Poisoning Due to Analgesics (Painkiller Overdose)

What to do right now

1. Call for help. In the US, call Poison Control at 1-800-222-1222 (open 24 hours) or call 911. Elsewhere, call your local emergency number or poison center.
2. If the person is unresponsive or breathing poorly, call 911, give naloxone if an opioid might be involved, and start CPR if they are not breathing normally.
3. Do not make them vomit and do not give salt water or other home remedies.
4. Bring the containers or packets, and note how much was taken and when. Timing matters a lot for treatment decisions.
5. Do not wait for symptoms. Acetaminophen poisoning often causes no symptoms for the first day, when treatment works best.

If the overdose was intentional, stay with the person, remove other medicines, and call 911 or call or text 988 in the US for the Suicide and Crisis Lifeline.

Acetaminophen (paracetamol) poisoning

Acetaminophen is in hundreds of products, including cold and flu remedies, sleep aids and prescription combinations such as hydrocodone with acetaminophen. Taking two products that both contain it is a common cause of accidental overdose.

How it damages the liver

Normally the liver safely processes acetaminophen. In overdose, the safe pathways are overwhelmed and a toxic by-product called NAPQI builds up. The liver's protective stores of glutathione run out, and liver cells die. Fasting, malnutrition, regular heavy alcohol use and some medicines lower glutathione stores and raise the risk.

Stages of symptoms

Treatment

• Blood level: a level taken 4 or more hours after a single overdose is plotted on a nomogram to decide treatment.
• Acetylcysteine (NAC): the antidote. It replenishes glutathione and is close to 100% protective when started within 8 hours. It still helps when started later.
• Activated charcoal may be given within about 1 to 2 hours of ingestion.
• Liver transplant for those with liver failure who meet specific criteria.

Aspirin and salicylate poisoning

Salicylates are in aspirin, some stomach remedies (bismuth subsalicylate), and oil of wintergreen (methyl salicylate), which is extremely toxic in small amounts.

Symptoms

• ringing in the ears (tinnitus) or reduced hearing, often the first sign
• nausea, vomiting and stomach pain
• fast, deep breathing
• fever and sweating
• confusion, agitation, seizures and coma in severe cases

Salicylates first make you breathe fast, then cause a build-up of acid in the blood (metabolic acidosis). Fluid can also leak into the lungs. Chronic poisoning in older adults taking regular aspirin can look like confusion or sepsis and is easily missed.

Treatment

Activated charcoal, intravenous fluids, sodium bicarbonate to make the urine alkaline so the kidneys excrete more salicylate, glucose, and hemodialysis for severe cases.

NSAID poisoning (ibuprofen, naproxen)

Most ibuprofen overdoses cause only mild symptoms: nausea, vomiting, stomach pain and drowsiness. Very large overdoses can cause seizures, acidosis, acute kidney injury and low blood pressure. Long-term overuse causes stomach ulcers and bleeding and kidney damage, particularly in older adults and those taking diuretics or blood pressure medicines. Treatment is supportive: fluids, stomach protection and monitoring of kidney function.

Opioid poisoning

Opioids include morphine, oxycodone, hydrocodone, codeine, tramadol, methadone and fentanyl. Overdose slows and stops breathing.

Signs

• pinpoint pupils
• extreme sleepiness or unresponsiveness
• slow, shallow or stopped breathing, with gurgling or snoring sounds
• blue or gray lips and fingertips

Treatment

Naloxone reverses opioid effects within minutes. It is available without a prescription in the US as a nasal spray. It may wear off before a long-acting opioid does, so the person must still go to hospital. Tramadol and codeine overdoses can also cause seizures, and combinations with acetaminophen add a liver risk. See opioid overdose.

Who is at risk

• people taking several products that contain the same drug
• people with chronic pain who exceed the label dose because pain is not controlled
• children who find medicines, patches or liquids
• older adults with poor memory or vision, or with kidney or liver disease
• people who drink heavily or are fasting
• people in crisis who take an intentional overdose

Prevention

• Read labels and check every product's active ingredients. Do not combine two products containing acetaminophen.
• Do not exceed the label maximum. Ask your doctor about a lower limit if you drink alcohol regularly or have liver disease.
• Use the measuring device that comes with children's liquid medicines, and dose by weight.
• Store medicines locked, up high and out of sight. Dispose of used fentanyl patches by folding them sticky sides together.
• Keep naloxone at home if anyone takes opioids.
• If pain needs painkillers for more than 10 days, see a doctor rather than increasing doses.

Frequently asked questions

What are the first symptoms of acetaminophen overdose?

Often there are none. In the first 24 hours a person may feel completely well or have only mild nausea, vomiting or sweating. Liver damage develops silently over 1 to 3 days. That is why anyone who may have taken too much needs medical help immediately, not when they feel unwell.

How much acetaminophen is an overdose?

Any amount above the label maximum can be harmful, and some people are at risk at lower amounts, including heavy drinkers, people who are fasting and those with liver disease. Do not try to judge it yourself: call Poison Control with the product, amount and time taken.

Can you survive a painkiller overdose?

Yes, most people survive when treated early. Acetylcysteine prevents liver damage from acetaminophen when started within 8 hours, and naloxone reverses opioid overdose within minutes. The outlook is worse when treatment is delayed, which is why calling for help immediately matters.

Is ibuprofen overdose dangerous?

Most ibuprofen overdoses cause stomach upset and drowsiness and are managed with observation. Very large amounts can cause kidney injury, seizures and acid build-up in the blood. Children, older adults and people with kidney disease are at greater risk. Always call Poison Control for advice.

What should I do if a child swallowed pain medicine?

Call Poison Control (1-800-222-1222 in the US) at once, or 911 if the child is drowsy, having trouble breathing or seizing. Do not make the child vomit. Have the container ready. Even one adult opioid tablet or patch can be dangerous to a small child.