which align with these laws and guidelines to provide a framework for implementing any opioid overdose program.

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On April 1, 2006, NYS enacted a public health law called the: “Community Access to Naloxone Law”. Public Health Law 3309 states that: “Use of an opioid antagonist pursuant to this section shall be considered first aid or emergency treatment for the purpose of any statute relating to liability…” This law allows trained non-medical, unlicensed persons to use naloxone on individuals suspected of having experienced an opioid overdose. Another law allows a physician or a nurse practitioner to issue non-patient specific orders for the administration of naloxone by registered nurses. Districts may operate opioid overdose prevention programs and share access to naloxone kits.

Resource:1 10 NYCRR § 80.138(a)(5)(v). Section 80.138 - Opioid Overdose Prevention Programs -Effective Date: 05/06/2015 http://w3.health.state.ny.us/dbspace/NYCRR10.nsf/56cf2e25d626f9f785256538006c3ed7/7cd10ccf2f32a94a85257139005ea1e9New York State's Opioid Overdose Prevention Programs http://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/

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Chapter 57 of the Laws of 2015 added section 922 to Education Law which permits NYS school districts, BOCES, charter schools, non-public elementary and/or secondary schools to provide and maintain opioid antagonists on site in each instructional facility to ensure emergency access for any student or school personnel having opioid overdose symptoms, whether or not they have a previous known history of opioid abuse. Schools choosing to participate as an opioid antagonist recipient may permit volunteer employees to be trained by a program approved under Public Health Law section 3309 to administer an opioid antagonist in the event of an emergency.

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A school or school district must create policies and procedures to provide guidance on opioid overdose prevention and response. All policies should be consistent with the laws and regulations of the State of New York. They should be signed and dated and reviewed at least annually to ensure they continue to meet the needs of the program and are consistent with recommended best practice. Use of naloxone should be included in district emergency response procedures. There should be protocols in place to monitor the inventory, storage, use and reporting of naloxone administration and overdose reversals. New York State NYSDOH has sample guidance for developing policies and procedures for registered opioid overdose prevention programs on their Opioid Prevention webpage. While specifically written for DOH registered programs, these may also be helpful resources for schools to develop their policies in conjunction with district counsel.

Resources:NYSDOH Opioid Overdose Prevention Guidelines for Policy and Procedures, March 21, 2014 http://www.health.ny.gov/diseases/aids/providers/prevention/harm_reduction/opioidprevention/programs/guidelines/docs/policies_and_procedures.pdf

NYS Harm Reduction Webpagehttp://www.health.ny.gov/diseases/aids/providers/prevention/harm_reduction/opioidprevention/programs/guidelines/docs/policies_and_procedures.pdf

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Part V of Chapter 57 of the Laws of 2015 added a new paragraph (f), to both subdivision 6 of sections 6527 (Article 131 Medicine) and subdivision 4 of 6909 (Article 139 Nursing) of the NYS Education Law, permitting registered professional nurses to execute non-patient specific orders prescribed by a NYS licensed physician or a certified nurse practitioner to administer urgent or emergency treatment of opioid related overdose or suspected opioid related overdose or suspected opioid related overdose. This addition places administration of non-patient specific naloxone within the scope and practice of the registered professional nurse.

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This flow chart details how Opioid Overdose antagonists (naloxone) can be administered in the school settings. Additional information implementing an opioid overdose prevention program is available in the NYSED Opioid Overdose Prevention Guidance Document available on the NYSED website. The next slide provides the requirements of how a school or school district may register as a NYSDOH registered Opioid Overdose Prevention Program. This resource chart is available on the NYSSHSC website and in the upper right corner of this webinar.

Resources: NYS DOH Opioid Overdose Regulations Q & A Title 10 of New York Codes, Roles and Regulations—Department of Health, Chapter II Administrative Rules and Regulations, Subchapter K Controlled Substances, Part 80 Rules and Regulations on Controlled Substances, Section 80.138 Opioid Overdose Prevention Programs

NYSDOH Opioid Overdose Prevention: http://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/Registration Form: http://www.health.ny.gov/forms/doh-4391.pdf

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If a school district chooses to register and become a NYSDOH Opioid Overdose Prevention Program, the school district or provider must complete the requirements on this slide. Registration forms are available on the Opioid Overdose Prevention page on the NYSDOH website.

