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SCOTLAND HAS AMONG THE HIGHEST DRUG OVERDOSE NALOXONE RATES OF DRUG-RELATED DEATHS IN 1/ ASSOCIATED 11/ WHAT IS NALOXONE EUROPE. THIS BOOKLET AIMS TO PROVIDE INFORMATION FOR DRUG USERS. 2/ DRUG EFFECTS 12/ WHEN TO USE NALOXONE 3/ THE MAIN CAUSES IT CAN BE USED AS A RESOURCE FOR DRUG WORKERS TO TALK THROUGH SOME OF 4/ HIGH RISK TIMES DANGER THE ISSUES AND FACTS SURROUNDING 5/ 13/ COMMON INFECTIONS IN DRUG DEATHS. 6/ WHAT YOU SHOULD DO DRUG USERS 14/ BLOOD-BORNE VIRUSES (BBVs) UNCONSCIOUS CASUALTY 15/ BACTERIAL INFECTIONS 7/ RECOVERY POSITION - 16/ ANTHRAX INFECTION HOW TO DO IT 17/ SEXUALLY TRANSMITTED 8/ WHAT IT LOOKS LIKE INFECTIONS (STIs) 9/ CARDIOPULMONARY 18/ RESPIRATORY INFECTION (CPR) 19/ ASSOCIATED RISKS 10/ COMMON MYTHS © Scottish Drugs Forum 2013 All Rights reserved ISBN: 978-1-903483-11-4 Scottish Drugs Forum 91 Mitchell Street Glasgow G1 3LN 4 www.naloxone.org.uk / www.sdf.org.uk 5 1/ 2/ DRUG DRUG OVERDOSE OVERDOSE ASSOCIATED DRUG DRUGS EFFECTS

THE MOST COMMON DRUGS IDENTIFIED IN A DRUG-RELATED ARE: / DOWNERS DEPRESSANTS / DOWNERS BREATHING PROBLEMS (SLOW, SHALLOW, IRREGULAR) / SLOW / FEELING LESS ALERT/ / DIAZEPAM (AND OTHER SUCH AS UNCONSCIOUSNESS / POOR MEMORY / TEMAZEPAM AND NITRAZEPAM) / / NOT FEELING / LOWER BODY / UPPERS / (SPEED) / ECSTACY

Although stimulants feature in some drug These could include -based STIMULANTS / UPPERS deaths, the depressants listed above are drugs such as: INCREASED HEART RATE / FASTER BREATHING / the top four drugs involved in overdose. / Dihydrocodeine. FEELING MORE ALERT / RAISED BODY TEMPERATURE There are other drugs, both illicit and / Over-the-counter medicines which prescribed, which could contribute to a contain . drug death when used in combination with / Prescribed drugs such as the main drugs listed above. anti-depressants. There is a greater danger of overdose through mixing drugs such as heroin (particularly when injected) and other drugs. 6 www.naloxone.org.uk / www.sdf.org.uk 7 3/ 4/ DRUG DRUG OVERDOSE OVERDOSE THE MAIN HIGH RISK CAUSES TIMES

