Opioids - Harm Reduction Coalition

Overdose Prevention and
Response Train the Trainer
Eliza Wheeler
Drug Overdose Prevention &
Education (DOPE) Project
Harm Reduction Coalition
510.444.6969 x 16
wheeler@harmreduction.org
Training overview:
Review of major drugs involved with
overdoses
l  Risk factors
l  Prevention Messages
l  Recognizing an OD
l  Responding to an OD
l  Practice
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Drug Overdose Trends
Drug overdose death rates in the US have
more than tripled since 1990 and have
never been higher.
l  In 2008, more than 36,000 people died from
drug overdoses, and most of these deaths
were caused by prescription drugs.
l  Approximately 200 people die each year in
San Francisco from unintentional drug
overdoses.
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Opioids:
Heroin and
Rx painkillers
Opioids
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Opiates and opioids are
classes of depressant
analgesics derived from
or chemically similar to
substances found in P.
somniferum, the opium
poppy. They include
both naturally occurring
and synthetic
substances.
Effects of Opioids
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Pain relief, euphoria
Itchiness
Dryness of the mouth
Sedation
Respiratory
Depression
Nausea/Vomiting
Sweating
Constipation
Opioids: Heroin
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Schedule I
Chemical Name:
Diacetylmorphine
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History
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Heroin was isolated from
morphine in 1874
It was thought to be the
cure for morphine
addiction
In 1914 the Harrison
Narcotic Act banned the
importation of Heroin into
the United States
Opioids:
Black Tar Heroin
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Blackish brown sticky tar
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Can be injected, snorted, smoked
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Black Tar Heroin is notorious for carrying
harmful bacteria and virii. Staph infections and
necrotizing fasciitis, abscesses, collapsed veins,
sepsis/shock (from injecting plant material), scar
tissue, etc are all much more common with BTH
than powder.
Opioids: Heroin
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Comes in the corners of
sandwich baggies or fingers
of gloves, condoms, etc.
Wholesale (Kilo): $10,000
Ounce (24 grams): $300$700
Gram: $40
Approx. ½ gram (.4 gram):
$20
1&1 (coke and heroin): $20
(Prices are approximate,
and change often)
Strong opioids
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Fentanyl*; hydromorphone**
Actiq®, Fentora®, Onsolis®,Duragesic®; Dilaudid®,
Palladone®
Moderate strength opioids
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Hydrocodone; oxycodone; oxymorphone,
morphine; codeine; methadone*
Vicodin®, Lortab®, Lorcet®; OxyContin®, Percocet®,
Percodan®, Tylox®, Combunox®;Opana®; Embeda®,
Kadian®, Avinza®, MS Contin®; Norco®, Tylenol-3®,
Weak opioids
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Tramadol; pentazocine; propoxyphene;
buprenorphine; meperidine
Ultram®, Ultracet®; Talwin®; Darvocet®, Darvon®; Subutex®,
Suboxone®; Demerol®
* synthetic
** semi-synthetic
Opioids: Fentanyl
•  100 times more potent than
morphine
•  Introduced in the 1960s as an
IV anesthetic, Sublimaze.
Commonly used in surgeries.
•  Duragesic: Fentanyl skin patch
used to manage chronic pain.
•  Actiq: Lollipop for pain
•  Overall biologic effects
indistinguishable from heroin,
except that Fentanyl has
superior potency [from 80 to
100x
Opioids: Codeine
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Most widely used naturally occurring narcotic in medical
treatment worldwide
Prescribed for mild pain relief, cough suppression [eg.
Wisdom teeth, back pain, etc].
Codeine is base material for both dihydrocodeine and
hydrocodone (Vicodin)
Promethazine-codeine or hydrocodone cough syrup
(antihistamine+opioid) widely prescribed and used
recreationally
Purple drank, Purple Tonic, Sip-Sip, Lean, mixed with
Sprite
Opioids:
Hydrocodone
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Semi-synthetic opioid
Most prescribed drug in
the US. 131 million
prescriptions in 2010.
