Opioid Poisoning

What to do right now

1. Try to wake them: shout their name and rub your knuckles firmly on their breastbone.
2. Call 911 or your local emergency number.
3. Give naloxone (Narcan or a generic) if available: one spray into a nostril, or an injection. It is sold over the counter in the US. Give another dose after 2 to 3 minutes if there is no response.
4. Support breathing: if they are not breathing normally, give rescue breaths or start CPR if trained.
5. Place them on their side (recovery position) once breathing, so they do not choke on vomit.
6. Stay with them. Naloxone can wear off in 30 to 90 minutes, sooner than many opioids. Remove and fold any fentanyl patch, sticky side in.
7. For a child exposure without symptoms, still call 911 or Poison Control (1-800-222-1222) at once.

The opioid overdose page covers recognizing and reversing an overdose in more detail.

How opioids cause poisoning

Opioids act on receptors in the brain and spinal cord to relieve pain. In the brainstem they also blunt the drive to breathe. At toxic levels breathing slows, becomes shallow and can stop, starving the brain and heart of oxygen (opioid-induced respiratory depression). Pupils shrink and consciousness falls.

The danger rises sharply when opioids are combined with other drugs that depress breathing:

• alcohol
• benzodiazepines such as alprazolam or diazepam (see benzodiazepine overdose)
• sleeping pills, gabapentin and pregabalin
• sedating antihistamines and muscle relaxants
• xylazine, a veterinary sedative increasingly found in illicit fentanyl, which naloxone does not reverse

Who is at risk of opioid poisoning

Young children

A single adult tablet of methadone, oxycodone or extended-release morphine, a buprenorphine film or a used fentanyl patch can be fatal to a toddler. Symptoms can be delayed for several hours after swallowing a long-acting product, so every exposure needs hospital assessment.

Older adults and people with organ disease

• Kidney failure lets active breakdown products of morphine and codeine build up over days.
• Liver disease slows opioid clearance.
• Older adults are more sensitive and more likely to take other sedating drugs.
• Signs often develop gradually: sleepiness, confusion, muscle twitching (myoclonus), falls and slowed breathing.

Medicine errors and changes

• starting a new opioid, switching between opioids, or increasing the dose
• taking extra doses for uncontrolled pain
• chewing or crushing extended-release tablets
• applying heat (heating pads, hot baths, fever) over a fentanyl patch, which speeds absorption
• codeine and tramadol in "ultra-rapid metabolizers," who convert them to stronger forms. The FDA warns against their use in children under 12 and in breastfeeding mothers.

See medication errors for preventing dosing mistakes.

Illicit drug use

Illicit fentanyl and related synthetic opioids, including nitazenes, are now found in counterfeit pills and other drugs such as cocaine and methamphetamine, so people may be exposed without knowing. Lower tolerance after a break, such as after prison, rehab or hospital, greatly raises risk.

Signs and symptoms

• extreme sleepiness, or being unable to wake
• slow, shallow or stopped breathing, snoring or gurgling sounds
• pinpoint pupils
• blue, gray or pale lips and fingertips
• limp body, cold or clammy skin
• slow heartbeat and low blood pressure
• vomiting
• in gradual toxicity: confusion, slurred speech, muscle jerks and hallucinations

Pinpoint pupils can be absent if other drugs are involved or the brain has been starved of oxygen.

Treatment in hospital

• Naloxone: given in small repeated doses or as a continuous drip for long-acting opioids such as methadone and extended-release products. The aim is to restore breathing without triggering severe withdrawal.
• Breathing support: oxygen, a bag-valve mask, or a breathing tube and ventilator.
• Observation: often at least 4 to 6 hours after the last naloxone dose, and 24 hours or more after long-acting opioids or in children.
• Tests: blood gases, acetaminophen and aspirin levels (combination products are common), kidney function, CK for muscle damage, ECG and a chest X-ray.
• Activated charcoal: occasionally used soon after swallowing in alert patients.

Complications

• hypoxic brain injury from lack of oxygen
• aspiration pneumonia from inhaled vomit
• fluid in the lungs
• rhabdomyolysis and compartment syndrome from lying still for hours
• kidney injury
• death from respiratory arrest

After opioid poisoning

A poisoning episode is a chance to make things safer:

• Review the opioid dose, the need for the drug and other sedating medicines with your doctor.
• Keep naloxone at home and make sure family members know how to use it.
• Lock up opioids, count pills, and dispose of unused medicines at take-back sites or as instructed on the label. Fold used patches sticky-side in before disposal.
• If the poisoning involved misuse, treatment for opioid use disorder with buprenorphine or methadone greatly lowers the risk of death. The SAMHSA National Helpline (1-800-662-4357) is free and confidential.

Frequently asked questions

What are the symptoms of opioid poisoning?

Main symptoms are extreme sleepiness or unresponsiveness, slow or stopped breathing, pinpoint pupils, blue or gray lips, and a limp body. When opioids build up gradually, early signs include confusion, slurred speech, muscle twitching and hallucinations. Any suspected poisoning needs emergency care.

What should I do if my child swallowed an opioid?

Call 911 or Poison Control at 1-800-222-1222 immediately, even if your child seems fine. Even one adult pill or a used fentanyl patch can stop a child's breathing, and symptoms may be delayed for hours with long-acting products. If your child is hard to wake or breathing slowly, give naloxone if available.

Can you get opioid toxicity from prescribed medication?

Yes. Toxicity can occur with prescribed opioids after a dose increase, a switch to a different opioid, extra doses, kidney or liver problems, or when combined with alcohol, benzodiazepines, sleeping pills or gabapentin. Older adults are especially vulnerable. Report new drowsiness or confusion promptly.

How long does opioid toxicity last?

It depends on the opioid. Short-acting opioids like heroin last a few hours, while methadone, extended-release tablets and fentanyl patches can cause toxicity for a day or more. Naloxone wears off in 30 to 90 minutes, so people are observed and may need repeated doses or an infusion.

Does naloxone work on fentanyl?

Yes, naloxone reverses fentanyl, though more than one dose may be needed with high-potency fentanyl or nitazenes. It does not reverse xylazine, benzodiazepines or alcohol, so a person may stay drowsy even after breathing improves. Always call 911 and support breathing as well.