SOME OF THE MAIN CAUSES OF OVERDOSE INCLUDE: THE FOLLOWING ARE ‘DANGER’ THE FESTIVE PERIOD CAN BE PERIODS WHEN PEOPLE MAY PARTICULARLY DANGEROUS FOR LOW TOLERANCE USING TOO MUCH BE MORE AT RISK OF OVERDOSE: THE FOLLOWING REASONS: As your body gets used to the repeated Specific circumstances such as a cash / On release from prison. / Bingeing on drugs bought in bulk for presence of a drug and learns to tolerate it windfall, or seeking oblivion can fear of dry up or reduced access to in your system, a higher is needed to lead to using too much. / On leaving residential rehabilitation dealers over the holiday period. maintain the same effect. Tolerance will be or hospital. reduced if there is a break or reduction in USING ALONE / Seasonal increase in alcohol use / When recently detoxed. drug use for a period. There will be a risk of Using on your own puts you at greater risk as combined with drug use. there is no one around to intervene or call for overdose if you return to high levels of drug / During relapse. / Access to more money to buy drugs. use following a break or reduction, e.g. after medical assistance. a spell in prison or residential rehabilitation. / When in poor physical or . INJECTING DRUG USE / Holiday dispensing arrangements which Injecting is the most risky route of drug use, / After a recent life event, such as supply take-home methadone to users MIXING DRUGS INCLUDING ALCOHOL bereavement, relationship breakdown not used to unsupervised consumption/ Mixing drugs, especially depressants, is although large numbers of deaths do occur among non-injectors, e.g. 44% of drug- or loss of custody of children. prescription. extremely dangerous. Each depressant on 1 its own can slow down breathing and heart related deaths in 2003 were non-injectors . / During Festive periods, weekends / Rises in stress and/or depression rate - but when used in combination these or holidays. associated with the festive period PURITY LEVELS physical effects become enhanced and much such as isolation from family, friends, Illegal drugs can vary in strength. Use of low more dangerous. The long-acting nature of children or support services, or added purity drugs followed by higher purity drugs Most overdoses occur in those who some depressant drugs can also lead to the pressure on finances. may have implications for tolerance levels. are not in treatment. risk of unintentional ‘topping up’ or polydrug misuse. Longer term users are also at high risk.

1 Source: Zador et al. National Investigation into Drug-related Deaths in Scotland, 2003. Scottish Executive (2005) For more information please see: www.scottishdrugservices.com 8 www.naloxone.org.uk / www.sdf.org.uk 9 5/ 6/ DRUG DRUG OVERDOSE OVERDOSE SIGNS AND WHAT YOU SYMPTOMS SHOULD DO

/ Be vigilant and think of your own safety first. BREATHING Watch out for needles that might be around IF YOU CAN CORRECTLY IDENTIFY THE Place the casualty in the recovery position the casualty. Never attempt to re-cap a PHYSICAL SIGNS AND SYMPTOMS OF (see section 7). needle. OVERDOSE, THERE IS A CHANCE YOU DIAL 999 and calmly ask for an ambulance. WILL BE ABLE TO SAVE A LIFE. / Check the casualty for a response – shake their shoulders and shout loudly ‘open your Give the location and status of the casualty SOME OF THESE INCLUDE: eyes’ or ‘wake up’. ie. the address and that the casualty is unconscious and breathing. / Pinpoint (this indicates whether When someone has overdosed they can / If there is no response, shout for help from Stay with the person until the ambulance arrives. are involved). look and sound like they are simply asleep. anyone that is around. Always check when you hear snoring that / Turn the casualty on their back and open / Breathing problems (e.g. slow/shallow the person is actually asleep and not in an their airway by gently placing two fingers NOT BREATHING NORMALLY or infrequent breaths, snoring/rasping overdose situation. Snoring/rasping can be under their chin and tilting their head back. DIAL 999 and calmly ask for an ambulance. sounds or not breathing at all). an indication of breathing difficulties. / Place your ear above the casualty’s mouth Give the location and status of the casualty / Pale skin colour. Lips, tip of nose, The time gap between a person using and LISTEN for breathing, FEEL for breath ie. the address and that the casualty is fingertips or nails with a bluish tinge. drugs and slipping into an overdose can on your cheek. Also LOOK at their chest unconscious and NOT breathing. / No response to noise (shouting) or be several hours. to see if it rises and falls. Do this for 10 Begin CPR (see section 9). seconds. touch (shoulder shake). Unintentional overdose through polydrug The emergency call handler can talk you / Loss of consciousness. use, especially when mixing long- through this process. acting drugs such as methadone and benzodiazepines, is a real danger. Important: The average adult will take between 12 and 20 breaths per minute. Some drugs can seriously affect breathing, and in overdose a person may breathe as little as 3-5 breaths a minute.

