Use of drugs – especially opioids – can cause impairment of mental status, unresponsiveness and breathing difficulties. These effects can be more pronounced and more dangerous in certain circumstances such as when used in combination with other substances, including alcohol, and may result in an overdose. An opioid overdose is a life-threatening condition resulting in abnormal breathing (e.g., taking irregular or noisy breaths, or stopping breathing altogether) and cardiac arrest. Deaths from opioid overdose are an increasing public health problem in many countries worldwide. Naloxone is a drug which reverses the effects of an opioid overdose if taken in time (WHO, 2020) so the administration of this antidote can be a powerful life-saving tool. However, this topic provides an example of complex social dynamics at play with whether or not people experiencing overdose receive help, and whether people surrounding those at risk of overdose are equipped to help.
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NOTE
This topic should be used in conjunction with Unresponsive and abnormal breathing (adolescent and adult) or Unresponsive and abnormal breathing (baby and child).
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Guidelines
- Cardiopulmonary resuscitation (CPR) should be started without delay on a person who is unresponsive and has abnormal breathing (e.g., taking irregular or noisy breaths, or they have stopped breathing altogether). **
Good practice points
- CPR should be provided with rescue breaths if the first aid provider is willing to give them.
- Naloxone may be administered by the first aid provider to a person who is unresponsive and has abnormal breathing with suspected opioid overdose. The first aid provider should follow the guidance on the package to administer it. Application is usually by nasal spray or by injection into the upper arm or thigh muscle. Continue to provide CPR while naloxone is being administered, if possible.
- Following administration of naloxone, if there is no improvement after 5 minutes or if the signs of intoxication reappear, the first aid provider may repeat the administration of a new dose of medication.
- People who use opioids should be trained to recognise an overdose, how to administer naloxone, and how to provide CPR.
- Family members, caregivers and peers of people who use opioids may also be trained in overdose recognition, providing CPR, naloxone administration, and how to access onward care.
- The signs of an opioid overdose can vary based on the type of chemical substance and the dose taken. Empty bottles or blisters packs of drugs, syringes, needles, spoons for preparing the injection may point toward an opioid overdose.
- The administration of naloxone to a person experiencing a suspected opioid overdose may be considered by first aid providers who have appropriate training, and if local regulations allow.
- The search for and use of naloxone should not delay the provision of CPR.
- Specially trained first aid providers like harm reduction workers and community health workers or other social care workers should be familiar with administering naloxone.
- Professional responders such as paramedics should know how to administer naloxone and train others to do so. They should be encouraged to treat people who use opioids with equity and dignity and to recognise people who use opioids can provide life-saving interventions in the instance of overdose.
- The lived experience of opioid overdose by people who use drugs should be drawn upon in education interventions to improve educational effectiveness.
Chain of survival behaviours
Prevention
- Support community programmes which help people who use opioids and their families to develop an awareness of the dangers of opioid use and the risks associated with overdose.
- Advocate for dedicated support to people at high risk of overdose (such as people newly released from prison and people with mental health disorders).
- Advocate safe prescribing regulations for opioids, and adequate support and education for those using prescription opioids.
Recognition
You may know the person uses prescribed or non-prescribed opioids. There may be signs to indicate an opioid overdose, for example, empty bottles or blisters packs of drugs, syringes, needles, or a spoon for preparing the injection.
The person is unresponsive with abnormal breathing. Their breathing may be slow or absent, or they may make a snoring or gurgling sound (this should be considered ‘abnormal’. For guidance on how to check for a response and breathing, see Unresponsive and abnormal breathing (adolescent and adult) or Unresponsive and abnormal breathing (baby and child).
First aid steps
- Begin CPR immediately, starting with two to five rescue breaths if possible.
- Ask a bystander to access emergency medical services (EMS), or if you are alone access EMS yourself. If using a phone, activate the speaker function.
- Ask a bystander to bring the naloxone as quickly as possible.
- Administer the naloxone according to the guidance provided as soon as it is available, only pausing CPR if is absolutely necessary.
- Continue CPR (with rescue breaths if possible) until the person shows signs of recovery, such as signs of life (opening their eyes, speaking or moving purposefully) or starts to breathe normally or until EMS take over.
- If there is no improvement after five minutes (or if the signs of overdose reappear), repeat the administration of a new dose of medication.