Resource:NYSDOH Opioid Overdose Prevention Programhttps://www.health.ny.gov/diseases/aids/consumers/prevention/opioidprevention/factsheet.htm

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10 NYCRR 80.138, requires that each opioid overdose prevention program have a program director. They have overall responsibility for managing the program and for being the primary liaison with the NYSDOH either directly or through a designee. Their responsibilities include those listed on this slide. This role may be filled by the district superintendent, director or CEO of a nonpublic school, or their designee. Designee options could include the principal or school nurse if employed. Because suspected drug overdoses may result in a situation where the student does not need naloxone, but does need follow up care of referral, it is important that clear protocols are in place to provide guidance and direct personnel response.

Resources: NYS DOH Opioid Overdose Regulations Title 10 of New York Codes, Roles and Regulations—Department of Health, Chapter II Administrative Rules and Regulations, Subchapter K Controlled Substances, Part 80 Rules and Regulations on Controlled Substances, Section 80.138 Opioid Overdose Prevention Programs http://w3.health.state.ny.us/dbspace/NYCRR10.nsf/56cf2e25d626f9f785256538006c3ed7/7cd10ccf2f32a94a85257139005ea1e9

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Clinical directors are the primary personnel designated in a program’s registration for prescribing naloxone to be administered by an individual or an identifiable pool of trained volunteers such as school personnel. In addition to prescribing and/or dispensing naloxone, their specific responsibilities include those listed on this slide. Clinical directors may be a NYS licensed physician or NP. While prescribers do not need to be present when responders are trained, procedures need to be in place to ensure that naloxone is given under either a patient‐specific and/or a non‐patient specific prescription and that all responders have been trained in overdose recognition and response. Shared access to naloxone kits which include the atomizer and medication is sometimes referred to as communal access. In a school district this role would typically be filled by the school medical director, which in NYS must be a physician or nurse practitioner.

Resource: NYS DOH Opioid Overdose Regulations Q & A Title 10 of New York Codes, Roles and Regulations—Department of Health, Chapter II Administrative Rules and Regulations, Subchapter K Controlled Substances, Part 80 Rules and Regulations on Controlled Substances, Section 80.138 Opioid Overdose Prevention Programs http://w3.health.state.ny.us/dbspace/NYCRR10.nsf/56cf2e25d626f9f785256538006c3ed7/7cd10ccf2f32a94a85257139005ea1e9

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The school nurse is the on-site health expert and may be designated in writing to complete the post-training skills check for non-medical, unlicensed school personnel at the request of the clinical director or (school medical director). School nurses also play a key role in planning and responding as part of the school’s emergency team. School district emergency response plans should include protocols for responding to opioid overdose, should be developed in conjunction with the medical director, and include provisions for ensuring AED and a responder trained in its use are available during on-site school and school sponsored activities. School nurses can also support prevention efforts by reinforcing risk factors for opioid overdose when appropriate during health interactions with students. The NYSDOH and OASAS created the resource on this slide to help school nurses be proactive in preventing young people’s non‐medical use of prescription drugs. It contains multiple links school nurses can use to educate themselves, students and parents on prescription drug abuse, including two National Association of School Nurse Programs. It is available on the Heroin and Opioid page of the NYSSHSC website.

Resource:Joint Advisory Letter for School Nurses: Non-Medical Use of Prescription Drugs by Young People - New York State OASAS and New York State DOH

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School personnel who wish to voluntarily become trained opioid overdose responders must complete an initial Opioid Overdose Prevention training program, post-test and skills check. To maintain their status as a trained school responder, they must complete training every 2 years, however the NYSED strongly recommends annual refresher training to maintain skills. School districts may require training annually if included in the district policy. It is important that trained school responders contact emergency medical services (EMS) when encountering a victim of a suspected drug overdose and inform responding EMS if an opioid antagonist has been used. School trained overdose responders must report all naloxone administrations for suspected drug overdose to the opioid overdose prevention program director or their designee for review. Maintaining accurate inventory records is important in assuring that naloxone is available and maintained in accordance with NYSDOH regulations.

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Opioids are any drugs that are derived from or are similar to opium. They can be swallowed, smoked, snorted or injected. They include illegal drugs such as heroin, as well as prescription medications used to treat pain. Heroin converts to morphine once it is inside the body. It has a high potential for abuse causing severe psychological and physical dependence. Legal opioid pain medications can lead to moderate or severe dependence, and are often combined with other pain relieving medications by manufacturers’, making them potential drugs of abuse. Common prescription opioids are listed on this slide. Opioids minimize the body’s perception of pain and affect body systems responsible for regulating mood, breathing and blood pressure. In excessive amounts, opioids can suppress a person’s urge to breathe.

