In this post, I will explain how opioids affect the brain, what steps you should take to reverse an overdose, how naloxone works and where it can be obtained, and what to do in the immediate aftermath of overdose.
How Opioids Kill
Opioids kill by shutting down our breathing or slowing it to a rate incapable of sustaining life.
When we breathe, the incoming oxygen is absorbed into tiny air sacs in our lungs called alveoli. There the gas is absorbed into our bloodstream where it is carried to the heart and then pumped throughout our body to our organs and brain, nourishing our cells, before being returned with waste products (carbon dioxide) to the lungs. Back in the alveoli, the carbon dioxide is expelled when we breathe out. If we get too much carbon dioxide in our blood, our body increases its respiratory rate to expel the gas. Our body is programmed to help us maintain the proper equilibrium. Oxygen in, carbon dioxide out. Without thinking about it, we breathe at a natural rhythm, rate, and depth. Without adequate oxygen our organs die.
Opioids attach to the receptors in our brain, which control breathing. As the receptors become overloaded with opioids, our breathing slows. Normally, as the carbon dioxide in our blood starts to rise, our body is triggered to breathe, but opioids can hinder this response. As we get less and less oxygen, we become cyanotic (a blue or purplish discoloration in the skin due to lack of oxygen in the bloodstream). Cyanosis is seen first in the fingers and near the lips. Our oxygen goes down and our carbon dioxide rises to dangerous levels. When our breathing stops in an opioid overdose, our heart will continue to pump blood to the brain, but with each beat the amount of oxygen in the circulating blood becomes even further depleted, and each beat itself becomes less powerful until the heart (starved of oxygen) itself stops altogether. There is a period of time when a stopped heart can be restarted and returned to normal functioning, but if the brain has gone too long without oxygen or with insufficient oxygen, permanent damage will occur.
Opioids, depending on our tolerance, the opioid (heroin, fentanyl, oxycodone, etc.) used, the dose and the route (intravenous, inhalation, ingestion, etc.) can either stop our breathing within seconds or, slowly reduce respirations over many minutes to the point they are ineffective or eventually stop altogether.
Opioids produce euphoria or ease of sickness for those in withdrawal. They also produce stupor. It is not uncommon to find people on opioids to be “On the nod.” They are breathing and may be standing or sitting with their heads slumped forward as if nodding. For some this depressed consciousness state is not an overdose, but often the intended dose, the feeling the user sought when taking the drug. They are still breathing adequately and often can be roused with a simple shake. An overdose begins when the drug exceeds its intended effects.
Signs of an Overdose
The most critical signs of opioid overdose are drastically slowed respirations. Overdose can present as gurgling, snoring, irregular, shallow or absent breathing. We normally breathe between 12 and 20 times a minute. If someone is only breathing 2-4 times a minute, and their breathing is labored or gasping, we call this agonal breathing. It can also be called a death rattle. The person is in trouble.
Depressed consciousness, which can precede or accompany decreased breathing, may lead to unconsciousness. The danger of unconsciousness is that a person may accidentally occlude their airway with their tongue, preventing them from taking in air. It is not uncommon for people in the nodding position to fall forwards into a praying or frog-like position. The great danger here is they can occlude their airway. Opioids can also depress the gag reflex making it hard for a person to protect the lungs from secretions and vomit.
Sometimes, fentanyl overdoses present as seizures with the fentanyl causing the person’s muscles to become rigid and appear to be in the tonic or rigid phase of a seizure. This can impair the ability of the chest to expand and can lead to suffocation. When a person’s airway becomes occluded by the glottis, a piece of tissue that guards the trachea or upper part of the airway, pressure builds up in the chest. The pressure can damage the alveoli, causing pink frothy foam known as pulmonary edema. A pink foam cone on the mouth and nose is not an uncommon finding in patients who are found dead of overdose.
One of the telltale signs of opioid use is constricted or pinpoint pupils, also known as miosis. Opioids act on the eyes’ pupillary response. Most other drugs or alcohol cause dilated or larger pupils. While there are many factors that affect pupillary response, if a person with a history of opioid use, has depressed respirations and pinpoint pupils, consider it a likely opioid overdose.
There are also external clues that can indicate opioid overdose. Syringes or paraphernalia such as small plastic bags, drug packaging, a bottle cap or cooker can often be observed in the room. Needle marks and scabbing may be present on a person over areas on their arms such as the crook of the elbow where their veins are close to the skin. Keep in mind not everyone who overdoses on opioids injects their opioids. Many overdoses are caused by inhalation or ingestion of the opioid. Since these overdoses take longer to present due to the slower delivery of the drug to the brain using these routes as compared to the intravenous, signs of the drug use may not be in the immediate vicinity.
How to Respond to an Overdose
When you suspect a person is suffering from an opioid overdose, the first thing you do is try to stimulate the patient. Often stimulation alone will restore breathing and consciousness. Shake the person’s shoulder while calling their name. If that doesn’t immediately work, rub your knuckles hard against their sternum (breastbone). This is painful and can elicit a response. While stimulation alone can restore adequate breathing and consciousness, patients may continue to drift off and should still be monitored and stimulated as necessary should their breathing again slow.
If the person is not breathing, check for a pulse by placing your fingers across the side of the patient’s neck. If, after several tries, you don’t feel anything, start CPR.
If a person has a pulse and is breathing adequately, but is not responsive, roll them onto their side to protect their airway in case they vomit.
If a person has a pulse, but is breathing inadequately despite stimulation, this person should receive naloxone. If you are alone with the patient and have naloxone, administer it, and then call 911. Get professional rescuers on the way. If someone is with you, have them call 911 while you administer the naloxone. There is some controversy as to the proper order of calling 911 versus giving naloxone first. My advice is use your common sense if you are alone. If the naloxone is in your hand, administer it, and then call 911. If you have to find the naloxone in a closet, call 911, and then find and administer the naloxone.
Naloxone is a drug that reverses the effects of opioids on our respiratory system. Naloxone has a stronger affinity for the brain’s breathing receptors than opioids do. Naloxone knocks opioids off the receptors, enabling a person to resume breathing. As long as a person’s heart hasn’t stopped, naloxone will usually always reverse an opioid overdose if given in time.
Years ago, only paramedics were able to carry naloxone. Today it is carried by most first responders, including police and fire, and is widely available to the lay public. Naloxone can be given in three forms: intranasally by nasal spray, intramuscularly by injection with a needle or intravenously through an IV line. Naloxone works fastest when given intravenously, but this requires a medical professional to first establish IV access. No matter which form you consider, if anyone in your household is using opioids, either with a prescription or illicitly, or has a past history of opioid use, you should have naloxone in your medicine cabinet. 80% of all overdose deaths occur in a home. Consider also carrying naloxone with you when you travel, keeping it in a purse, backpack or the glovebox of your car.
The intranasal spray is the most common form of naloxone available to laypeople and the easiest to use, but it is the slowest to take effect. Its brand names include Narcan and Kloddaxo. They account for 96% of all prescription naloxone products sold in 2021. They are FDA approved and specifically formulated for intranasal administration.
The intranasal naloxone comes in a blister pack. The Narcan device contains 4 milligrams of Naloxone in just 0.1 cc of fluid. The 4 milligrams is the equivalent of 2 milligrams injected into the muscle. The device is quite simple to use. Tilt the patient’s head back, insert the nozzle into the nose and press the plunger with your thumb. Be careful not to press the plunger until the device is in the nose to prevent accidental discharge.
The package instructions call for naloxone to be redosed every 2-3 minutes until the patient is awake. This differs from professional health care settings where the goal is to restore breathing. Consciousness usually follows restored breathing, often several minutes later. Stimulation will help the person regain both breathing and consciousness sooner. If you do have to administer a second dose, use the second nostril.
Until the person is conscious, be certain to place the person on their side in the recovery position. This will help protect their airway in the event they vomit.
Kloxxado contains 8 mg of naloxone. Many argue that that is too much, and will lead to severe withdrawal in patients addicted to opioids. But if that is all you have, go ahead and use it. A vomiting patient is better than one not breathing.
There is a second type of intranasal spray device that is not FDA approved and is more complicated. It involves screwing a prefilled vial of naloxone into a tube and then attaching a cone shaped atomizer to the end of the tube. The vial contains 2 milligrams of Naloxone in 2 ccs of fluid. It is the equivalent of 0.4 milligrams injected into the muscle. It is less concentrated than the naloxone in the nasal spray. Insert the atomizer in one nostril, push the vial to the halfway point, then switch nostril and push the remaining amount in the vial (1 cc). The naloxone will not work unless the atomizer is attached. You must also push briskly or the fluid will not be successfully turned into a spray of the tiny particles necessary to pass through the brain’s blood barrier and have a chance to displace the opioids from the brain’s receptors. While containing far more fluid, this device contains far less active ingredient than the nasal spray. Nevertheless, it has proven effective and is also less likely to induce withdrawal. It may take longer to work.
There are two chief types of intramuscular injection — an autoinjector and a syringe and vial. The autoinjector, called Envisio is very expensive, and has largely disappeared from the market due to his expense. The autoinjector involves removing the device from its case, pulling off a red safety guard, and then placing the autoinjector against a patient’s outer thigh (the upper part of the leg). Press firmly and hold in place for five seconds. You can go through the clothes if you have to. The Envisio contains 2 milligrams of Naloxone. A new autoinjector on the market called Zimhi has 5 milligrams. Again, many feel that this is an excessive dose more than two and a half times the most powerful dose a paramedic would deliver intramuscularly.