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NOTE
- When delivering CPR, rescue breaths may be beneficial for someone who is experiencing an opioid overdose as their cardiac arrest is usually due to abnormal breathing, so there may be low levels of oxygen in their blood.
- If you are alone and the naloxone is in the immediate vicinity, you can leave the person to quickly get it.
- It is possible the administration of naloxone may cause the person to wake up suddenly with confusion and sometimes aggressiveness. Be prepared for this and adjust your distance and behaviour to respond to the situation.
- If possible, make note of the time the naloxone is administered and provide this information to EMS or another medical professional.
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Access help
- In an instance where you are unable or unwilling to approach the person experiencing an opioid overdose, access help as quickly as possible.
- An opioid overdose is a life-threatening condition requiring urgent medical care. Explain the condition of the person clearly and accurately to EMS so they can prioritise your case.
- Even if naloxone has been administered, and the person shows signs of recovery, EMS should be accessed as there is a chance the person may relapse into overdose. Naloxone generally remains effective for about 5 – 10 minutes. Monitor the person’s breathing closely in case further administration of naloxone or CPR is required while waiting for help to arrive.
Education considerations
Context considerations
- The administration of naloxone varies depending on the context. Consult local authorities on the prevalent administration methods and regulations.
- Opioid overdose is a growing concern worldwide and programme designers need to consider the prevalence in their country, the populations it affects and the contexts in which those populations live.
- Stigma and marginalisation from mainstream healthcare services are common among people who use drugs. Consider education approaches with this in mind, ensuring your behaviour is inclusive and ethical, and actively advocate against discrimination.
- Tailor education approaches to the appropriate context whilst being careful not to label learners or make assumptions about them (such as literacy levels, attention span, ability, etc).
- Develop education opportunities through partner organisations with specialist knowledge of the learners where possible.
Learner considerations
- There are many learner groups who can be targeted with education on this topic, including social workers, community health workers, first responders, and the friends, peers and families of people who use opioids (Strang et al., 2000; Seal et al., 2003; Buchman et al., 2018).
- Bear in mind that some learners might struggle to find a time when they can learn. Work with partner organisations to identify when sessions should happen, how long they should last and what other adaptations you might need to make (Taylor et al., 2019).
- Some learners may have had a traumatic experience of an opioid overdose. Ensure facilitators are aware of this and prepared to deal with it (Taylor et al., 2019).
- Learners might feel disconnected with, or unable to access EMS, possibly because they are afraid, or they have had a bad experience. Help these learners to build confidence to act by describing their role in the chain of survival behaviours, and in the continuum of care that they become part of (Lackenau, 2013; Orkin & Buchman, 2017).
- Be considerate of the stigma that some learners feel (Denchman, 2013; Neale, 2018).
Facilitation tips
- The focus of education should be on:
> How to recognise an opioid overdose.
> How to react to an emergency involving an opioid overdose.
> How to effectively administer naloxone. - Develop learner-led education sessions where learners are encouraged to share their experience, knowledge, and fears to shape education. Learners might well have lived experience of this topic that facilitators can draw, both empowering the learner and enriching the learning experience for others (Buchman et al., 2018; Taylor et al., 2019).
- If scenarios are used, be careful not to stereotype the situation or the person who is overdosing. Opioid use covers all sectors of society.
- Try using a guided (non-scripted) approach to sessions as this allows the learners to direct the session with the facilitator confirming the techniques in summary.
- Ensure learner groups are not too small as this can reduce the potential for conversation and discussion. Groups of 5 or 6 learners can work well, allowing time for each learner to share experiences. Avoid facilitating large learner groups as this can be intimidating and hard to develop engagement.
- If the learner group is composed of people who use opioids, consider keeping education sessions short (20 to 30 minutes) with regular breaks.
- Be alert to the fact that learners may know more about street drugs (names and types) and how they affect people than the educator. Facilitators should not pretend to know everything but should empower learners to share what they know.
- Raise awareness that most of the time, the first aid provider will know of the person and that they use opioids. It is more uncommon to need to respond to a stranger.
Facilitation tools
- Storytelling may be a very effective method of delivery for this learner group.
- Peer to peer learning can be an effective way for learners to provide mutual support to each other.
- If using the AVPU scale (Alert, Verbal, Pain, Unresponsive) which describes what kind of stimulus a person reacts to and can be used to determine the level of responsiveness, highlight that a person with an opioid overdose may respond to a painful stimulus.