Resource:Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) 14-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. page 4. accessed 6/21/15 http://store.samhsa.gov/shin/content//SMA14-4742/Overdose_Toolkit.pdf

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Dependency, withdrawal and addiction is reviewed on this slide.

Resource: Combating the Opioid Overdose Epidemic -Public Safety Naloxone. 11/11/14Michael W. Dailey, MD FACEP, Regional EMS Medical Director, Associate Professor of Emergency Medicinehttp://www.slideshare.net/mwd101/ems-world-expo-naloxone-11112014handout?from_action=save accessed 6/28/15

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Opioid overdose happens when a toxic amount of an opioid—alone or mixed with other opioid drugs or substances overwhelms the body’s ability to handle it. Many opioid-related overdoses result from mixing prescription painkillers or heroin with benzodiazepines (benzos), cocaine or alcohol. Combined drugs can have a “synergistic” effect, which means that the effect of taking mixed drugs is greater than the effect of taking the drugs separately. In this case 1+1 does not equal 2, 1+1 = 10.

Resource:Overdose Prevention & Reversal Training. Amu Ptah Riojas, MA, Harm Reduction Coordinator , Monique Wright, MEd, Harm Reduction Educator. NYC Department of Health and Mental Hygiene Bureau of Alcohol and Drug Use Prevention, Care and Treatment, 5/19/14

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Opioid overdose can occur when someone misuses a prescription opioid or uses an illicit drug such as heroin. Also at risk is the person who takes opioid medications prescribed for someone else, or an individual who combines opioids — prescribed or illicit — with alcohol, certain other medications, and even some over-the-counter products that depress breathing, heart rate, and other functions of the central nervous system. Regular use of opioids leads to greater tolerance, i.e. more needed to achieve the same result. Overdose occurs often when people start using again following a period of not using (abstinence). Common situations leading to loss of tolerance include: incarceration, detox, “Drug Free” treatment, or self imposed breaks from use. Tolerance can decrease in as little as 72 hours. Using alone is a risk factor for opioid overdose death, because there is no one to intervene or call for assistance. Using multiple drugs at the same time as opioids is a significant risk factor.

Resource:Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) 14-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. page 4. accessed 6/21/15http://store.samhsa.gov/shin/content//SMA14-4742/Overdose_Toolkit.pdf

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Anyone who uses opioids for long-term management of chronic pain is at risk for opioid overdose, as are persons who use heroin, which is cheap and highly addictive. Prescription drug abuse by youth is an increasing problem. Opioid overdose impacts all socio-economic groups and regions. Statistics in NYS show an alarming trend- drug overdoses are the leading cause of accidental death with people dying each day due to over dose.

Resource: DCJS-Law Enforcement Naloxone Overview

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Signs of an opiate overdose include some of those on this slide. Please be aware that other medical conditions can also cause these symptoms, and initiating emergency response to provide support is critical.

Resources:New York State Department of Health Opioid Overdose Prevention Guidelines for Training Responders Addiction medicine educational series workbook NYS OSASPhoto: http://roguemedic.com/page/20/?s=intubation, licensed under Creative Commons Attribution accessed 7/14/15Medline Plus http://www.nlm.nih.gov/medlineplus/ency/imagepages/9895.htm

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Naloxone hydrochloride is an opioid antagonist medication which reverses the effects of opioids on the brain and other parts of the body causing sudden withdrawal and restoring breathing. It is available as a nasal spray and an injection. One injectable formulation of naloxone is Evzio auto-injector which was approved by the FDA in 2014. We will not be covering that product in this training. The small molecules in naloxone are easily absorbed through the nasal mucosa and eliminate the risk of needle stick injury to responders. It generally takes effect within 3-5 minutes. If you give naloxone to someone who is not experiencing an overdose, it will not hurt them. Naloxone has been used safely by medical professionals for more than 40 years and has only one function, which is to reverse the effects of opioids on the brain and respiratory system in order to prevent death.

