ADFFA-R
Protocol and Procedure for School Nurse Management of Potential Life Threatening Opioid Overdose Program
Background
It is strongly recommended that school nurses have access to Naloxone medication in the school setting to ensure its immediate availability to students, staff and building visitors.
Recognizing that fatal and non-fatal overdoses from opioids play an increasing role in the mortality and morbidity of Massachusetts residents, the Massachusetts Department of Public Health launched the Overdose Education and Naloxone Distribution (OEND) prevention program using intra-nasal Narcan (naloxone) in an attempt to reverse this trend. Naloxone is an opioid antagonist which means it displaces the opioid from receptors in the brain. An overdose occurs because the opioid is on the same receptor site in the brain that is responsible for breathing. Naloxone usually acts dramatically, allowing slowed or absent breathing to resume. It is both safe and effective and has no potential for abuse. Naloxone has been used by paramedics in ambulances and by emergency room clinicians for decades. While not a controlled substance, naloxone is what is known as a “scheduled” drug and therefore does require a prescription.
The Department of Public Health is operating a naloxone distribution program as a pilot program in accordance with M.G.L. c. 94C and DPH/Drug Control Program regulations at 105 CMR 700.000. The distribution of naloxone by approved trainers is authorized by the Department of Public Health.
What are Opioids
Opioids are chemicals that are either derived from the opium poppy or are synthetically manufactured by pharmaceutical companies. Whether synthetic or naturally occurring, opioids all act in similar ways at specific sites in the body. They are depressants, and slow down the central nervous system. At high levels, opioids reduce consciousness and decrease breathing (respiratory depression). Opioids attach to specific receptors in the brain, spinal cord, and gastrointestinal tract and block the transmission of pain messages. They induce euphoria and users generally report feeling warm, drowsy, and content. Opioids relieve stress and discomfort by creating a relaxed detachment from pain, desires, and activity. They also cause slow heart rate, constipation, a widening of blood vessels, and decrease the natural drive to breathe.
Severe Opioid Reaction (Overdose)
Description: An overdose occurs when the body has more drugs in its system than it can handle, resulting in potentially life threatening dysfunction. People can overdose on many different substances including other drugs or alcohol. During an opioid overdose there are so many opioids or a combination opioids and other drugs in the body that the victim becomes unresponsive to stimulation and/or breathing becomes inadequate. Those experiencing an overdose become unresponsive, or unconscious, because opioids fit into specific brain receptors that are responsible for breathing. When the body does not get enough oxygen, lips and fingers turn blue. These are the signs that an overdose is taking place. A lack of oxygen eventually affects other vital organs including the heart and brain, leading to unconsciousness, coma, and then death.
With opioid overdoses, the difference between surviving and dying depends on breathing and oxygen. Fortunately, opioid overdose is rarely instantaneous; people slowly stop breathing after the drug is used. There is usually time to intervene between when an overdose starts and a victim dies. Furthermore, not all overdoses are fatal. Without any intervention, some overdose victims may become unresponsive with slowed breathing, but will still take in enough oxygen to survive and wake up.
Signs and Symptoms of Opioid Overdose:
Blue skin-tinge – usually lips and fingertips show first
Body is very limp
Face is very pale
Pulse (heartbeat) is slow, erratic or not there at all
Vomiting
Passing out
Choking sounds or a gurgling/snoring noise
Breathing is very slow, irregular or has stopped
Unresponsive
Assessing for Responsiveness and Breathing
In order to determine if the individual is experiencing an overdose, the most important things to consider are presence of breathing and responsiveness to stimulation. There are some relatively harmless ways to stimulate a person. These strategies are:
Yelling their name
Rubbing knuckles over either the upper lip or up and down the front of the rib cage called a sternal rub
If an individual responds to these stimuli, they may not be experiencing an overdose at that time. It is best to stay with the person to make sure the person wakes up and is ok. It is possible that the person could become unresponsive and require further assistance.
Continued attempts at stimulation will waste valuable time in helping the individual breathe.
Responding to an Opioid Overdose:
Call 911 to get help
Perform rescue breathing to provide oxygen
Administer Naloxone
Stay with the person until help arrives
Individuals who overdose can die because they aspirate (can choke on their own vomit). This can be avoided by putting the individual in the recovery position. The recovery position is when you lay the person on his/her side, his/her body supported by a bent knee, with his/her face turned to the side. This position decreases the chances of the individual choking on his/her vomit. If you have to leave the person at all, even for a minute to phone 911, make sure you put them in the recovery position.