Scientific foundation
Systematic review
A 2020 review by the International Liaison Committee on Resuscitation (Olasveengen, 2020) did not identify any studies reporting any critical or important outcomes for adults or children with suspected opioid-associated cardiac or respiration arrest in any setting, comparing bystander naloxone administration (intramuscular or intranasal) plus conventional CPR, to conventional CPR only.
ILCOR did identify a summary of four case-series including 66 people, in which 39/39 people who received naloxone after an opioid overdose recovered, compared to 24/27 who did not receive naloxone. ILCOR stated that at the population level, there is evidence to demonstrate improved outcomes in communities after the implementation of various naloxone distribution schemes. A recent systematic review identified 22 observational studies evaluating the effect of overdose education and naloxone distribution using the Bradford Hill criteria, and found causation between the implementation of these programs and decreased mortality rates to be likely.
Non-systematic review
The safety of naloxone in a prehospital setting administered by first aid providers has not been formally established but will likely parallel medically supervised experiences. Naloxone dose and route of administration can produce a variable intensity of potential adverse reactions and opioid withdrawal symptoms. Serious adverse reactions after naloxone administration occur rarely and may be affected by other co-intoxicants and the effects of prolonged hypoxia.
As a response to the growing epidemic, naloxone has been widely distributed by health care authorities to people in various opioid overdose prevention schemes. Overall, these programs report beneficial outcomes at the population level. The ILCOR basic life support task force, therefore, considers it very likely that the desirable effects outweigh undesirable effects, and that use of naloxone is acceptable by key stakeholders as well as the general population (Olasveengen, 2020).
Education review
Ten papers are included in this review which provides insight at different points over the last 20 years on this topic. They are all from either the US, Canada or the UK reflecting an evidence gap from other parts of the world.
Willingness to help
Strang et al. (2000) present findings from interviews with 115 people attending a methadone maintenance clinic. It was found that people who use drugs have a high level of willingness to help others experiencing an overdose. Strang et al. conclude there is an urgent need to increase education opportunities and effectiveness to the user group. This would make the most of this willingness in a population that is likely to witness an overdose.
Take-home emergency naloxone
Seal et al. (2003) reflect on the potential of access to take-home naloxone. The study frames this access as a peer-based, life-saving addition to accessing emergency services but acknowledges the need for it to be embedded within a wider overdose management plan which incorporates education and community support. Strang et al. (2013) develop this concept further in a randomised trial where prisoners were given take-home naloxone and identified the need for training to be integral to the provision of the antidote. Klimas et al. (2015) add to this by identifying a need for healthcare professionals to be trained in how to support people to take naloxone.
Improving access to emergency care
Following a study in Scotland of the effectiveness of overdose education and naloxone distribution programmes (McAuley et al., 2017), Orkin and Buchman (2017) stated that such educational programmes should not distance people from emergency medical services at the very moment when they are most vulnerable and most in need of professional care. Rather, education should integrate bystander and first aid interventions for opioid overdose with a continuum of appropriate care.
This theme was explored further by Buchman et al. (2018) in a discussion paper on the ethics of such education programmes and the intentional and unintentional impact that they might have on vulnerable populations. They argue that having alternative approaches to care for people already excluded from mainstream services does little to dismantle the structural barriers that separate stigmatised people from healthcare systems—and may in fact entrench exclusion. They go on to suggest naloxone distribution programmes only provide part of the answer, and the bigger question is one about the broader social determinants of drug use and stigma. While empowering learners from vulnerable and excluded populations through acknowledgement of their lived experience, the challenge of inaccessibility to mainstream healthcare for them is exacerbated.
In a study to assess community based opioid prevention programmes in the US, a key barrier identified to providing help was fear that calling EMS would draw police to the scene in addition to paramedics (Lankenau, 2013). Dechman (2014) reports on a similar barrier to calling for help which is the attitude of those who arrive to provide care, which can sometimes be humiliating and degrading. This can lead to first aid providers (peers) developing a host of additional roles in order to support their peer group without having to face professional healthcare providers.
Competence to help
Neale et al. (2018) built on this evidence base with training for people who use opioids to test their competency to help effectively. They cited literature and experiences of people who felt stigmatised and routinely associated with incapacity to deal with the harms they cause. Their experiment found high levels of competency despite the diverse cognitive, emotional, experiential, interpersonal and social factors over which they had little control.
