In direct response to the ongoing U.S. opioid epidemic, which has claimed hundreds of thousands of lives from all over the nation, and, sadly, continues to do so, federal and state governments and agencies, along with numerous national and local health organizations and authorities, developed their own “opioid overdose toolkits.”
These toolkits were established with a single purpose in mind – to provide the relevant members of these organizations, and the community members they serve, with quick, easy access to all the information they needed to tackle the issue within their own communities as effectively as possible.
The toolkits are an absolute mine of information, with expert advice, guidelines, drug addiction treatment advice, and the strategies required for all the separate entities within a region, state, county or community to establish working relationships, open lines of communication, and come together to confront the opioid epidemic and its profound effects.
For example, here in Arizona, the “opioid overdose toolkit,” though not specifically named as such, is available via the state’s official Arizona Department of Health Services website, where all the information required can be found.
What is a “Toolkit”?
According to the American Library Association, a “toolkit,” in the sense of providing a community service, is a specifically-assembled “collection of authoritative and adaptable resources for front-line staff that enables them to learn about an issue, and identify approaches for addressing [the issue].”
A toolkit – a set of exhaustive resources – is specifically designed “to offer practical advice and guidance regarding an issue of concern or importance when the issue is emerging or evolving, and well-established processes for addressing them are not yet widely adopted” – in this case, the U.S. opioid epidemic.
For the purposes of this article, we will look at the opioid overdose toolkit written by the Substance Abuse & Mental Health Services Administration (SAMHSA), and currently being used, among others, by the Bureau of Justice Assistance (BJA), a part of the U.S. Department of Justice.
Additionally, we’ll look at a few more opioid overdose toolkits produced by different types of organizations; however, when you study the content, they all follow a similar pattern and are packed with resources.
The U.S. Opioid Epidemic: A Disturbing Status Update
Long before the U.S. first encountered the coronavirus pandemic, the signs that the opioid epidemic was consolidating its presence in the nation even further were already here – opioid-related deaths from overdose were unrelentingly still rising, with more and more lost lives added every day to the growing overall death toll.
Once the pandemic had arrived, the situation was only to worsen, as state governments, localized health services, and the private addiction treatment industry felt the full knock-on effects of temporary business closures and stay-at-home orders. Drug and alcohol rehabs, outpatient programs, and support services lost the continuum of care so vital in addiction recovery.
Those in addiction recovery, for a considerable extent of 2020, were literally left in isolation. Even the church halls and community centers that housed weekly AA and NA meetings, and other mutual-help groups, had no option but to shut, and then lock their doors.
Fatal Opioid Overdoses Still Rising
As we have seen from the various national and state reports on overdose mortality during 2020, sadly, many of these people didn’t survive the year. For example, the December press release from the Center for Disease Prevention & Control (CDC) – “Overdose Deaths Accelerating During COVID-19” reported that 81,000 drug overdose deaths occurred in the U.S. in the 12 months ending in May 2020 – this is the highest number of overdose deaths ever recorded in the U.S. during a 12-month period.
In the year of the COVID-19 pandemic, when hundreds of thousands lost their lives from a respiratory virus, these thousands of people lost their lives to another medical condition entirely, all caused by a pre-existing and ongoing national crisis. Clearly, fundamental errors were made when it came to disrupting addiction treatment services.
In Arizona, the opioid epidemic was breaking records here, too. For example, in Pima County, as if mirroring the nation itself, saw unprecedented drug overdose mortality. According to an official Pima County Health Department drug overdose alert, published on November 4th., even before the end of 2020, it was stated that there had been as many deaths from drug overdose in the first 9 months of the year than there had been for the entirety of 2019.
Fentanyl & Other Synthetics: Driving the Opioid Crisis for Years to Come
However, it is no longer the virtually free and unregulated distribution of opioid prescription painkillers driving a now-worsening epidemic; it is the far greater availability of far more potent and cheaper opioids, such as fentanyl. Synthetic opioids, particularly fentanyl and its various analogs, are now pushing the crisis to even greater losses of life.
“We haven’t seen anything like this since heroin first hit the streets more than 100 years ago. It’s more useful to think of the fentanyl crisis as a mass poisoning than as a traditional drug epidemic. The margin of error is so narrow – one more milligram, and that could put you in the grave.” – Bryce Pardo, associate policy researcher, RAND Corporation, and lead author of “The Future of Fentanyl and Other Synthetic Opioids”
The majority of the fatal opioid overdoses seen in 2020 were caused by fentanyl, fentanyl analogs, such as acetyl fentanyl, acrylfentanyl, carfentanil, and furanyl fentanyl, and novel synthetic opioids, like the little known U-47700.
Fentanyl is an exceptionally powerful synthetic (man-made) opioid, normally between 30-50 times stronger than morphine; however, it has been shown to be as powerful as 100 times stronger. Experts agree it is the man-made primary catalyst that has worsened the opioid crisis.