Procedures:
The School Nurse will respond to any member of the school community when on school property with a life threatening opioid overdose in the school setting. The management of Life Threatening Opioid Overdose takes a multidisciplinary approach of collaboration between school community, emergency responders, and law enforcement officers. Awareness, prevention and emergency preparedness are crucial elements in the management of a person with a potential Life Threatening Opioid Overdose.
School Nurse Responsibilities
The school nurse is the key resource for medical direction, assessment and response to a potential Life Threatening Opioid Overdose. The school nurse MUST be contacted as soon as a potential Opioid overdose is identified.
Call 911
It is important to report to the dispatcher if the victim’s breathing has slowed or stopped, he/she is unresponsive, and the exact location of the individual. If Naloxone was given and if it did/did not work, this is important information to tell the dispatcher.
Perform rescue breathing
For a person who is not breathing, rescue breathing is an important step in preventing an overdose death. When someone has stopped breathing and is unresponsive, rescue breathing should be done as soon as possible because it is the quickest way to get oxygen into the body. Steps for rescue breathing are:
Place the person on his/her back and pinch their nose or use Ambubag to administer rescue breaths.
Tilt chin up to open the airway. Check to see if there is anything in the mouth blocking the airway. If so, remove it.
Give 2 slow breaths
Blow enough air into the lungs to make the chest rise.
Assess each breath to ensure the chest is rising and falling.
If it doesn’t work, tilt the head back more.Administer breaths again every 5-6 seconds.
Administer Nasal Naloxone (Narcan)
Naloxone is a medication that reverses overdose from heroin or other opioids. Nasal Naloxone may work immediately, but can take up to 8 minutes to have an effect. The effect of the naloxone will last for about 30 to 90 minutes in the body. Because most opioids last longer than 30 to 90 minutes, the naloxone may wear off before the effects of the opioids wear off and the person could go into an overdose again. This depends on several things, including:
the quantity and purity of opioids used
the presence of other drugs or alcohol
the effectiveness of the liver to filter out the drugs
if the victim uses opioids again once the naloxone is administered
In response to these issues, the nasal naloxone rescue kits should include 2 doses. Naloxone administration may be repeated without harm if the person overdoses after the first dose wears off. Due to the complex nature of each of these medical emergencies, it further highlights the necessity of calling 911.
Bleeding from the nose
If the person overdosing has substantial nasal bleeding, naloxone may not work because the blood will interfere with absorption of the naloxone. Call for help and rescue breathe.
How to assemble nasal naloxone device:
Pop off two yellow caps and one red (or purple) cap.
Hold spray device and screw it onto the top of the plastic delivery device.
Screw medicine vial gently into delivery device.
How to administer nasal naloxone (Narcan):
Spray half of the naloxone (1mg/1ml) in one nostril and the other half (1mg/1ml) in the other nostril. If there is no breathing, continue to perform rescue breathing while waiting for the naloxone to take effect. If there is no change in 3-5 minutes, administer another dose of naloxone and continue rescue breathing until they breathe for themselves or help arrives.
Monitor the victim:
Naloxone blocks opioids from acting so it can cause withdrawal symptoms in someone with opioid tolerance. Therefore, after giving someone naloxone, he/she may feel withdrawal symptoms and want to use again. It is important that the victim does not use opioids again after receiving naloxone so that an overdose does not re-occur. If possible, the bystander who administered the naloxone should stay with the person who overdosed.
Storage:
Nasal Naloxone Hydrochloride will be kept in unlocked medication cabinet in each school nurses office. Store at 59° to 86° F, away from direct sunlight.
Documentation:
Record encounter in student’s school health record and on incident report for student, employee, or visitor, as applicable. Documentation must include patient presentation, route (intranasal), and dose that was administered as well as the patient’s response to the naloxone administration.
School Nurse Training:
A school nurse, as defined by the Massachusetts Department of Elementary and Secondary Education (DESE), may be trained by the Massachusetts Department of Public Health approved trainers for the purpose to administer naloxone by nasal administration in a life-threatening situation when first responders are not immediately available.