Considerations for learning design
Taylor et al. (2019) used quantitative methods to test whether introducing an additional naloxone component to overdose education for people who use drugs and their peers would affect the confidence and willingness to respond effectively to an overdose and collected qualitative feedback from educators. Findings were pertinent to educators in the following ways:
- The need for facilitators to create a safe space for learners to talk, and for space in the session to be given to learners to share experiences and provide peer to peer support.
- The need for facilitators to be extremely flexible in when to plan sessions given the chaotic nature of the lives of some of the participants, including attention spans and the need for frequent breaks.
- Consideration of learning materials bearing in mind reading levels and time available for providing feedback during a time-limited session.
References
Systematic reviews
Olasveengen, T. M., Morley, P.T. On behalf of the Adult Basic Life Support Collaborators. (2020). Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation, 142(suppl 1), S41–S91.
DOI: 10.1161/CIR.0000000000000892
Olasveengen, T. M., Mancini, M. E., Perkins, G. D., Avis, S., Brooks, S., Castrén, M., … Morley, P.T. (2020). Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation, 156, A35-A79.
DOI: 10.1016/j.resuscitation.2020.09.010
Non-systematic reviews
World Health Organization. (2020). Opioid overdose. 28 August 2020. Retrieved from: https://www.who.int/news-room/fact-sheets/detail/opioid-overdose
Education references
Buchman, D. Z., Orkin, A. M., Strike, C., & Upshur, R. E. (2018). Overdose education and naloxone distribution programmes and the ethics of task shifting. Public Health Ethics, 11(2), 151-164. Full article: https://academic.oup.com/phe/article/11/2/151/4837138
Dechman, M. K. (2015). Peer helpers’ struggles to care for “others” who inject drugs. International Journal of Drug Policy, 26(5), 492-500. Full article: https://www.sciencedirect.com/science/article/pii/S095539591500002X
Klimas, J., Egan, M., Tobin, H., Coleman, N., & Bury, G. (2015). Development and process evaluation of an educational intervention for overdose prevention and naloxone distribution by general practice trainees. BMC medical education, 15(1), 206. Full article:
https://link.springer.com/article/10.1186/s12909-015-0487-y
Lankenau, S. E., Wagner, K. D., Silva, K., Kecojevic, A., Iverson, E., McNeely, M., & Kral, A. H. (2013). Injection drug users trained by overdose prevention programs: responses to witnessed overdoses. Journal of community health, 38(1), 133-141. Full article:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3516627/
Neale, J., Brown, C., Campbell, A. N., Jones, J. D., Metz, V. E., Strang, J., & Comer, S. D. (2018). How competent are people who use opioids at responding to overdoses? Qualitative analyses of actions and decisions taken by lay first-responders during overdose emergencies. Addiction. Full article: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc6411430/
Orkin, A. M., & Buchman, D. Z. (2017) Naloxone programs must reduce marginalization and improve access to comprehensive emergency care. Addiction, 112(2), 309-310. Full article: https://onlinelibrary.wiley.com/doi/pdf/10.1111/add.13662
Seal, K. H., Downing, M., Kral, A. H., Singleton-Banks, S., Hammond, J. P., Lorvick, J., … & Edlin, B. R. (2003). Attitudes about prescribing take-home naloxone to injection drug users for the management of heroin overdose: a survey of street-recruited injectors in the San Francisco Bay Area. Journal of Urban Health, 80(2), 291-301. Full article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3456285/pdf/11524_2006_Article_216.pdf
Strang, J., Best, D., Man, L. H., Noble, A., & Gossop, M. (2000). Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation. International Journal of Drug Policy, 11(6), 437-445. Full article: https://doi.org/10.1016/S0955-3959(00)00070-0
Strang, J., Bird, S. M., & Parmar, M. K. (2013). Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial. Journal of Urban Health, 90(5), 983-996. Full article:
https://link.springer.com/content/pdf/10.1007/s11524-013-9803-1.pdf
Taylor, T. A., Ellis, L., Newell, P., & Oliver, E. (2019). Insights From a Pilot Study of Naloxone Education. International Journal of First Aid Education, 2(2), 32. Full article: https://pdfs.semanticscholar.org/bd39/7148871c77858fdc7dfac50f2d13e318ff60.pdf
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Published: 15 February 2021
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