Resource:Harm Reduction Coalition: Guide to Developing & Managing Overdose Prevention & Take-Home Naloxone Projects 11/10/12http://harmreduction.org/wp-content/uploads/2012/11/od-manual-final-links.pdf

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Opioid receptors in the brain and other areas of the body and are where opioid molecules bind and cause responses in the body. During opioid overdose they cause breathing to stop. When breathing stops, the heart stops and circulation of blood to the brain stops. This generally happens over the course of 1-3 hours, allowing time for intervention. Naloxone is an opioid antagonist which fits into the receptor, in effect “stealing the parking place” and preventing opioids from going where they want to go. This restores respiration and prevents death. Naloxone starts to wear off after about 30 minutes and is mostly gone after about 90 minutes. By this time the body has metabolized enough of the opiates that the user is unlikely to stop breathing again. However, in some cases – such as after taking a massive dose or long-acting opiates like methadone – the person might need another dose of naloxone. Naloxone can help even if opiates are taken with alcohol or other drugs. It has no effect on someone not having an opioid overdose.

Resource:Harm Reduction Coalition: Guide to Developing & Managing Overdose Prevention & Take-Home Naloxone Projects 11/10/12http://harmreduction.org/wp-content/uploads/2012/11/od-manual-final-links.pdf

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Someone experiencing opioid overdose needs immediate medical attention and emergency responseintervention. The following actions align with emergency response actions for unconscious victims as provided in American Heart Association and American Red Cross training programs. Checking for signs of overdose and responsiveness are the first actions for responders. If they do not respond, rub your knuckles hard up and down their breast bone for 5 -10 seconds. This is called a sternal rub and would typically be uncomfortable in someone experiencing overdose who has not yet become unconscious. Ask someone to call 911 and activate your school’s emergency response system which for public schools, must include obtaining the AED. Administer naloxone following the steps on the next slides. After administering naloxone, place the victim on their side and monitor. Continue to provide rescue breathing or CPR if needed. Stay with the overdosed person until the ambulance arrives. Maintain your safety by following universal precautions in touching body fluids. If possible, ask a bystander what the person may have injected, ingested, or inhaled or if they have used a patch on their skin, so you can provide this information to EMS. This is especially helpful if the person may have used more than one substance. Notify administration and family and document the use of naloxone in accordance with district policy and procedures.

Resources:Overdose Prevention & Reversal Training. Amu Ptah Riojas, MA, Harm Reduction Coordinator , Monique Wright, MEd, Harm Reduction Educator; New York City Department of Health and Mental Hygiene -Bureau of Alcohol and Drug Use Prevention, Care and Treatment American Heart Association: Highlights of the 2010 American Heart Association Guidelines for CPR and ECC http://www.heart.org/HEARTORG/CPRAndECC/Science/Guidelines/Guidelines_UCM_303151_SubHomePage.jspAmerican Red Cross Guidelines: Checking an injured or ill adult appears to be unconscious. https://www.redcross.org/images/MEDIA_CustomProductCatalog/m4240170_Adult_ready_reference.pdf

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To administer Naloxone the person must exhibit non-responsiveness, shallow/slow or no breathing. Lips and nail beds will typically be bluish. Follow this diagram to determine what to do.

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The naloxone overdose kit should be stored in a secure but accessible location determined in conjunction with the district emergency response plan, which includes AED delivery to the scene of an emergency. One option for placement is to store the naloxone overdose kit inside flap of the AED case. It is important to note that naloxone and the AED are both heat and cold sensitive. Additional information on storage and access is available in the NYSED Opioid Overdose Prevention Guidance Document available on the NYSED website.

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School staff should follow district policy and procedures for reporting the use of naloxone. It will be important to document the location, type of substances used by the victim if known, the status of the person before giving the naloxone, details regarding the administration such as number of vials used and how long it took the person to respond, if CPR was administered, and if the victim survived. Additional guidance is provided in the NYSED Guidance Document on Opioid Overdose Prevention in Schools.

Resource: NYSDOH Opioid Prevention Webpage: http://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/

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The inventory of naloxone and other overdose supplies should be routinely assessed, with a recommended frequency of once per week, to determine whether there are any discrepancies between documented inventory and actual inventory and to prevent such discrepancies, and make sure the solution in the vial is clear and not discolored. The naloxone vial has an expiration date on the back. Checking this date should be part of any district protocol, similar to checking the AED. The expiration date should be recorded at the time the kit is received and monitored so it is ready for emergency use. New kits should be requested prior to the expiration date or if used even if only one of the naloxone vials is used. Naloxone should be stored in a secure location according to manufacturers recommendations at room temperature, away from light. If the solution is discolored or is not clear, the clinical provider should be informed so that it may be disposed of and replaced. Used atomizers or syringes should be given to EMS personnel or disposed per district policy and procedure. It is important to include information about bloodborne pathogens and safe needle disposal in district guidance.