2 CPR - Cardiopulmonary resuscitation 10 www.naloxone.org.uk / www.sdf.org.uk 11 7/ 8/ RECOVERY RECOVERY POSITION POSITION HOW TO WHAT IT DO IT LOOKS LIKE

THE RESUSCITATION COUNCIL (UK) RECOMMENDS THE 1/ 2/ FOLLOWING SEQUENCE OF ACTIONS TO PLACE A CASUALTY IN THE RECOVERY POSITION:

/ Remove the casualty’s glasses (if worn). / Adjust the upper leg so that both the hip / Kneel beside the casualty and make sure and knee are bent at right angles. that both their legs are straight. / Tilt the head back to make sure the airway / Place the arm nearest to you out at right remains open. angles to the body, elbow bent with the / Adjust the hand under the cheek, hand palm uppermost. if necessary, to keep the head tilted. Say ‘hi’ Support my face / Bring the far arm across the chest, and / Check their breathing regularly. hold the back of the hand against the 3/ 4/ casualty’s cheek nearest the ground. / With your other hand, grasp the far leg just Important: Ensure you have dialled above the knee and pull it up, keeping their 999. Stay with the casualty until help foot on the ground. arrives. Always look after your own / Keeping the hand pressed against the safety too – look around you and cheek, pull on the far leg to roll the make sure you are in a safe position, casualty towards you onto their side. e.g. not in close proximity to a road or dangerous equipment. Be vigilant about potential needle stick injuries. Lift my leg Roll me over 12 www.naloxone.org.uk / www.sdf.org.uk 13 9/ I MADE CARDIO- THE PULMONARY CALL RESUSCITATION (CPR) THAT

IN THE CASE OF AN OVERDOSE, CPR CAN BE PERFORMED AS FOLLOWS: SAVED

/ If the casualty is not breathing normally, / You will see the chest rise if CPR is give 30 chest compressions. Place your performed correctly. hands on top of each other and place them in / Continue the process of 30 compressions A LIFE the centre of the chest (on the breastbone). to 2 rescue breaths until someone takes Compress the chest by pushing straight down over for you, emergency help arrives or approximately 2 inches deep. the casualty’s condition improves. Over 80% of casualties / You are aiming for a rate of 120 compressions are already dead by per minute (2 every second). the time an ambulance / Give two rescue breaths (use a protective mouth arrives. That is why it guard if you have one). Ensure the head is still is important to call tilted back keeping the airway open and pinch the casualty’s nose closed. Make a seal with the ambulance early. your mouth over the casualty’s mouth and breathe for about one second.

Important: An is not a cardiac related event. The person is at risk of dying from lack of due to respiratory depression, hence why it is essential to provide rescue breaths. 14 www.naloxone.org.uk / www.sdf.org.uk 15 10/ DON’T WALK THE CASUALTY AROUND DON’T INJECT SALT WATER There is a real danger of dropping the There is a common misconception around COMMON person and causing additional injury. injecting salt water which may have its Walking can also increase the rate at origins in the use of saline drips in hospital. which the drugs are absorbed. MYTHS  DON’T THROW WATER OR PUT THE DON’T INFLICT PAIN, I.E. SLAPPING, CASUALTY IN THE BATH OR SHOWER BURNING This could result in triggering or lead People mistakenly think that inflicting pain to the victim accidentally drowning. will rouse someone who is unresponsive or unconscious. This will not work on someone who is unconscious. DON’T PUT THE CASUALTY OUTSIDE This could result in hypothermia.

