As Steve Rummler Hope Network’s (SRHN) overdose prevention manager, a big part of Almarely Guerrero Sanchez’s job is to train people how to use naloxone to reverse an opioid overdose. Until a few weeks ago, Sanchez regularly traveled around the state, delivering free overdose-prevention rescue kits assembled by volunteers for the opioid-addiction awareness and activist organization and showing individuals and groups how to administer the lifesaving drug.

It was a hands-on job: Sanchez, who earned a degree in public health, would demonstrate how to determine if a person is overdosing, how to understand the content of the kits, and how to administer naloxone. To give her trainees an opportunity to practice, she’d even bring along a specially designed injection pad that mimics the feel of administering an intramuscular injection.

“My background is health education,” Sanchez explained, “so I like to do very interactive, hands-on training. That’s my preferred method of working.”

In mid-March, as the number COVID-19 cases in the state began to climb, SRHN leadership announced that staff would work from home and naloxone trainings would be shifted from in-person to virtual, using platforms like Zoom and FaceTime, audio calls or step-by-step video trainings available on their website.

Sanchez moved her supplies out of SRHN’s Minnetonka offices and into her home. Her last in-person training was March 13.

With her job now virtual, Sanchez reached out to everyone who had a scheduled naloxone training on the books. “I gave them the option to reschedule the training entirely for a later date or training virtually,” she said. “Then I followed up with them.”

So far Sanchez said she had a positive response from everyone she’s contacted.

“People are OK with the virtual training options. They want to stay safe. They are taking precautions, not just for us as trainers but for themselves as trainees. And everyone has been very great with rescheduling, if that’s the path they want to take.”

Alicia Haugh, SRHN communications and community relations coordinator, explained that when they made the decision to go remote, the organization’s leadership quickly approved the use of multiple platforms to make virtual training as easy and accessible as possible.

“We’re offering different options, depending on what the individual has access to or is comfortable with,” she said. “We can use video chats via Google Hangouts or Skype or FaceTime. We can also conduct trainings over the phone, if those other options are not available to people.”

The key is to make sure that as many people as possible still have access to naloxone education, Haugh said. Because in-person trainings, often conducted in large groups, have been a hallmark of the way the organization does business, this shift has required patience, flexibility and cooperation from everyone — staff, volunteers and trainees.

“Having to take a step back and do remote individual trainings is going to be hard for us because we are limiting our outreach,” she said, “but even in this new environment, we are trying to keep things as hands-on as possible. That’s always been a big priority for us.”

Anne Pylkas, M.D., SRHN’s medical director for overdose protection, said that hands-on connection is what has made the organization impactful.

“Being in touch with people personally, I think that was a giant part of our programming,” she said. “It’s having that personal connection, learning how to save a life and knowing that you can always call someone and ask the questions.”

Pylkas, medical director of Sage Prairie Clinic, an independent treatment and recovery program for people with substance use disorder (SUD) based in Burnsville, Eagan and Maple Grove, said that she has some concerns that virtual naloxone trainings may less impactful. For many trainees, building comfort around giving injections may be the biggest stumbling block.

“I give naloxone prescriptions all the time in my clinic, but the people I see there have used lots of drugs,” Pylkas said. “They know how to use needles.” Because injecting a drug can be a hurdle for some people, she wonders if a video conference or, worse yet, a phone call, will suffice. “Giving the training in person will always be best,” Pylkas said.

Haugh said she understands Pylkas’ concern, adding: “We want to make sure that people are as comfortable as they can be as far as giving injections with our IM naloxone kits. That’s something people usually feel more comfortable doing after having an in-person training experience. But we’re making the best of the situation, and I’m confident that our overdose prevention manager will do an excellent job.”

While making the transition to virtual trainings felt tricky at first, Sanchez said that it didn’t take long for her to figure out how to make the most out of the technology.

“I’ve done lots of video conferencing before,” she said, “so it hasn’t been a big change for me, but I do miss the face-to-face contact.”

Sanchez said that for the time being, she’s focused on making the most of technology and what it offers for virtual connection.

“With the video-chat calls,” she said, “I can show people the presentation and still have a visual of that person or group.” Platforms like Zoom, Skype, Google Hangouts or FaceTime make it possible for her trainings to replicate her in-person presentations, and that feels important.

“I can still do hands-on things, like show people how to use the needle and the vial. I can still be visual. I can still make sure that all questions are being answered. I can demonstrate how things work, and I can make sure that people are getting the training that’s needed to save somebody’s life.”

Fighting another epidemic

While COVID-19 dominates the headlines, SRHN staff try to remain focused on the epidemic of opioid addiction and overdose deaths, since opioid use continues at alarming rates.

Haugh said that she is concerned that the stress of social distancing might actually increase rates of addiction.

“I feel like this whole situation in general is going to have a lot of unpredictable effects on patterns of substance use. The likelihood of stress and isolation has increased, and that can often mean that rates of substance use will rise.” Combine that reality with addiction treatment resources being hamstrung by stay-at home restrictions, and it only emphasizes the importance of organizations like SRHN figuring out ways to forge ahead with programming and services.

The majority of opioid-related deaths are overdoses. An injection of naloxone can reverse the effects of opioids, quickly restoring normal breathing in a person whose breathing has slowed or stopped as a result of an overdose. From its inception, SRHN has focused on naloxone distribution and education, in the hopes that if more people have access to the medication, more will be saved from accidental overdose. The organization offers free overdose-prevention rescue kits to any individual or group that requests them.