Resource:New York State Department of Health Opioid Overdose Prevention Guidelines for Policies and Procedures, March 21, 2014http://www.health.ny.gov/diseases/aids/providers/prevention/harm_reduction/opioidprevention/programs/guidelines/docs/policies_and_procedures.pdf accessed 6/25/15

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The NYSSHSC has created an Opioid Overdose Prevention Toolkit on our website with a wealth of resources for schools, parents and students. Additional information specific to the role of the school medical director is available on the NYSSHSC School Medical Director Page. Click the blue link to view the page now.

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In 2014, Governor Andrew M. Cuomo launched Combat Heroin, a campaign designed to inform and educate New Yorkers about the risks of heroin and prescription opioid use, the signs of addiction, and the resources available to help. The NYS Office of Alcoholism and Substance Abuse Services (NYOASAS), the NYS Department of Health, and the NYS Office of General Services Media Services Center have worked together to create a multifaceted media campaign which includes an easy to navigate website targeted toward parents, adults, and young people who are seeking help and information concerning heroin and opioid abuse and misuse. The website, noted at the top of this slide includes information about the warning signs of heroin and opioid abuse, a link to OASAS services, listings of treatment providers, and many other resources for schools to use in prevention and training. These resources are free and can be ordered using the form found under resource link on the Combat Heroin website. The website is included in the resources tab in the upper right corner of this presentation.

Resource:Combat Heroin Website: https://www.combatheroin.ny.gov/http://combatheroin.ny.gov/sites/default/files/resources/Heroin_OrderForm_031015rev.pdf

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According to the NY Youth Risk Behavior Survey, the percentage of New York State high school students who reported using heroin has more than doubled in recent years. In 2013, there were over 89,000 admissions into treatment facilities for heroin and prescription opioid abuse in NYS. School personnel play a critical role in educating students about substance abuse, addiction and overdose prevention. Recognizing behaviors or symptoms which indicate at-risk students and following district procedures for referral can be critical to reducing potential overdose in the school community. The NYSDOH and OASAS have free resources for classrooms, health offices, parents and students. Some of them are displayed on this slide.

Resource: Dear Colleague Letter: NYSDOH, NYSED, NYOASAS (1Youth Risk Behavior Survey, 2005 and 2011). https://www.combatheroin.ny.gov/sites/default/files/resources/HeroinHealthProfessionalandEducationalLeaderLetterSIGNEDFINAL2014.pdf

New York State Department of Health (NYSDOH) and New York State Office of Alcoholism and Substance Abuse Services (OASAS) Materials Pertaining to Opioid Overdose Materials for Patients and the Public http://www.health.ny.gov/diseases/aids/consumers/prevention/opioidprevention/materials.htm

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Trained responders should know where the overdose kit is stored so they can access it quickly. The kit contains everything needed for response.

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There are two types of kits. One contains nasal naloxone and one contains intramuscular or IM naloxone. You may only administer the type that you have received training for. The nasal overdose kit contains 2 needle-free syringes, 2 nasal atomizers and 2 vials of Naloxone Hydrochloride and 1 set of gloves. It also has instructions of what to do in English and Spanish, alcohol pads and a disposable face shield to use as a barrier to provide rescue breathing. Two sets of naloxone medication are provided as the victim may need a second administration if they do not respond in 3-5 minutes after the initial administration or if EMS is delayed and symptoms return after 30-90 minutes. Gloves are provided so that responders can maintain universal precautions if there is contact with body fluids.

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Each box in the nasal overdose kit contains a needle-free syringe and a 2 milliliter single use pre-filled vial of naloxone hydrochloride medication solution.

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The steps for administering naloxone are listed on this slide. They will be reviewed step by step in the following slides.

Resource:http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/responding-to-opioid-overdose/administer-naloxone/

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Pull or pry the protective caps from both ends of the needle-free syringe.

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Remove the red or purple cap off the glass vial.

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Remove the nasal atomizer (white cone) from its package. Grip the clear plastic wings on the atomizer and gently twist or screw it clockwise on to the top (narrow end) of the syringe.