COMMON MYTHS ABOUT Important: Depressants, especially heroin and other /opioids, HOW TO HANDLE AN DON’T DO NOTHING! OVERDOSE. dull the sensation of pain. THESE MYTHS ARE MORE LIKELY TO CAUSE HARM. DON’T INJECT STIMULANTS (UPPERS) Important: Even if you have tried drugs, such as cocaine, crack the ‘don’ts’ above before and they cocaine, ecstasy and amphetamine (speed), cannot counteract or reverse the physical appeared to have worked at the time, effects of an opioid overdose on the part it is highly likely that either of the of the brain which regulates breathing. following scenarios occurred: There is an added danger that someone / The casualty did not consume the administering these stimulants could be amount of drugs which would lead implicated in any formal investigation into a death. to a fatal overdose, and/or / Once the drug began to wear off, the casualty recovered naturally. 16 www.naloxone.org.uk / www.sdf.org.uk 17 11/ WHAT IS NALOXONE

NALOXONE IS A VERY COMMONLY TO PUT IT ANOTHER WAY: FACTS USED ‘COMPETITIVE OPIOID Naloxone is a medicine that can / Naloxone CANNOT make someone ‘presentations’ (pharmacy speak for ANTAGONIST’. THIS MEANS THAT IT temporarily reverse the effect of an opioid intoxicated/stoned/high. packages, concentrations and doses). BINDS WITH THE OPIOID RECEPTORS overdose by removing the opioid from / Naloxone is not poisonous and causes In the UK Naloxone comes in ampoules, IN THE BRAIN/BODY WITHOUT the receptors, thereby assisting with the NO harm if swallowed. pre-filled syringes and ‘mini jets’. It is manufactured in two different ACTIVATING THEM. restoration of breathing. / Naloxone is a ‘Prescription Only concentrations, 0.4mg per ml, and Naloxone has been used for many years ’ and is currently only 1mg per ml. by doctors and nurses in hospitals for licensed in the UK for administration reversal of post-operative respiratory by subcutaneous, intramuscular or / In Scotland (and at the time of writing) depression, and reversal of respiratory intravenous . it has been decided to use a 1mg per ml concentration that comes in a 2 ml pre and ‘Central ’ depression / In Scotland Naloxone is also supplied to from opioid administration during labour filled syringe, meaning that people are people under a Patient Group Direction supplied with 2mg of the medication. and child birth. (PGD). The PGD for supply of Naloxone is Naloxone is also used by paramedics a document, agreed by senior clinicians, / Naloxone is very safe but does have in communities to reverse the effect nurses and pharmacists, so that they can some ‘contraindications’. of opioid overdose. LEGALLY supply the medicine to people who might be at risk of opioid related overdoses WITHOUT first looking at the person’s medical record or consulting a doctor, who would normally be responsible for writing a prescription. / Naloxone comes in various 18 www.naloxone.org.uk / www.sdf.org.uk 19 12/ I SAVED WHEN MY SON’S TO USE LIFE NALOXONE

NALOXONE SHOULD BE GIVEN TO ANY Even if there is no opioid drug using PERSON IF THEY ARE SUSPECTED OF paraphernalia (silver foil sheets/tubes; EXPERIENCING AN OVERDOSE WHERE syringes and needles; medication bottles/ OPIOIDS ARE INVOLVED. packets) but you suspect opioids may have been taken, you can still use naloxone. If the person who has overdosed is someone you were with when they used opioids, don’t Even if it does not help, it will do no harm. hesitate to administer naloxone - even if you have not been trained. If you didn’t see opioids used, you may need to ask any friends/witnesses some questions about the drugs used. If you do not know which drugs have been used, the decision to administer naloxone should be based on evidence of signs and symptoms of overdose (see section 5).

Please note: this section focuses on when naloxone should be used in a community setting, NOT when it should be used in a hospital/clinical setting wwwby doctors/nurses..nalo xone.org.uk 20 www.naloxone.org.uk / www.sdf.org.uk 21 13/ 14/ DANGER DANGER COMMON BLOOD- INFECTIONS IN BORNE VIRUSES DRUG USERS

