Responding to an overdose: Signs to look for, and how to administer naloxone

The overdose crisis spreading nationwide and locally is fueled by the powerful opioid, fentanyl. Local agencies are working to widely distribute free naloxone (brand name, Narcan) and free trainings to the public on how to use it.

For more information about the free naloxone and trainings, call YouthThink, Wasco County’s drug and alcohol prevention program, at 541-506-2673.

Fentanyl has rapidly taken over the nation’s illicit drug supply in the last few years. Many times more powerful than heroin — which can’t be found anymore — fentanyl is often found in other drugs as well, such as methamphetamine.

First, how do you know if someone is overdosing?

Mid-Columbia Fire & Rescue Firefighter/Paramedic Cameron Debozy worked for several years in Multnomah County before coming to MCF&R 18 months ago. Due to his time in the Portland area, he estimated he’s given naloxone about 100 times.

Overdose signs are usually “pretty obvious,” Debozy said. Opioids reduce our body’s drive to breathe, and an overdose has a typical progression.

First is slurred words and confusion. It becomes difficult to talk or follow commands. Then drowsiness, leading to slower and increasingly shallow breaths. Then they don’t respond to painful stimuli, like firmly rubbing their sternum with your knuckles.

Then their pupils become very small, and they become completely unresponsive, sweaty, and their body temperature drops. With no oxygen intake, they begin to change color and become bluish/purplish, especially in the lips, eyelids and fingers.

They may have pale/clammy skin, vomiting or gurgling, according to a webinar hosted last November by the Oregon Health Authority.

One overdosed person that The Dalles Police Officer John Caminiti responded to was clinically dead: Not breathing and no heartbeat.

“They appear to be passed away,” Caminiti said. They have “no signs of life and their lips are purple.”

As to where overdoses have happened locally, Debozy believes about half are outdoors or in a vehicle, another 25% are in a public bathroom, and the rest are in a residence.

How do you reverse an overdose?

The simple guideline for responding to an overdose is: Call 911 first, give a dose of naloxone, wait 2-3 minutes, and continue giving additional doses — if you have them — at 2-3 minute intervals if they do not begin breathing on their own. While waiting between doses, do chest compressions if they aren’t breathing and don’t have a pulse. Do rescue breaths if you are willing, and wait for help to arrive.

The naloxone that is distributed for free locally is a single-dose nasal spray called Narcan. Stick the tip of the nasal spray fully up a person’s nostril, then quickly and completely push the plunger.

Each box of Narcan comes with two doses. If you need a second dose, use the other nostril. The big reason for waiting between doses is “they want you to give Narcan time to work,” Debozy said.

A key message from Caminiti and Debozy: You can’t hurt anybody by giving them Narcan. “That’s the beautiful thing about Narcan, but a lot of people don’t know that,” said Debozy.

There’s even a Good Samaritan Law that protects people from any liability when they give someone Narcan in good faith.

Narcan kits provided by YouthThink include disposable plastic face shields with one-way valves so people can provide rescue breaths without actually touching the person.

But it’s also understood that people may not want to do that, Debozy said.

If a person wants to only give naloxone, that is valid, and is better than nothing, the Oregon Health Authority webinar speaker said.

If you come upon someone who is overdosed and you don’t have naloxone, empty their backpack if it’s nearby by turning it upside down (don’t put your hand in backpack) and see if they have naloxone in it, the webinar speaker suggested.

Paramedics typically start providing naloxone and oxygen as soon as they arrive. “If they are getting enough oxygen, naloxone can be withheld or given in small doses, and we can monitor them on the way to the hospital,” Debozy said.

Because police are always on patrol, they often arrive first to overdoses because paramedics are responding from their station. Caminiti said it can be stressful to be first on scene.

“I think administering Narcan for the first time can be challenging,” Caminiti said. “You’re not really sure what the person took, you haven’t seen the signs before if you’re the average public person. And then you’re sitting there wondering when they’re going to start breathing again, or wake up.”

He advised anyone who has a job that sees a high volume of the public to carry naloxone.

Once an overdose is reversed, how will the person respond?

Debozy said the most common reaction is confusion and being scared. He keeps his distance to let them have their space as they slowly reorient themselves.

Caminiti described people as being “in an extreme fog or daze. They don’t know what’s going on and initially they’re kind of surprised by people.”

Debozy estimated maybe 25-33% of the time, people become verbally aggressive as they come out of overdose, yelling at people to stay away, but he feels “that’s preventable” with patience, understanding, telling them what’s happened, and giving them space.

Rarely — less than 10% of the time — does an awakened person actually become violent, Debozy said. “That’s why I suggest giving them some space and talking to them, explain what is going on, who you are, the fact you’ve provided Narcan, which is what caused them to wake up.”

Caminiti said none of the five people he’s seen revived from an overdose have been combative, and just one person was “a little agitated.”

The OHA webinar speaker said people coming out of withdrawal may also be cold. He suggested giving them water, hand warmers or a blanket, and a piece of candy for a bit of endorphin release. Some may be confused, and some may cry.

The webinar speaker said it is traumatic for a bystander to respond to an overdose, and he urged bystanders to talk to someone about their experience.

Caminiti said, “I definitely understand why it might be challenging or trauma inducing for the average person to walk upon. All you see is somebody down on the street or in an alleyway.”

As a paramedic, Debozy said his goal isn’t actually to get them to wakefulness, it’s to get them breathing on their own so they can take them to the hospital for further care.

“We don’t want to give them so much that we’ve put them into a state of withdrawal because that’s something that happens very easily and very quickly,” Debozy said.

He said that risk of putting someone into acute withdrawal is also behind the Narcan manufacturer’s recommendation of giving doses 2-3 minutes apart.

Debozy said that compared to heroin, it is much harder to reverse a fentanyl overdose and takes much more Narcan/naloxone because they are in a deeper state of overdose.

Even if someone is so fully awakened and has been given enough naloxone that they start to have withdrawal symptoms, “the good news is that they’re alive,” Debozy said. “That’s an easy trade when it comes to bystander care or treatment.”

Fentanyl withdrawal is very painful, much more than other drug withdrawals, and often people who experience it will leave paramedics, or leave the hospital, so they can get more fentanyl to ease withdrawal symptoms.

Caminiti said people in the depths of addiction are no longer chasing a high, but warding off withdrawal symptoms.

Debozy said it’s not uncommon for people to not want to go to the hospital, but it’s risky, since naloxone wears off faster than the fentanyl.

Debozy said people have many reasons for not going to the hospital: No insurance, or worrying someone will take their stuff. “A big concern is theft. It’s a pretty hard life,” he said of those who are houseless.

Caminiti said he’s been surprised by how many people choose not to go to the hospital for care after an overdose. Two of the people he gave naloxone refused to go to the hospital.

Caminiti said there is immunity from drug-related offenses for emergency medical assistance which prevents people from being criminally charged with possessing drugs or drug paraphernalia, or being arrested on warrants for either of those.

“I don’t want people to be afraid to call 911 for a drug overdose, because they are worried about getting in trouble,” Caminiti said. He tells those who overdose, “Hey look, you’re not in trouble, we just want to get you help.”