Opioids: Oxycodone
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Oxycodone Hydrochloride
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Oxycodone/Acetaminophen
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Percocet, Roxicet, Endocet,
Tylox
Oxycodone/Aspirin
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Oxycontin, Roxicodone,
Endocodone, Oxyfast
Percodan, Roxiprin
Oxycodone/Ibuprofen
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Combunox
Oxycontin (oxycodone)
The NEW OxyContin
Opioids: Morphine,
hyrdromorphone, oxymorphone
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Kadian (morphine)
Oramorph (morphine)
MSContin (morphine
sulfate)
Dilaudid
(hydromorphone)
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Opana (oxymorphone)
Numorphan
(oxymorphone)
Opioids:
Methadone
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Methadone (Symoron,
Dolophine, Methadose,
Heptadon, etc.) is a
synthetic opioid, used
medically to treat pain, or as
an opioid replacement
therapy.
Full agonist
It was developed in
Germany in 1937.
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Methadone is eliminated
from the body at a slower
rate than many other
opioids.
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Although chemically unlike
morphine or heroin,
methadone also acts on the
opioid receptors and thus
produces many of the same
effects
Methadone continued
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A proper dose used in methadone maintenance
therapy will block or greatly reduce cravings for illicit
opioids, while not inducing any euphoric feelings
or other sense of being high, and if dose is high
enough, will actively prevent the patient from
experiencing any high if they do use other opioids.
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In 2004, SAMHSA reported that the increase in
methadone-deaths did not appear to stem from the
liquid issued by methadone treatment center, but
instead from an increase in solid tablets or diskettes
used to treat pain
Rx Opioid costs
Depends, pills can sell from around $.10 per
milligram up to about $1 per milligram or
more (OCs).
l  For example, a 80mg OC is currently selling
for about $80-100, where you could get a
10/325 Norco (hydrocodone/aceteminophen)
for $4, $.40 per milligram.
l  Access, demand, knowledge of quality
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Depressants,
Sedatives and
Hypnotics
Non-opioid
Benzodiazipines
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Schedule 4
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The first benzodiazepine,
chlordiazepoxide (Librium),
was discovered accidentally
by Leo Sternbach in 1955,
and made available in 1960
by Hoffmann–La Roche,
which has also marketed
diazepam (Valium) since
1963.
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Benzos have sedative,
hypnotic (sleep-inducing),
anxiolytic (anti-anxiety),
anticonvulsant, muscle
relaxant properties.
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These properties make
benzodiazepines useful in
treating anxiety, insomnia,
agitation, seizures, muscle
spasms, alcohol withdrawal.
The Benzo Family
Most Commonly Used:
l  (Klonopin)
Clonazepam
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Alprazolam
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Diazepam
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Lorazepam
Less Commonly Used:
l  Oxazepam (Serax)
l  Prazpam (Centrax)
l  Halazepam (Paxipam)
l  Clorazepate (Azene, Tranxene)
l  Chlordiazepoxide (Librax, Librium)
l  Halcion (Triazolam)
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Sold for about $1-2 per milligram
Benzos
Risks
l  Cause heavy sedation,
memory loss
l  Overdose, especially when
mixed with opioids and/or
alcohol
l  Aggression, impulsivity,
irritability
Benefits:
l  Treat symptoms of anxiety,
panic disorder
l  Enhance the effects of
heroin, alcohol, and/or
l  Physical dependence,
marijuana
withdrawal that can be
l  Stimulant users often take
benzos when over-amping on dangerous
speed or coke, or after to
come down.
l  Ease withdrawal from opiates
l  Benzos are easy to obtain &
cheap
Muscle Relaxers & Sleep Aids
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Somas and Flexeril are the
most common and available
muscle relaxers
Ambien and Lunesta are
common sleep aids
All have sedative effects
that are manageable when
taken in correct dosage.
When mixed with other CNS
depressants or alcohol, can
be dangerous
About $1-5 per pill
Stimulants
Stimulants
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Class of drug that has
historically been used to
treat asthma and other
respiratory problems,
obesity, neurological
disorders, and a variety of
other ailments.
Prescribed for the treatment
narcolepsy, ADHD, and
depression that has not
responded to other
treatments.
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Stimulants increase alertness,
attention, and energy, as well
as elevate blood pressure,
increase heart rate and
respiration, constrict blood
vessels, increase blood
glucose, and open up the
pathways of the respiratory
system.