TAKING ANY ILLEGAL DRUG POSES SIGNIFICANT UNKNOWN RISKS DUE TO THE HIV, Hepatitis B and Hepatitis C are blood (GPs, sexual health centres and some drugs borne viruses (BBVs). Sharing any type of drug services). A vaccine is available for Hepatitis TOTALLY UNCONTROLLED PRODUCTION AND PROCESSING OF THE MATERIALS. using paraphernalia (needles, syringes, filters, B, and anyone at risk (including people who NOT ONLY IS THERE A RISK OF ACCIDENTAL OVERDOSE BUT THERE IS ALSO THE spoons, water, crack pipes and even rolled use drugs) should consider getting themselves RISK OF PICKING UP INFECTIONS WHICH CAN LEAD TO THE AMPUTATION OF LIMBS bank notes / tubes for snorting drugs) can vaccinated. The vaccine is available from OR DEATH. result in BBVs being passed from one person GPs and sexual health centres. There is no to another via blood to blood contact. vaccine available for Hepatitis C, but effective treatments are available. The following pages describe the main The infections most commonly experienced by It is important that injecting drug users categories of infection and how they are injecting drug users can generally be grouped use sterile equipment for every injection to The most common BBV amongst drug users in contracted. If someone is concerned about into four categories: prevent transmission of BBVs. Sterile injecting Scotland is Hepatitis C. Hepatitis C can lead to equipment can be accessed free of charge serious liver damage and may eventually lead the risk of infection through drug use and / Viruses that spread through the needs more information they should speak through injection equipment providers (needle to death, particularly if left untreated. bloodstream, like hepatitis B, C and exchanges) in pharmacies in local communities to their health care provider (e.g. GP or other HIV (blood-borne viruses). professional). and some drug services. Liver disease can slow the body’s breakdown / Bacteria that can infect the skin and In the early stages of infection there may of drugs and alcohol. This can significantly possibly spread to the whole body. be few obvious signs and symptoms which increase the length of time someone is at risk / Sexually-transmitted infections. means people are often unaware that of overdose after using substances. / Infection of the respiratory system – they have acquired a BBV. It is therefore the lungs and air passages (organs) important that anyone who has been involved associated with breathing. in risky behaviours, such as sharing drug For more information on Hepatitis B using equipment, should consider getting and Hepatitis C please see: themselves tested. HIV, Hepatitis B and Hepatitis C are diagnosed using blood tests, www.hepatitisscotland.org.uk which are available at lots of different services 22 www.naloxone.org.uk / www.sdf.org.uk 23 15/ 16/ DANGER DANGER BACTERIAL ANTHRAX INFECTIONS INFECTION

Injecting drug users can be exposed to a Just because people have been injecting for a In 2009 and 2010 batches of heroin SYMPTOMS OF ANTHRAX INFECTION: wide range of bacteria in various ways that long time does not mean that they have a safer contaminated with Anthrax were being / Redness, swelling or pain at the injection can give rise to local or systemic (throughout and hygienic injecting technique. supplied in Scotland with a further case site, or in the part of the body that was or affecting the whole body) disease. Recent Some bacteria can cause infections that vary in in 2012. injected e.g. foot, calf, leg, buttock, hand, research showed that over 30% of injecting how severe they are, from minor skin and soft It is likely that the heroin was contaminated arm, shoulder. drug users have experienced infections tissue infections to life-threatening diseases on route from the souce countries resulting in abscesses or open wounds at / Redness, swelling or pain in any part of the like septicaemia (blood ), necrotising Afghanistan or Pakistan, with contamination body after injecting. or near the place on the body that they had fasciitis (commonly called ‘flesh-eating from an animal carcass or hide in Turkey / Flu-like symptoms, such as high injected. infection’ which can be caused by a range of thought to be the most likely source. Sharing contaminated needles and other different bacteria), gangrene or endocarditis temperature, sore head, aching muscles This outbreak has seen many people infected and/or joints. equipment, injecting without (infection of the heart valves). and resulted in the tragic loss or lives. first cleaning the injection site and injecting If you know someone who has any of these Infections caused by spore forming bacteria Public health experts have warned that the contaminated drugs are all situations that can such as bacteria from the Clostridium family symptoms after injecting or using drugs, it is transmit bacteria. risk that heroin and other drugs could be essential that they are checked at the nearest have caused deaths in heroin users. These contaminated again with anthrax (or other General poor health and hygiene can also bacteria have contaminated batches of heroin A&E immediately. Treatment with antibiotics harmful organisms) remains. Drug users need can be given, and may save a life. increase the risk of infection with the drug user’s causing occasional outbreaks of infection to be constantly aware of this infection risk and own naturally occurring skin bacteria. amongst heroin users in Scotland. Some of need to avoid high risk exposure to contracting Injecting into muscles (known as muscle these bacteria are: harmful organisms, especially through any popping) and using too much citric acid to / Clostridium novyi – which has been found in form of injection. For more information please dissolve heroin increases the chances of some injecting drug users who have died. see: www.hps.scot.nhs.uk/ bacterial infections developing in drug users. / Clostridium botulinum – which can cause anthrax/resources.aspx for more Injecting technique is important in reducing wound botulism. information. the risk of such infections. / Clostridium tetani – which causes Tetanus. 24 www.naloxone.org.uk / www.sdf.org.uk 25 17/ 18/ DANGER DANGER SEXUALLY RESPIRATORY TRANSMITTED INFECTION INFECTIONS (STIs)