Recently, illicit drug manufacturers have been “cutting” (or mixing) this opioid not only into other opioids, like heroin, to make them more potent, but into virtually every other illicit drug available, such as cocaine, methamphetamine, ecstasy, counterfeit drugs, like Xanax and “M30” tablets – counterfeit oxycodone.
Fentanyl analogs are derivations of the chemical structure of fentanyl – similar but not exact. They pose a challenge for forensic pathologists and toxicologists when it comes to identification, as the extreme potency of these analogs results in blood, urine and vitreous concentrations so minute that they are technically difficult to identify.
Additionally, standard drug screening normally won’t pick these substances up, so you can have a fatal drug overdose with no readily identifiable source, such as in overdoses from furanyl fentanyl toxicity.
What Happens During an Opioid Overdose?
Fentanyl can be fatal if (i). a drug user, knowingly or unknowingly, uses substances that contain the opioid, and (ii). the amount of fentanyl in the drug is sufficient to cause an adverse, toxic reaction – thus resulting in an overdose. Obviously, other opioids can and do also result in fatal drug overdoses.
A “drug overdose” is medically defined as “taking too much of a substance, whether it’s prescription, over-the-counter, legal, or illegal, and can be either accidental or intentional, resulting in a severe and possibly fatal physical reaction.”
A physical side-effect of using opioids is severe respiratory depression. This is where the drug user’s ability to breathe either becomes very low (depressed) or stops working altogether, meaning their body becomes starved of oxygen. Unless urgent medical treatment is provided, this is normally fatal.
Opioid Overdoses: Respiratory Depression & Oxygen Starvation
Because of this profound lack of oxygen, vital organs can be significantly affected. Firstly, depleted levels of oxygen will stop the heart, resulting in cardiac arrest, and then the brain shuts down. Without immediate medical intervention, the consequences can be deadly: unconsciousness, coma, and then death. If that wasn’t enough, after 3-5 minutes of no oxygen entering the bloodstream, brain damage begins rapidly, soon followed by death.
Therefore, the detailed information contained within an opioid overdose toolkit, explaining the steps needed if an overdose occurs, now becomes critical in saving the life of the individual. The key is to reverse the physical effects of the opioid, ensuring the respiratory system recovers. In fact, surviving or dying from an opioid overdose depends entirely on the body receiving enough oxygen.
Lastly, it is important to remember that after an individual takes opioids, respiratory depression doesn’t happen immediately – the process is usually a slow one, happening minutes or sometimes hours after the drug was used. It is this valuable “window of opportunity” that can save a life, as long as there is emergency medical assistance available.
What’s Inside an Opioid Overdose Toolkit?
The opioid overdose toolkit written by the Substance Abuse & Mental Health Services Administration (SAMHSA) is a perfect example of what these groups of expertly researched and written resources are attempting to achieve. These toolkits are normally provided in the form of a publication, either a physical one or as a .PDF document accessible online or downloaded for offline use.
The SAMHSA toolkit is divided into 5 distinct sections, each offering subsets of resources for each of the representative elements of the “community” they serve, as shown below:
1. Facts for Community Members
This section provides all the necessary background to the opioid epidemic, as well as:
- General information about opioids, such as how overdoses occur and who is at risk
- Proven strategies to reduce the impact of the opioid epidemic, such as education, access to both effective treatment and naloxone (the opioid overdose reversal medication), and Prescription Drug Monitoring Programs, and
- Community resources – essential contact information for SAMHSA, State Substance Abuse Agencies, and the CDC, among others
The phrase “Community Members” includes all the “stakeholders” (those directly affected and those able to assist) in the opioid crisis, eg. service organizations, government agencies, emergency services, and the public.
2. Five Essential Steps for First Responders
Note: Because this is an absolutely essential resource of information for all members of a community where opioids are being used, and not just First responders, a summary of the pertinent points (adapted for general use) of “Five Essential Steps” is provided below.
Opioid Overdose: What You Should Do
STEP 1: CALL FOR HELP (DIAL 911)
- AN OPIOID OVERDOSE NEEDS IMMEDIATE MEDICAL ATTENTION
- Dial 911 Immediately: All you have to say is: “Someone is not breathing”
- Be sure to give a clear address and/or description of your location
STEP 2: CHECK FOR SIGNS OF OPIOID OVERDOSE
- SIGNS OF OVERDOSE which often results in death if not treated, include:
- Extreme sleepiness or inability to awaken verbally or upon sternal rub
- In unconscious patients, breathing is slow to shallow
- Fingernails or lips turning blue/purple
- “Pinpoint” pupils
- Slow heartbeat and/or low blood pressure
- SIGNS OF OVERMEDICATION which may progress to overdose, include:
- Unusual sleepiness, drowsiness, or difficulty staying awake despite loud or vigorous stimulus
- Mental confusion, slurred speech, intoxicated behavior
- Slow or shallow breathing
- “Pinpoint” pupils; although normal size pupils do not exclude opioid overdose
- Slow heartbeat, low blood pressure
- Difficulty waking the person from sleep
STEP 3: SUPPORT THE PERSON’S BREATHING
- Ideally, individuals who are experiencing opioid overdose should be ventilated with 100% oxygen before naloxone is administered, so as to reduce the risk of acute lung injury. In situations where that is not feasible, rescue breathing can be very effective in supporting respiration.