Benefits:
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Increased alertness and
energy
Cocaine
Risks:
Feelings of intense pleasure,
well-being and euphoria
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Heart arrhythmia
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Nasal, throat or lung damage
Feelings of competence and
superiority
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Depression and anxiety
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Self-confidence
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Sociability
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High blood pressure
Constriction of blood vessels
Elevated body temp
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Heightened sexual arousal
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Paranoid or violent behavior
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Hallucinations
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Loss of appetite
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Decreased sex drive
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Headaches
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Insomnia
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Heart Attack, Stroke, Seizure
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Powder Cocaine
Typical Cuts:
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Levamisole (veterinary antiparasitic)
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Corn starch
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Vitamin C powder
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Sugar
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Talcum powder
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Baby milk powder
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Local anesthetic (Rocaine)
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Other amphetamines
Appearance:
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White to off white in color
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Powder, Flake, or Rock (not
crack, but compressed powder)
Price/quantity
l  Bump (20-30 bumps to a
gram)
l  Lines, about a 1/10 of a
gram
l  Around $40-50 a gram
(compared to $60-80 in
NYC!)
l  Around $75-125 for a
Teener (1.75g or 1/16th of
an oz)
l  $120-180 for an 8-ball (1/8
of an ounce) compared to
about $150-250 in NYC.
Crack
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Crack is usually made by mixing
two parts of cocaine hydrochloride with one part baking soda
in about 20ml of water.
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Appearance
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White to tan in color
Rock-like substance
Waxy appearance
Cost
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Small rock $5-10
$10 to $20 per 1/4 gram
Medium size block ($50)
Sugar cookie ($900)
Crack
Amphetamines
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Schedule 2
Amphetamines Synthesized in 1887
in Germany as synthetic form of
ephedrine
Methamphetamine synthesized in
1893 in Japan
1930s - 1950s
l  Primary ingredient in the
Benzedrine inhaler
l  Treatment for narcolepsy
l  Used to keep soldiers alert
during combat
l  Widely used as diet pills
By 1970, 10 billion amphetamine pills
were produced in the US per year
in 1954 methylphenidate (Ritalin)
was synthesized
Ritalin (Methylphenidate) and
Adderall (Amphetamine)
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Ritalin and Adderall are
central nervous system
(CNS) stimulants.
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Researches speculate that
Ritalin and Adderall amplify
the release of dopamine
thereby improving attention
and focus in individuals who
have dopamine signals that
are weak such as people
with ADHD.
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Ritalin 10 mg
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Adderall 10 mg
Ritalin/Adderall
Benefits:
l  Wakefulness
l  Increased focus/attentiveness
l  Euphoria
l  Appetite suppression
Risks:
l  Increased blood pressure, heart
rate
l  Crashing: extreme fatigue,
insomnia, irritability, and
depression
l  Psychosis
l  Heart attack, seizure, stroke
Methamphetamine:
Crystal Meth, Speed, Tina, Crank
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Schedule 2
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Can be produced in small
meth labs, using a variety of
recipes, for example Red,
White and Blue: red
phosphorus,
pseudoephedrine or
ephedrine (white), and
iodine (which is technically
a purple color in elemental
form
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Can look like clear shards of
glass, or off whitish powder
Crystal Meth/Speed
Benefits:
l  Increased alertness and
energy
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Feelings of intense
pleasure, well-being and
euphoria
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Feelings of competence
and superiority
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Self-confidence
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Sociability
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Heightened sexual arousal
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Intense focus
Risks:
l  Insomnia, restlessness
l  Paranoid psychosis
l  Hallucinations
l  Violent & aggressive behavior
l  Weight loss, reduced appetite
l  Increased heart rate
l  Increased blood pressure
l  Fatal overdose is possible, but
not common
Crystal Meth/Speed
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Causes rapid heart rate,
although not usually
accompanied by arrhythmia
(irregular heartbeat).
Compared with cocaine use,
speed causes fewer heart,
pulmonary, and circulatory
problems.
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Drug-induced psychoses
in speed users are likely
to last longer than those
of cocaine users
Speed users are more
likely to appear in the
ER as a result of trauma
from fighting, firearm or
motor vehicle accidents
than for physical
complaints.
Miscellaneous Drugs
Phenergan (Promethazine)
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Promethazine is used to relieve
the symptoms of allergic reactions
Promethazine is used with other
medications to treat anaphylaxis
(sudden, severe allergic reactions)
and the symptoms of the common
cold
Promethazine is also used to relax
and sedate patients before and
after surgery, during labor, and at
other times.
Promethazine is also used to
prevent and control nausea and
vomiting that may occur after
surgery, and with other
medications to help relieve pain
after surgery.
Prescribed off-label for its
sedating properties.
Neurontin (Gabapentin)
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Gabapentin is used to help control certain
types of seizures in patients who have
epilepsy.
Gabapentin is also used to relieve the pain
of postherpetic neuralgia (the burning,
stabbing pain or aches that may last for
months or years after an attack of shingles).
Gabapentin is in a class of medications
called anticonvulsants.
Gabapentin treats seizures by decreasing
abnormal excitement in the brain.
Symptoms of overdose may include:
double vision
slurred speech
drowsiness
Diarrhea
Caution use of antacids, alcohol,
hydrocodones, morphine and naproxen
when taking Gabapentin because these
drugs may decrease the effectiveness of
Gabapentin, increasing the risk for a
seizure.
Seroquel (Quetiapine)
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Quetiapine is indicated for the
treatment of schizophrenia,
depressive episodes associated
with bipolar disorder, acute manic
episodes associated with bipolar I
disorder and maintenance
treatment of bipolar I disorder.
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The most common side effect of
quetiapine is drowsiness. Other
common side effects include:
sluggishness, fatigue, dry mouth,
sore throat, dizziness.
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Frequently prescribed off-label for
other purposes, including
insomnia and the treatment of
anxiety disorders.
Clonidine (Catapres)
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Has been prescribed historically
as an antihypertensive drug.
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It has found new uses, including
treatment of some types of
neuropathic pain, opioid
detoxification, anesthetic use, and
off-label, to counter the side
effects of stimulant medications
such as methylphenidate or
amphetamine.
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It is becoming a more accepted
treatment for insomnia, as well as
for relief of menopausal
symptoms.
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Clonidine has mild sedative
properties, but when mixed with
other CNS depressants, alcohol or
pain relievers can have dangerous
effects, including overdose.
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Caution use of MAOIs, beta
blockers, acetaminophen/opiate
combos, methadone, opiates.
Use of some meds with Clonidine
may make Clonidine ineffective
and increase risk for high blood
pressure, and possible breathing
problems.
Overdose Prevention, Recognition,
and Response Training
Components of a Training
1. 
2. 
3. 
4. 
5. 
6. 
7. 
What is an overdose?
What causes an overdose?
Prevention messages
Recognition
Response
Aftercare
Follow-up and refills
What puts people at risk for
ODs?
Mixing Drugs
l  Variation in strength and content of street
drugs (purity)
l  Tolerance changes
l  Using alone
l  Physical Health (liver functioning, weight loss,
asthma, immune system problems,
dehydration, malnutrition, etc.)
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Risk Factors & Prevention
Messages
Mixing:
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Use one drug at a time
Reduce amounts of
everything
Don t mix alcohol with
heroin/pills
If drinking or taking pills
with heroin, do heroin first
Have a friend with use
who knows what you took
Risk Factors & Prevention
Messages
Tolerance:
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Use less when sick, or
after jail or detox
Be aware of your body,
physical health impacts
tolerance
If using after period of not
using, go slow
Do a tester shot, or go
slow
Use different method, i.e.
snort instead of inject
Risk Factors & Prevention
Messages
Quality/Purity:
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Using Alone:
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Do a tester shot
Try to use the same
dealer
Talk to others who
copped from same
source—share info!
Fix with a friend
Leave door unlocked
Call someone trusted
Risk Factors and Prevention
Messages
Physical Health
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Drink lots of water or other
fluids, try to eat
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Avoid pills, especially with
Tylenol in them if you have
liver damage
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Carry your inhaler if you
have asthma, tell your
friends where it is, and that
you have trouble breathing
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Go slow if you ve been sick,
lost weight, or have been
feeling under the weather or
weak—this can effect your
tolerance.
What is a stimulant overdose?
Some users call it overamping when the
effects of a stimulant like cocaine (powder),
crack or speed become distressing or
dangerous.
l  Can be a problem with the body, or it can be
psychological, or both.
l  Sometimes overamping is considered part of
the high for some users, not always negative.
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Can it be fatal or harmful?
Yes. It is more likely that cocaine will cause a
fatal overdose than speed though, because
cocaine use greatly increases the risk of
having a heart attack.
l  Other serious medical complications from
stimulant use include seizure, stroke, and
overheating (hyperthermia).
l  Drug-induced psychosis can result in people
putting themselves in dangerous situations,
or feeling suicidal.
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Symptoms of a Stimulant OD
Physical:
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Nausea and/or Vomiting
Falling asleep/passing out (but still
breathing)
Chest pain or a tightening in the chest
High Temperature/sweating profusely,
often with chills
Fast Heart Rate, Racing pulse
Irregular Breathing or shortness of breath
Convulsions, or tremors
Limb jerking or rigidity
Feeling paralyzed but you are awake
Severe headache
Hypertension (elevated blood pressure)
Teeth grinding
Insomnia or decreased need for sleep
THESE SYMPTOMS COULD LEAD TO
HEART ATTACK, SEIZURE, STROKE, or
OVERHEATING
Psychological:
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Extreme Anxiety
Panic
Extreme Paranoia, Delusions,
Hallucinations, Obsessions (Speed
Psychosis)
Extreme Agitation
Increased Aggressiveness
Agitation, restlessness, irritability
Hypervigilance (being super aware of
your environment, sounds, people, etc.)
Enhanced sensory awareness
Suspiciousness
Suicidal ideation
Prevention Strategies
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A healthy body is the best
prevention for overdose.
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Make sure you get your heart
checked out, your blood
pressure, cholesterol,
circulation, etc.
l 
Having high blood pressure or
an irregular heart beat or other
types of heart disease can put
you at really high risk for a
heart attack, especially when
you when you smoke, shoot or
snort coke because it puts a lot
of stress on your heart
If you re on medication for high
blood pressure, make sure you
take it, if you re diabetic, make
sure you try to manage your
diabetes, try to eat, sleep and
drink fluids even on a run.
How to respond to a Stimulant OD?
First, figure out what is needed, medical
assistance, or support and rest?
l  There is no antidote to a stimulant OD, like
Naloxone.
l  A stimulant OD can result in serious medical
emergencies like seizure, stroke, overheating
or heart attack.
l  If the problem is primarily with the body,
these are some important things you can do.
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Strokes
The symptoms of stroke are
distinct because they happen
quickly:
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Sudden numbness or weakness of
the face, arm, or leg (especially on
one side of the body)
Sudden confusion, trouble
speaking or understanding speech
Sudden trouble seeing in one or
both eyes
Sudden trouble walking, dizziness,
loss of balance or coordination
Sudden severe headache with no
known cause
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Strokes are caused by a blood
clot that blocks or plugs a
blood vessel or artery in the
brain or a blood vessel in the
brain that breaks and bleeds
into the brain.
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If you believe someone is
having a stroke – if he or she
suddenly loses the ability to
speak, or move an arm or leg
on one side, or experiences
facial paralysis on one side –
call 911 immediately.
Seizures:
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The brain is full of electrical
activity. It is how the brain talks
to the rest of the body.
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If there is abnormal or excess
electrical activity in a part of the
brain it can cause a misfire and
result in a seizure or convulsion.
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Seizures fall into two general
groups: general and partial. A
partial seizure affects small parts
of the brain. A general seizure
affects the whole brain and can
cause loss of consciousness and/
or convulsions. This is the type
that most people think of when the
word seizure is mentioned.
Some typical symptoms of a general
seizure are:
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Drooling or frothing at the mouth
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Grunting and snorting
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Tingling or twitching in one part of the
body
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Loss of bladder or bowel control
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Sudden falling
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Loss of consciousness
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Temporary absence of breathing
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Entire body stiffening
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Uncontrollable muscle spasms with
twitching and jerking limbs
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Head or eye deviation (fixed in one
direction)
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Aura before the seizure which may be
described as sudden fear or anxiety, a
feeling of nausea, change in vision,
dizziness, or an obnoxious smell (not
as common with drug-related
seizures).
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Skin color may be very red or bluish.
Seizure continued…
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If someone is having
a seizure, make sure
there is nothing within
reach that could harm
them (objects that
could fall, furniture
they could bump
themselves on, etc).
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Do not hold the
person down
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Do not put anything in
the person's mouth.
Heart Attacks:
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Even though a heart attack
may be related to drugs, it
will still look similar to the
heart attacks that might not
be drug-related.
Keep an eye out for the same
symptoms, although
sometimes it may be tricky to
figure out what is from the
drug (sweating, for example)
and what may be the signs of
a heart attack.
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Things to look out for:
l  Uncomfortable pressure,
fullness, squeezing, or pain
in the center of the chest.
These symptoms can range
from mild to severe, and
they may come and go.
l  Discomfort in other areas,
such as the neck, arms, jaw,
back, or stomach.
l  Shortness of breath,
lightheadedness, nausea, or
breaking out in a cold sweat
Overheating (hyperthermia):
What does it look like?
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Hot, dry skin is a typical sign of
hyperthermia.
The skin may become red and hot
as blood vessels dilate in an
attempt to get rid of excess heat,
sometimes leading to swollen lips.
The dehydration associated with
overheating can produce nausea,
vomiting, headaches, and low
blood pressure.
Dehydration can lead to fainting or
dizziness, especially if the person
stands suddenly.
The person may become
confused or hostile, and may
seem intoxicated.
Overheating can be fatal
What can be done?
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Slow down and stop agitated
movements
Try to cool down with ice packs,
mist and fan techniques.
Make sure they are drinking water
or a sports drink with electrolytes
so they don t dehydrate.
Place cool, wet cloths under the
armpits on back of knees, and/or
on the forehead.
Open a window for fresh air.
When the body temperature
reaches about 104 F, or if the
person is unconscious or showing
signs of confusion, hyperthermia is
considered a medical emergency
CALL 911
Psychological Symptoms:
If you are confident that the problem is not
medical in nature (seizure, stroke, heart
attack, overheating), but you or your
friend is experiencing anxiety or other
psychological symptoms of overamping
there are things you can do as well
Some tips from fellow users:
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Drink water or a sports drink, eat some food
Try to sleep
Switch how you re doing your speed or coke, sometimes if
you re shooting, switching to smoking can help
Change your environment or the people you re with
Take a benzo (a small, safe dose, like an Ativan or other
sedative/hypnotic)
Breathing or meditation exercises
Physical contact, like massaging yourself or having someone
else do it for you
Walking, walking, walking—walk it off!
Take a warm shower
Get some fresh air
Speed Psychosis
Speed Psychosis can consist of a variety of
psychological symptoms, including paranoia,
delusions, hallucinations and obsessions.
l  Sometimes speed psychosis can lead to
someone becoming a danger to themselves
or others.
l  In some cases, people have checked
themselves into Psych ER for help, and in
cases they have been sent involuntarily
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Recognizing a Depressant OD
REALLY HIGH
OVERDOSE
Muscles become relaxed
Deep snoring or gurgling (death rattle)
or wheezing
Speech is slowed/slurred
Blue skin tinge- usually lips and
fingertips show first
Sleepy looking
Pale, clammy skin
Will respond to stimulation like yelling,
sternum rub, pinching, etc.
Heavy nod, will not respond to
stimulation
Nodding out
Breathing is very slow, irregular, or has
stopped/faint pulse
If an OD happens…
Calling 911
Clearly give address or nearest intersection
l  Keep loud noise in background to a minimum
—if it sounds chaotic, they will dispatch police
to secure the scene and protect the
paramedics
l  Avoid using words like drugs or overdose—
stick to what you see:
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Not breathing, turning blue, unconscious, nonresponsive, etc.
Recovery Position
Narcan reversing an OD
Heroin
Narcan
Opioid
receptor
Narcan has a stronger
a ff i n i t y t o t h e o p i o i d
receptors than the heroin,
so it knocks the heroin off
the receptors for a short
time and lets the person
breathe again.
Using IM Narcan:
Administer one dose (1cc) intramuscularly
into the upper arm, thigh or butt
l  Return to Rescue Breathing
l  Narcan should work in about 1-3 minutes, if it
doesn t work in 3 minutes or so give 2nd dose
l  Narcan wears off in 20 minutes-1 hour
l  OD could come back, stay with the person or
transfer care to EMS.
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Thank You
Eliza Wheeler
DOPE Project
Harm Reduction Coalition
510.444.6969 x 16
wheeler@harmreduction.org