How to recognize and respond to an opioid overdose

Overdose occurs when the body ingests more of a substance than it can handle. This can be very dangerous, even fatal. However, this event is entirely preventable. Most opioid users (64-97%) report that they have witnessed at least one overdose, so the opportunity for rescue exists.

How to recognize an opioid overdose

The skin is blue—usually the lips and fingertips turn blue first.
The body is very limp.
The face is very pale.
The person is conscious but unable to respond.
The person makes choking sounds or a gurgling/snoring noise.

What is the difference between being high and an overdose?

Being high on opioids	Opioid overdose
Muscles become relaxed.	Breathing is very infrequent or has stopped and the pulse is slow.
Speech is slow/slurred.	Deep snoring or gurgling (death rattle) is present.
The person is sleepy looking.	The skin is pale and clammy.
The person is nodding.	The person exhibits heavy nodding.
The person will respond to stimulation like yelling, sternal rub, pinching.	The person is not responsive to stimulation.

Naloxone (Narcan, Envisio) for overdose

Naloxone is a medication that reverses opioid overdose. It is an opioid antagonist, which blocks heroin and other opioids from binding to receptors in the brain and reverses the respiratory depression caused by an opioid.
It can be safely administered by the intranasal, intravenous, intramuscular, or subcutaneous routes.
It works quickly (2-8 minutes), but this depends on an individual’s metabolism, the type of opioid used (i.e., a short-acting opioid like heroin or longer acting opioid like methadone), and the amount of drug used.
Naloxone usually wears off before the heroin or other opioid that was taken, so a person must be monitored closely even after naloxone is given. This is especially important for someone who has overdosed on a longer acting opioid. In this case, it may be necessary for an intravenous continuous infusion of naloxone to be given in a hospital setting. This is why it is important to activate the emergency response system by calling 911.
Naloxone has no abuse potential; people cannot get high on naloxone.
Naloxone has no effect if opioids are not present.
Naloxone has practically no side effects. If opioids are present, the overdose is reversed and the person starts breathing again. However, due to the antagonist effect, opioid withdrawal signs and symptoms will emerge. Opioid withdrawal symptoms are unpleasant but not life threatening.
Videos of naloxone rescue: Prevent an Overdose, Save a Lifeopens in new window and Prevent an Overdose, Save a Life (Naloxone by Intra-Muscular Injection)opens in new window

Rescue procedures

Listed below are common recommendations for action when someone is suspected of having overdosed. This summary is no substitute for formal training in identifying and responding to an opioid overdose. Formal training can be obtained through a number of local resources, such as Get Naloxone Nowopens in new window or from Addiction Policy Forumopens in new window. Counseling family members to receive such training is an important component of family intervention.

References

New York State Department of Health. (2016). Opioid overdose prevention: Guidelines for policies and procedures. Retrieved from https://www.health.ny.gov/diseases/aids/general/opioid_opens in new window overdose_prevention/docs/policies_and_procedures.pdfopens in new window

NYC Health. (n.d.). How do I put together an overdose rescue kit? Available from https://www1.nyc.gov/assets/doh/opens in new window downloads/pdf/basas/naloxone-kit-req.pdfopens in new window

Riojas, A. P. (2014). NYC Overdose Awareness Day [Presentation at overdose response training]. New York, NY: Bureau of Alcohol & Drug Use Prevention Care & Treatment.

San Francisco Department of Public Health. (n.d.). Training manual of the Heroin Overdose Management Training Program [Urban Health Study]. San Francisco, CA: UCSF/ Harm Reduction Coalition and Training Institute.

Tracy, M., Piper, T. M., Ompad, D., Bucciarelli, A., Coffin, P. O., Vlahov, D., & Galea, S. (2005). Circumstances of witnessed drug overdose in New York City: Implications for intervention. Drug and Alcohol Dependence, 79(2), 181-190. doi:10.1016/j. drugalcdep.2005.01.010

Wheeler, E., Burk, K., McQuie, H., & Stancliff, S. (2012). Guide to developing and managing overdose prevention and take-home naloxone projects. Retrieved from https://harmreduction.org/wp-content/uploads/2012/11/od-manual-final-links.pdfopens in new window

Wheeler, M., & Alba, C. (n.d.). Recognition, response and administration of naloxone (Narcan): Opioid overdose 101. Lynn, MA: CAB Health and Recovery Services, Healthy Streets Outreach Program. Retrieved from https://slideplayer.com/slide/12627650/opens in new window

5-step rescue plan for opioid overdose

Step 1: Stimulate—give sternal rub

Sternal rub: Rub knuckles hard up and down on the breast bone:

It hurts, but will not cause damage.
It can help to assess whether the person is conscious.
It may make the person breathe, even if it doesn’t wake the person up.
Check for breathing:
- Chest rising and falling.
- Nostrils moving in and out.

Step 2: Call 911

Call 911 and tell them that someone is not breathing or is unresponsive.

Step 3: Administer rescue breathing

Rescue breathing alone can sustain someone until emergency personnel arrive:

First make sure there is nothing in the mouth/throat. Clear the throat before beginning rescue breathing.
Tilt the head to open the airway by lifting the neck or chin.
Pinch the nose shut.
Make a seal over the mouth with your mouth.
Give 2 quick breaths.
Then give 1 breath every 5 seconds until emergency personnel arrive or the person breathes on his/her own.

Step 4: Administer naloxone

Intranasal administration:

Tilt the victim’s head back.
Spray into one nostril until all of the liquid has been expelled.
Continue rescue breathing until EMS arrives or the person breathes on his/her own.

Intramuscular administration:

Put on the provided gloves.
Uncap the syringe in the kit.
Uncap the naloxone vial.
Pierce the membrane on the vial and pull up the entire contents of the vial into the syringe.
Inject the full amount of naloxone into the shoulder or thigh—just like a flu shot.

Step 5: Continue rescue breathing

Continue rescue breathing for 3–5 minutes, and if the person is not responding, give the second dose of naloxone that is included in the overdose kit (exactly like the first dose) and stay with the person until help arrives.

After the overdose reversal:

Once naloxone begins working, the person may show signs of opioid withdrawal:

Don’t leave the person alone, as sedation may return; if you must leave, put the person on his/her side and call 911.
Wait for emergency personnel to arrive, or encourage the person to seek medical care.
Reassure the person that the naloxone will wear off and the effects of the opioids may return. Do not let the person use more opioids.