Opioid Safety, Overdose Recognition, and Naloxone
18-minute refresher · For: All health professionals, including nurses, pharmacists, pharmacy technicians, prescribers, EMS providers, medical assistants, behavioral health staff, and laboratory personnel, as well as students who may encounter opioid use or overdose in clinical or community settings.
- Identify risk factors for opioid overdose, including combinations with other sedating substances.
- Recognize the signs of opioid overdose.
- Describe the steps of overdose response, including naloxone administration.
- Summarize safe storage and disposal practices and resources for treatment referral.
Opioids and Overdose Risk
Opioids include prescription pain medications such as oxycodone, hydrocodone, and morphine; synthetic opioids such as fentanyl; and heroin. Opioids act on opioid receptors in the brain and can slow or stop breathing at high doses. CDC reports that illicitly manufactured fentanyl has been a major driver of overdose deaths in the United States.
Factors that increase overdose risk include:
- Combining opioids with other central nervous system depressants, such as benzodiazepines, alcohol, or other sedatives. FDA requires boxed warnings on opioid and benzodiazepine labeling about the risks of concurrent use.
- Higher opioid doses and recent dose increases.
- Reduced tolerance, such as after detoxification, a period of abstinence, or release from incarceration.
- Unknown drug content, since illicit drugs may contain fentanyl or other substances without the user's knowledge.
- Medical conditions such as sleep apnea, respiratory disease, and kidney or liver impairment.
- A history of prior overdose or substance use disorder.
Safe Prescribing and Use
The CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022) provides recommendations for clinicians. Key themes include:
- Maximizing nonopioid and nonpharmacologic therapies when appropriate.
- Discussing realistic benefits and known risks with patients.
- Prescribing immediate-release opioids at the lowest effective dose when opioids are started for acute pain, for no longer than needed.
- Reviewing prescription drug monitoring program (PDMP) data.
- Offering naloxone when overdose risk is increased.
- Avoiding abrupt discontinuation and tapering collaboratively when changes are needed.
- Offering or arranging evidence-based treatment for patients with opioid use disorder.
The guideline is intended to support, not replace, individualized clinical judgment. Patient education should cover taking medications only as prescribed, avoiding alcohol and other sedatives unless approved by the prescriber, and never sharing medications.
Recognizing an Opioid Overdose
CDC and SAMHSA describe the following signs of possible opioid overdose:
- Small, constricted (pinpoint) pupils
- Falling asleep or loss of consciousness; unable to be awakened
- Slow, shallow, or stopped breathing
- Choking or gurgling sounds
- Limp body
- Pale, blue, or cold skin, and blue or gray lips or fingernails
Opioid overdose can occur in any setting, including waiting rooms, restrooms, parking areas, and patient homes. If you are unsure whether someone is experiencing an opioid overdose, treat it as one; naloxone is not expected to harm a person who has not taken opioids.
Responding to an Overdose
Based on SAMHSA's Opioid Overdose Prevention Toolkit and CDC guidance, the general steps are:
- Try to wake the person by shouting and applying a firm sternal rub.
- Call 911, or activate your facility's emergency response.
- Give naloxone according to the product instructions.
- Support breathing: provide rescue breathing or CPR according to your training.
- Place the person in the recovery position on their side if they are breathing.
- Stay with the person until emergency help arrives.
- Give another dose if there is no response after 2 to 3 minutes, as directed on the product labeling.
Naloxone works for a limited time, and its effects may wear off before the opioid's effects do, so breathing can slow again. Monitoring and emergency care are important even after the person responds. Naloxone may cause withdrawal symptoms in people who are dependent on opioids. Most states have Good Samaritan laws that offer some legal protections to people who call for help during an overdose; details vary by state.
About Naloxone
Naloxone is an opioid antagonist that can rapidly reverse opioid overdose. It is available as a nasal spray and as an injectable. In 2023, FDA approved 4 mg naloxone nasal spray for nonprescription, over-the-counter use, increasing availability in pharmacies and other retail settings.
Key points:
- Naloxone does not reverse overdoses caused by non-opioid sedatives, such as benzodiazepines, alcohol, or xylazine. Because these substances are often mixed with opioids, naloxone should still be given when an opioid overdose is suspected, and rescue breathing and emergency care remain essential.
- Store naloxone at room temperature, away from light, and check expiration dates.
- Encourage patients at increased risk, and their family members, to keep naloxone accessible and know how to use it.
Storage, Disposal, and Treatment Resources
Safe storage: keep opioids in their original containers, out of reach and sight of children and visitors, ideally in a locked location.
Safe disposal: FDA and DEA recommend drug take-back options first, such as DEA-registered collection sites and DEA National Prescription Drug Take Back Day events. If a take-back option is not readily available, FDA's flush list identifies certain medicines, including many opioids, that should be flushed. Other medicines can be mixed with an unappealing substance, sealed, and placed in household trash.
Treatment: opioid use disorder is a treatable medical condition. FDA-approved medications for opioid use disorder include buprenorphine, methadone, and naltrexone. Since the federal DATA-waiver (X-waiver) requirement was eliminated in 2023, practitioners with a current DEA registration that includes Schedule III authority may prescribe buprenorphine for opioid use disorder, subject to applicable state law.
Resources:
- SAMHSA National Helpline: 1-800-662-HELP (4357), free and confidential, 24/7.
- FindTreatment.gov, SAMHSA's treatment locator.
- 988 Suicide & Crisis Lifeline: call or text 988.
Reducing Stigma
Stigma can discourage people from seeking treatment or calling for help during an overdose. SAMHSA and the National Institute on Drug Abuse (NIDA) encourage person-first, medically accurate language:
- Say person with a substance use disorder rather than labels such as addict or abuser.
- Say medications for opioid use disorder rather than describing treatment as replacing one drug with another.
- Describe test results as positive or negative rather than dirty or clean.
Respectful language and nonjudgmental care help build trust, which supports engagement in treatment and safer outcomes.