Drugs can affect decision-making and Smokers aren’t the only people at risk for Drug users who choose as their judgement, so when under the influence drug-induced lung damage. People who are at greater risk of some substances (including alcohol), inject drugs can contract a life-threatening of a number of respiratory problems. people may engage in risky behaviour. lung condition called talcosis, in which This can include risky sexual behaviour Smoking increases the risk of chronic and talc accumulates in the lungs and causes serious lung infections regardless of the and may lead to having unprotected sex, complications like emphysema, pulmonary and possible infection. substance smoked. Hot smoke irritates fibrosis and cancer. airways and damages the protective cilia lining Some STIs can have long-term consequences Various pill form drugs, both illicit and the lungs, leading to decreased resistance to including damage to, or loss of, fertility. prescribed, contain talc or similar substances infections like pneumonia and bronchitis. as a binder and are sometimes melted down/ Respiratory conditions caused by drug use can partially dissolved and injected by drug be either short-term but possibly recurring, users, a dangerous practice that can result in as in bronchitis, or permanent, as with For more information please see: respiratory complications and death. emphysema. www.hps.scot.nhs.uk/bbvsti/ Talc or similar substances may also be used Anyone who experiences trouble breathing, sexuallytransmittedinfection.aspx to cut/bulk up drugs like cocaine and heroin chest pain or bloody sputum (coughed up because of its similar texture and appearance. spit), should seek emergency medical treatment immediately to avoid potentially life-threatening consequences. 26 www.naloxone.org.uk / www.sdf.org.uk 19/ DANGER ASSOCIATED RISKS

DRUG USERS FACE SIGNIFICANT RISKS NOT ONLY FROM THE DRUGS THEY TAKE BUT FROM THE HAZARDS ASSOCIATED WITH THEM.

THERE ARE RISKS: / From contamination with bacteria and chemicals. / From cutting agents used. / From variations in ‘purity’ and ‘potency’ creating accidental overdose. / From introducing contaminants/organisms into the body via injecting through the skin. The risks are many and varied – / From sharing injection paraphernalia if you know someone at risk get due to the potential for transmission of them to seek help. Recovery is blood-borne viruses. possible with the right assistance. / From inhaling drugs. FURTHER INFORMATION/ CONTACT

[email protected]

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FOR MORE INFORMATION ON NALOXONE VISIT/ WWW.NALOXONE.ORG.UK

© Scottish Drugs Forum 2013 All Rights reserved ISBN: 978-1-903483-11-4 Scottish Drugs Forum 91 Mitchell Street Glasgow G1 3LN

FEBRUARY 2013