Syringe and Vial
The syringe and vial method is the most inexpensive and is often preferred by users because it works quicker than intranasal and has fewest side effects. It is the first line medicine (after oxygen) used in New York City’s safe injection sites. The medicine comes in a small vial, which contains 0.4 milligrams of Naloxone in 1 cc of fluid. Pop the top off the vial. Insert the syringe through the vial’s rubber top, turn the vial upside down and pull back on the plunger until the vial is empty. The syringe can then be inserted into a large muscle either the thigh (preferred) or the upper arm. Push the plunger forward until it stops.
Treatment for Patients who are not Breathing and Those who May or May Not Have a Pulse.
Determining breathing is much easier than finding a pulse. If the chest isn’t moving and there is no air coming out of the nose or mouth after waiting for a sufficient time (15-30 seconds), feel the person’s neck for a pulse. If you don’t initially feel anything, keep trying. Pulses are not always easy to detect. If the patient has a pulse and isn’t breathing, start rescue breathing if you are comfortable with it.
Rescue breathing involves putting the person on their back, tilting their head backwards. If you have a breath barrier or mask, use these, for your protection. Pinch their nose closed, and give one breath every five seconds. Watch the chest for rise indicating air is going into the lungs. If you can’t find a pulse and the patient still isn’t breathing, assume the patient doesn’t have a pulse and start CPR.
Put your hands over the center of the patient’s chest with the heel of one hand against the chest bone and the other hand on top of your first hand. Keeping your elbows staight, put your shoulders above your hands and begin compressing to a depth of 2 inches. Allow the chest to recoil and don’t move your hands. Compress at a rate of 120 a minute. If you can’t remember that, press to the beat of the BeeGee’s “Staying Alive.” If you don’t want to pause to give rescue breaths, it is okay to continue to just give compressions. The movement up and down on the chest provides passive ventilation.
Advanced medical professionals don’t give naloxone to people who are in cardiac arrest. Naloxone won’t restore breathing if the heart is stopped. But it is okay for lay people to administer naloxone on the chance that the person still has a pulse, even if it is too hard to feel. Finding a pulse is not the easiest task. Sometimes it is hard to find in even awake healthy people. Compressions are often the stimulation needed to rouse someone (not in cardiac arrest) from overdose.
Response to Naloxone
The instructions call for naloxone to be given every 2-3 minutes until the person is breathing on their own. After you have given naloxone, continue to stimulate the person. This may speed up their visible response to the drug. In an emergency it is sometimes difficult to judge time. It is important to remember that return to adequate breathing is the end goal, not consciousness, which usually follows after adequate breathing has been restored. If the person is breathing adequately and they are no longer cyanotic, even if they have not returned to full consciousness, no additional naloxone needs to be given.
Sometimes if the person is under the effects of another substance, they may not return to consciousness, but as long as they are breathing, the immediate catastrophe has been avoided.
If a person is addicted to opioids, naloxone may put the person into opioid withdrawal, characterized by sweating, nausea, vomiting, diarrhea, confusion and agitation. Try to be reassuring when a person is coming around from an overdose. Tell them they overdosed and that you gave them naloxone because their breathing was inadequate. Do not be judgmental.
Stay with the patient until professional help arrives.
Things Not to Do
There are some home remedies that we in EMS often encounter. Laying the person in a cold bath, dousing them with water, putting ice in their pants are among the most common. While they may achieve some stimulation effect, if the person does not respond to initial stimulation they are unlikely to respond to these measures. They have no effect on the person’s breathing mechanisms. Also, do not pour liquids into a person’s mouth. This will only cause them to choke.
Where to Obtain Naloxone:
Naloxone can be obtained at pharmacies with a prescription. In some states the pharmacist has the power to write you a prescription if you simply ask. Many insurances will cover naloxone for the simple price of a copay. It can be free for patients on Medicaid. Public health departments and harm reduction services also provide free naloxone and training. A typical training for naloxone takes only a few minutes. The Food and Drug Administration is soon expected to approve intranasal naloxone as an over the counter medicine, making it available to anyone to purchase at a pharmacy, gas station or corner store. .
Good Samaritan Law
Most states have good Samaritan laws to protect you if you assist someone overdosing in a good faith attempt to save them. While laws vary from state to state, many protect people from arrest for drug use and possession if they report an overdose. Laws will not protect people if they are possessing drugs with intent to sell those drugs. States with Good Samaritan laws have lower overdose death rates, according to the Government Accountability Office.