- Rescue breathing for adults involves the following steps:
- Be sure the person’s airway is clear – check that nothing inside the person’s mouth or throat is blocking the airway.
- Place one hand on the person’s chin, tilt the head back, and pinch the nose closed.
- Place your mouth over the person’s mouth to make a seal, and give 2 slow breaths.
- The person’s chest should rise, but not the stomach).
- Follow up with one breath every 5 seconds.
STEP 4: ADMINISTER NALOXONE (IF AVAILABLE)
- Naloxone should be administered to any person who shows signs of opioid overdose, or even when overdose is suspected. Comfort the person being treated, as withdrawal symptoms triggered by naloxone can feel unpleasant. As a result, some persons become agitated or combative when this happens, and may need help to remain calm.
STEP 5: MONITOR THE PERSON’S RESPONSE
- Anyone who experiences, or may have experienced, an opioid overdose should be monitored in preparation for when the EMS arrive. Stay with them. If you have administered naloxone, and have been unable to call 911, the medication should continue to work for 30-90 minutes; it is essential to get the person to an emergency department or other source of medical care as quickly as possible, even if he or she revives after the initial dose of naloxone, and seems to feel better.
In addition to these essential steps, this section includes further information for EMS personnel, including detailed information about naloxone, and a list of “Do’s and Don’ts in Responding to Opioid Overdose,” which is shown below:
- DO support the person’s breathing by administering oxygen or performing rescue breathing.
- DO administer naloxone.
- DO put the person in the “recovery position” on the side, if he or she can breathe independently.
- DO stay with the person, and keep him/her warm.
- DON’T slap or try to forcefully stimulate the person – it will only cause further injury. If you are unable to wake the person by shouting, try rubbing your knuckles on the sternum (center of the chest or rib cage), or light pinching, as he or she may be unconscious.
- DON’T put the person into a cold bath or shower. This increases the risk of falling, drowning or going into shock.
- DON’T inject the person with any substance (salt water, milk, “speed,” heroin, etc.). The only safe and appropriate treatment is naloxone.
- DON’T try to make the person vomit drugs that he or she may have swallowed. Choking or inhaling vomit into the lungs can cause a fatal injury.
3. Information for Prescribers
Written solely for those who actually prescribe opioid medications, such as family physicians and clinicians, this section offers advice about minimizing overdose risk, such as:
- Opioid Overdose Risk, including:
- Patients assessments
- Precautions for new patients
- Accessing a patient’s prescription history through the state’s specific Prescription Drug Monitoring Program
- Medication selection
- Patient education
- Patient “Informed Consent” – an agreement made between the physician and the patient dealing with various aspects of the use of opioid medication
- Prescription order adherence, and
- Terminating opioid therapy
- Treating an Opioid Overdose
- Legal & Liability Considerations
- Claim Codes & Billing, and
- Resources for Prescribers, such as links to further information about prescribing opioids for chronic pain:
4. Safety Advice for Patients & Family Members
5. Recovering From Opioid Overdose
The last 2 sections are specifically for patients prescribed opioids, and their families, and include a wealth of detailed information and resource links.
How Naloxone Saves Lives in Opioid Overdose
Source: National Institute on Drug Abuse (NIDA)
Opioid Overdose Toolkits: Alternative Examples
In Arizona, as an alternative to an “opioid overdose toolkit,” all the necessary resources and information can be accessed from the state’s official Arizona Department of Health Services website. Alternatively, the Opioid Response section can be found by using the following menus:
- ADHS Home → Public Health Prevention → Women’s and Children’s Health → Injury Prevention → Opioid Epidemic
On this web page, you will find the Arizona Opioid Dashboard:
Additionally, you will find button links to all the relevant information about Arizona state and organizational responses, which include further links to more resources; for example, you can access the “Arizona Opioid Action Plan – June, 2019 – June, 2021,” FAQs (Frequently Asked Questions, and Community Resources.
You will also be able to access Arizona’s “Real Time Opioid Data,” providing the latest data available, including the state’s opioid mortality, suspected overdoses, and the number of administered doses of naloxone:
Furthermore, here are a couple more examples of other organizational opioid overdose toolkits, in Arizona and elsewhere:
Arizona Care Network: “Opioid Toolkit”:
Source: An excerpt from the Arizona Care Network: “Opioid Toolkit”
American Hospital Association: “Stem The Tide” (Opioid Toolkit):
Source: Front cover of the American Hospital Association: “Stem The Tide”
National Institute on Drug Abuse
Lastly, the National Institute on Drug Abuse (NIDA), like Arizona’s Department of Health Services, has no specifically named toolkit; however, they do provide a wealth of national information about opioids, including: