Opioid Overdose: Signs and Emergency Response

What to do right now

1. Try to wake them. Shout their name and rub your knuckles firmly on the breastbone.
2. Call 911 or your local emergency number. Many US states have Good Samaritan laws that protect people who call for help during an overdose.
3. Give naloxone. - Nasal spray: tilt the head back, insert the nozzle into one nostril and press the plunger fully. - Injection: inject into the outer thigh or upper arm, through clothing if needed.
4. Support breathing. If they are not breathing or only gasping, give rescue breaths (1 breath every 5 to 6 seconds) or start CPR if you are trained. If there is no pulse or you are unsure, do CPR.
5. Repeat naloxone after 2 to 3 minutes if there is no response. Fentanyl overdoses may need more than one dose.
6. Recovery position: once breathing, roll them onto their side to prevent choking on vomit.
7. Stay with them until emergency help arrives. Naloxone lasts 30 to 90 minutes, and the overdose can return.

Naloxone is safe. It has no effect on someone who has not taken opioids, so give it if you are unsure.

Signs of an opioid overdose

• unresponsive or very hard to wake
• slow, shallow or stopped breathing
• choking, gurgling or loud snoring sounds
• pinpoint (very small) pupils
• pale, clammy skin
• blue or gray lips and fingertips (on darker skin, look inside the lips and nail beds)
• limp body
• slow or absent pulse

How opioids cause overdose

Opioids act on receptors in the brainstem that control breathing. High doses reduce the brain's response to rising carbon dioxide, so breathing slows and stops. Low oxygen damages the brain within minutes and leads to cardiac arrest and death. See opioid-induced respiratory depression.

Risk factors

• fentanyl and its analogues in counterfeit pills, heroin, cocaine and methamphetamine, often without the user knowing
• reduced tolerance after detox, prison release, hospital stay or a period of not using
• mixing opioids with alcohol, benzodiazepines, gabapentinoids or sleep medicines
• xylazine ("tranq") contamination, which causes sedation not reversed by naloxone and serious wounds
• using alone
• high-dose prescribed opioids or changing formulations
• long-acting opioids such as methadone
• medical conditions: lung disease, sleep apnea, kidney or liver problems
• opioid use disorder

Treatment in hospital

• oxygen and breathing support, sometimes a ventilator
• repeated naloxone doses or a naloxone infusion for long-acting opioids
• monitoring for several hours, longer for methadone or extended-release opioids
• treatment of complications: aspiration pneumonia, muscle breakdown, kidney injury, low oxygen brain injury
• testing for other substances
• offering treatment for opioid use disorder, including starting buprenorphine in the emergency department

Complications

• hypoxic brain injury
• aspiration pneumonia
• cardiac arrest
• rhabdomyolysis and kidney injury
• withdrawal symptoms after naloxone: agitation, vomiting, sweating, aches

Preventing overdose

• carry naloxone and tell friends and family where it is
• never use alone. If you do, use a never-use-alone hotline where available
• start low and go slow, especially after a break
• use fentanyl test strips where legal
• avoid mixing with alcohol or sedatives
• store prescription opioids securely and dispose of unused medicine
• treatment for opioid use disorder: buprenorphine, methadone and extended-release naltrexone reduce overdose deaths substantially

Frequently asked questions

What are the signs of an opioid overdose?

Signs include being unresponsive, slow or stopped breathing, gurgling or snoring sounds, pinpoint pupils, blue or gray lips and fingertips, pale clammy skin and a limp body. Call 911 and give naloxone right away.

How does naloxone work?

Naloxone knocks opioids off their receptors in the brain, reversing the slowed breathing of an overdose, usually within 2 to 3 minutes. It is safe and does nothing if no opioids are present. More than one dose may be needed.

Can you get naloxone without a prescription?

Yes. In the US, naloxone nasal spray is approved for over-the-counter sale and is available at pharmacies, and often free from health departments and community programs.

Why does someone still need to go to the hospital after naloxone?

Naloxone wears off in 30 to 90 minutes, while many opioids, especially long-acting ones and fentanyl analogues, last longer. Breathing can slow again. Emergency care monitors for this and treats other complications.

What should I do if a child swallows an opioid?

Call 911 or Poison Control at 1-800-222-1222 immediately, even if the child seems fine. Children can become seriously ill from a single pill or patch. If they are hard to wake or breathing slowly, give naloxone and start rescue breathing.