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Take the naloxone medication vial and place the open end into the open end of the syringe. Thread or screw the naloxone vial onto the syringe by gently twisting it clockwise about 3 half turns or until you feel the rubber stopper “catch”. Go slowly and if you see any clear medication at the tip STOP. You will notice that the vial has marks on the side. There are a total of 2 milliliters of medicine in the vial. ½ of the total amount or 1 milliliter is used for each nostril.

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Wipe the nose if it is soiled and hold the persons head with one hand, keeping the head tilted backward to prevent the medication from running out of the nose. Place the nasal atomizer in one nostril and push the vial into the syringe until you reach the 1 mark on the vial. Move the atomizer to the other nostril and push the vial to spay the remaining 1 milliliter into the other nostril. If you accidently spray all of the medication into one nostril, the medication will still work. If for some reason you do not have the cone-shaped atomizer in the kit, just place the tip of the syringe near or inside the nostril to administer.

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After naloxone, the person should begin to breathe more normally and it will become easier to wake them. If the person does not respond after 3-5 minutes, administer a 2nd dose as ordered by the medical director. Naloxone only lasts for 30-90 minutes, so an additional dose may also be needed if EMS has not arrived by that time. The person should be placed on their back on his/her back for any additional naloxone administrations so the naloxone does not run out of their nose. Rapid opiate withdrawal may cause nausea and vomiting. It is important to roll the person to their side to keep their airway clear. This is called the recovery position and is shown on this slide. The hand supports the head and the bent knee supports the body to keep them from rolling onto their stomach. When the person wakes up, explain what happened. They may become combative or upset. When the ambulance arrives, tell them that naloxone has been given. If a victim is not responsive to stimulation, not breathing, and has no pulse after receiving naloxone and rescue breathing, then the victim needs cardiopulmonary resuscitation (CPR) via a trained bystander and the emergency medical system. You will be able to review these steps in action by watching a video at the end of this presentation. The video is also available on the Heroin and Opioid resource page of the NYSSHSC website.

Photo:Opioid Overdose Resuscitation CardAmerican Society of Anesthesiologists (ASA) and White House Office of National Drug Control Policyhttps://www.asahq.org/WhenSecondsCount/resources.aspx

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Administration of injectable naloxone by a licensed professional follows the same steps in recognizing and responding to an overdose with the only difference being that the naloxone is administered by injection rather than nasally. They are reviewed on this slide. Injectable naloxone comes packaged in single dose flip-top vials with a pop off top. With all formulations of naloxone, it is important to check the expiration date and make sure to keep it from light if it is not stored in a box.

Resource: Harm Reduction Coalition: http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/responding-to-opioid-overdose/administer-naloxone/

This 5 minute video provides a overview about administration naloxone in schools by Martha Morrissey, Associate in School Nursing, NY State Education Department and Dr. Sharon Stancliff, Medical Director of the Harm Reduction Coalition in New York City. If you have questions about implementing a voluntary Opioid Overdose Prevention Program contact the NYS Education Department Office of Student Support Services at 518-486-6090 or email StudentSupportServices@nysed.gov

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You are now ready to become an opioid overdose responder for your school or district.

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Push the red button to view the video on assembling the naloxone nasal atomizer. After viewing the video, return to this presentation by clicking next. View the next slide to print your post-test, training skills checklist, and certificate.

Button Photo: Tech Happens Blog by TLTC, Buena Vista University and all its posts are licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.https://bvutechhappens.wordpress.com/2011/04/14/fearless/ accessed 7/14/15

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If you are a non-medical, unlicensed school staff member, you must complete the post-test and training skills checklist to obtain your certificate of completion in Opioid Overdose Prevention. Print out and complete the post-test. Check your answers against the slides in this presentation. The slide which contains the correct information is provided on the post-test. If you have not achieved 100% accuracy, review the training and take the test again. Once you have achieved 100% on the test, take it and the Training Skills Checklist to the designated review person. In most cases this will be a school nurse employed by your school or district. They will review administration of intranasal naloxone and your ability to do it correctly. Upon completion of the skills check, you will receive a certificate of training completion. This certificate is valid for a period of 2 years from the date of the training, however NYSED strongly recommends annual review to maintain proficiency in naloxone administration. Please retain the certificate for your records. School nurses are typically the on-site medical professional and as such may be requested to provide this training and perform the post-test skills check. If you are a registered professional school nurse, please discuss your role in opioid overdose prevention with your district administration. The link to the Post-test, Training Skills Checklist and certificate can be found on the Heroin and Opioid page of the NYSSHSC website. The link is located at the top of this slide.

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