“Part of what is endearing about Steve Rummler is we’re ready to go get out into the community and do what we can do to get naloxone in the hands of people who need it,” Pylkas said.

A dedicated crew of volunteers, many of whom have lost loved ones to opioid overdose, assemble SRHN’s naloxone kits. The assembly normally happens in large groups, but when SRHN moved to remote operations, supplies were distributed so the kits could be assembled in individual volunteers’ homes.

Because getting rescue kits into the hands of people who need them remains so central to their mission, Sanchez explained that SRHN keeps turning them out at the same pace as before.

“We are still building those kits,” she said. “I have been diligently keeping an inventory of our supplies without having an overstock. We try to keep what we need at the moment and have those kits sent out as soon as they are requested. We are continuing with our delivery.”

In the past, Sanchez hand-delivered many of the requested kits. That’s still happening in many cases, Haugh said, though the hand-off is indirect now, with kit drop-off arranged while observing social distancing.

“If we have somebody that is close in the metro area, each of the staff has a stock of kits that we’re keeping,” Haugh said. “We can go drop those off or we can mail them if they are further out. We’re making that determination case-by-case.”

Haugh said that one thing she’s confident in is that SRHN will keep churning out rescue kits.

“Where we have not been concerned is in our ability to keep up,” Haugh said. “We to still have a very dedicated staff. We have a very dedicated volunteer base. We’re all coming together and we are going to keep up with every request we get.”

New guidelines

Coronavirus has prompted another significant change in the way SRHN conducts naloxone trainings. In the past, the organization had recommended injection of naloxone be followed by a series of “rescue breaths” similar to those used in CPR.

“We used to say, ‘Give naloxone. If there is no response, give rescue breaths,’” Pylkas said. “If the rescue breaths don’t work, we’d say, ‘Give another dose of naloxone.’”

In the first part of March, SRHN was still saying that people should use rescue breathing when saving someone from an overdose with naloxone, Sanchez said. “We were saying that people continue providing rescue breaths, but if you are in a high-risk population you are supposed to make sure to take precautions.” Then fears around the virus ramped up, and the guidelines changed. “With everything going on now,” Sanchez explained, “we have transitioned to stopping the rescue breathing.”

The change was a tough one, Pylkas said. The organization’s rescue kits all include a face shield, or guard, that can be used during rescue breathing. That guard may reduce the likelihood of transmission, but fear was running high, and the organization decided it had to act.

“Not so long ago, I got asked if we can still recommend mouth-to-mouth rescue breathing,” Pylkas said. “I said at the time, ‘If you are a high-risk person, don’t do that. You shouldn’t be out anyway. But if you are low risk and the person in front of you is in need of rescue breathing, go ahead and do it, but use the guard, because the person in front of you is going to die, whereas the risk of them giving you COVID and you dying of it is much lower than them dying in front of you from an overdose.’ We’re not recommending that now.”

Pylkas said she believes that even without the rescue breathing, naloxone will save many people from a fatal overdose. And there will be a much lower risk of virus transmission.

“A person can survive with just the naloxone,” she said. “Not everybody needs the rescue breathing. Not everybody gives it. I think in a crisis they forget that’s what they’re supposed to do.” Plus, she added, many organizations don’t tell their trainees to use rescue breathing with naloxone injections. “It’s something we do,” Pylkas said, “but I don’t think it’s something that is taught widely.”

Sanchez explained that naloxone works to “jumpstart” an overdosing person. “Rescue breathing helps the process further,” she said, and rescuers who are trained in CPR could instead add chest compressions. Each kit contains three doses of naloxone. If they can’t find a pulse, the rescuer should call 911 and administer a second, and even a third, dose.

Haugh said that the extra doses are included in the kits for a reason: “When you use the additional doses, there is a higher chance that they will be able to be revived.”

How SRHN works virtually

 A statewide stay-at-home order hasn’t significantly changed the pace of Sanchez’s work. While her in-person trainings have all be canceled or rescheduled, she’s been busy communicating with clients, conducting remote trainings and distributing rescue kits.

“I’m still busy getting the word out about these changes,” she said. “I just keep getting lots of emails every day.”

Many of the emails are from individuals and organizations requesting more kits. Sanchez tries to use each interaction as an opportunity for building connections and expanding the organization’s reach.

“I try to introduce that educational component to every call or email, even though they are just reaching out for kits,” she said. “That’s when I would try to schedule some type of training or arrange to follow up later, after the pandemic.”

In an effort to expand its virtual reach, SRHN has developed a 20-minute video that demonstrates how to use the kits and inject naloxone. It has also created a training module for its website.

“We go over an accelerated version of our actual training,” Haugh said. “We cover not only the steps of the training but also signs of an overdose. We are also adding another piece now with regard to safety practices with COVID-19. We’ve been working hard over the last few weeks on getting that set up.”

Sanchez said that, just like her colleagues, she’s committed to continuing SRHN’s work — especially in these trying times.

“I want to prevent disease and provide resources to the community,” she said. While she wasn’t involved in chronic pain or addiction work before starting her job at SRHN a year ago, she now understands that her work can save lives. That gives her hope, even in trying times: “I’m really pro-helping people. I do my best and hope it has a positive impact. Every little bit counts.”