Opioid-Induced Respiratory Depression

Overview

Opioid-induced respiratory depression is a dangerous slowing of breathing caused by opioid drugs. Opioids include prescription pain medicines such as morphine, oxycodone, and fentanyl, as well as illicit drugs such as heroin. They relieve pain by acting on the brain, but at higher doses they also reduce the brain's drive to breathe. Breathing can become slow and shallow, or stop altogether, which lowers oxygen to the brain and body and can be fatal.

This is the central danger of an opioid overdose. It can happen with illicit use, but also with prescribed opioids, especially at high doses, when combined with alcohol or sedatives, or in people new to opioids. The good news is that the effect can be rapidly reversed with a medicine called naloxone, and recognizing the warning signs early can save a life. If you suspect an opioid overdose, call emergency services right away.

Warning Signs

The key danger sign is breathing that is too slow, too shallow, or absent. Other warning signs include:

• Very slow, shallow, or stopped breathing
• Extreme drowsiness or being unable to wake the person
• Pinpoint (very small) pupils
• Limp body and loss of consciousness
• Bluish or grayish lips, fingertips, or skin
• Gurgling, snoring, or choking sounds

These are signs of a medical emergency. If a person cannot be woken, is breathing slowly or not at all, or has bluish lips, call emergency services immediately and give naloxone if available.

Causes

Respiratory depression happens when the amount of opioid in the body overwhelms the brain's control of breathing.

• High or repeated opioid doses: Taking too much, or doses too close together.
• Combining substances: Mixing opioids with alcohol, benzodiazepines, or other sedatives greatly increases the risk.
• Potent opioids: Very strong opioids such as fentanyl can cause overdose in tiny amounts, sometimes when mixed into other drugs unknowingly.
• Reduced tolerance: People who have not used opioids recently, including after a period of abstinence, are far more sensitive.

Health problems affecting the lungs, liver, or kidneys can also raise the risk.

Risk Factors

• Use of high-dose opioids or potent opioids such as fentanyl
• Combining opioids with alcohol, benzodiazepines, or other sedatives
• Returning to opioid use after a break, when tolerance has dropped
• Using opioids alone, with no one nearby to help
• Older age and serious lung, liver, or kidney disease
• A history of overdose or opioid use disorder

Recognition and Evaluation

In an emergency, the condition is recognized clinically rather than waiting for tests, because rapid action is essential.

• Clinical signs: Slow or stopped breathing, unresponsiveness, pinpoint pupils, and bluish skin in someone who may have used opioids.
• Response to naloxone: Improvement after naloxone strongly supports an opioid cause.
• In hospital: Oxygen levels, blood tests, and monitoring help guide ongoing care after the immediate crisis.

Emergency Treatment

Opioid-induced respiratory depression is a medical emergency. Call emergency services immediately. While waiting for help:

• Give naloxone: Naloxone is a medicine that rapidly reverses opioid effects on breathing. It comes as a nasal spray or injection and can be given by bystanders. Repeat doses may be needed.
• Support breathing: Try to wake the person, keep the airway open, and provide rescue breaths if trained.
• Stay with the person: Place them on their side if breathing, and stay until help arrives, since the opioid can outlast naloxone and breathing may worsen again.

In hospital, treatment includes oxygen, monitoring, repeated naloxone if needed, and care for any complications. Everyone treated for an opioid overdose should be evaluated, as effects can return after naloxone wears off.

Prevention

• Take prescription opioids only as directed and never share them
• Avoid mixing opioids with alcohol, benzodiazepines, or other sedatives
• Keep naloxone on hand if you or someone you know uses opioids, and learn how to use it
• Do not use opioids alone, so someone can help in an emergency
• Be aware that tolerance drops after any break from opioids
• Store opioids safely away from children and others

When to Seek Emergency Care

Call emergency services immediately if a person has slow, shallow, or absent breathing, cannot be woken, has bluish lips or skin, or has pinpoint pupils after opioid use. Give naloxone if it is available and provide rescue breaths if trained, then stay with the person until help arrives. Always seek medical evaluation after any suspected overdose, even if the person seems to recover, because dangerous breathing depression can return as naloxone wears off.

Related Topics

Frequently Asked Questions

References

1. Substance Abuse and Mental Health Services Administration (SAMHSA). Opioid Overdose Prevention.
2. Centers for Disease Control and Prevention (CDC). Preventing Opioid Overdose.
3. MedlinePlus, U.S. National Library of Medicine. Opioid overdose and naloxone.