When you call 911, your call is answered by an emergency dispatcher. Depending where you live, the dispatcher could be in a large regional center with many operators or they could be a single person sitting in front of a console in a small police department. While the dispatcher asks you what your emergency is, your address should already be appearing on the dispatcher’s screen. The dispatcher will ask you a series of questions, but don’t worry; responders are already on the way. Again, depending where you live, you will see different responses. In most systems, the first responders who arrive will either be police or fire. An ambulance crew should follow shortly after. Make certain your house is well lit and marked so the responders know which house to enter. If you have someone else there with you, have them stand by a door to flag the responders.
The responders will begin assessing the patient while asking you what happened. If naloxone hasn’t already been given, or if it has and the patient continues to have depressed respirations, the responders will administer additional Naloxone. They will also position the patient to secure his airway. If breathing is depressed, they will use a bag-valve device, which consists of a plastic mask that they seal over the patient’s nose and mouth, and an attached balloon type bag that they squeeze to send air into the patient’s lungs. They may also insert a plastic airway device in the nose or mouth to keep the tongue from occluding the airway. Sometimes the insertion of such a device or even the pressing of a mask against a face causes enough stimulation to rouse a patient. If the crew is able to effectively ventilate a person with a bag valve mask, they could in theory continue to do so until the opioid wears off. Ambulance crews will usually stay on scene until the naloxone has had a chance to work and the patient no longer needs bag-valve-mask ventilation.
EMS and Cardiac Arrest
Crews will also stay on scene if the patient is in cardiac arrest, meaning the patient’s heart has stopped. They will provide CPR, and administer the cardiac drug epinephrine through an intravenous line to try to restart the heart. Naloxone at this point is ineffective. Breathing cannot be restored if the heart is not working. Studies have shown that CPR is ineffective when a patient is being moved. This is also true of attempting CPR in moving ambulances where every bump or sudden turn can lead to hands coming off the chest and a disruption of the necessary cadence. If a patient in nontraumatic (not caused by a blunt or penetrating injry) cardiac arrest is not resuscitated on scene, there is little hope they will be successfully resuscitated at the hospital. (A person in traumatic cardiac arrest likely needs a surgeon and capabilities that an ambulance crew cannot typically provide.) Paramedic crews have everything on scene needed to resuscitate a patient in opioid overdose. The focus must be on providing perfect cardiac compressions and effective ventilations to keep the brain perfused with oxygen rich blood until the heart can be restarted.
Most people who receive naloxone before their heart has stopped do well provided the naloxone is given in time. A person who is addicted to opioids may be sick or agitated after being resuscitated, particularly if given large amounts of naloxone. The naloxone has wiped the opioids out of their system and the drug has put them into withdrawal. Patients may be agitated, but they are rarely truly combative toward others. It is not uncommon for people to deny drug use, particularly if law enforcement responded to the house. In most jurisdictions today, law enforcement will not arrest people who have suffered overdoses. Their concern is increasingly helping people find the resources they need.
The EMS responders will evaluate a person post resuscitation and always recommend that they go to the hospital for monitoring and further evaluation. Naloxone does not last as long as many opioids so there is a concern that someone will lapse back into an overdosed state. This is far more likely if the person is ingested delayed acting pills than if they injected heroin or fentanyl.
If a person is alert and oriented, they have a right to refuse transport. If they do refuse transport, it is important that they have someone to stay with them and make certain they don’t re-overdose. Many EMS services are now leaving behind Naloxone kits with patients and their families and friends. The kits include not only naloxone and a face shield (if rescue breathing is needed), but information on where a patient can access help and other needed resources.
EMS will also reassess a patient’s vital signs and check their oxygen saturation. Some people aspirate stomach contents into their lungs when they overdose. Aspiration may present as a low oxygen saturation and coarse sounds in the lungs. It is important that post resuscitation patients with low oxygen saturations be seen at the hospital for treatment.
It is not uncommon for people who have overdosed to be treated poorly at hospitals, as well as sometimes by first responders. We haven’t done a good job at educating health care providers in the science of addiction or the dangers of stigma. Even if treated well, not all emergency departments have the resources to help people who have overdosed get the follow-up care they need. Services can be sparse. After observing a patient for two hours, the hospital may discharge the patient with instructions to stop doing heroin. They may be given a mimeographed list of treatment programs all that have lengthy waiting lists. They are then sent back out to the streets, even those who are in active drug withdrawal and are in danger of using again just to keep the sickness at bay. Fortunately, many hospitals are changing their approach.
Recovery navigators are people in long-term recovery who work at hospitals either as hospital staff or contracted from social service agencies. They meet with overdose patients in the Emergency Department and continue to work with them after they are discharged. They talk them through the various recovery and treatment options to find one that might work for them.
Some hospitals offer buprenorphine treatment right in the emergency department to patients who are in drug withdrawal. Buprenorphine, also known as suboxone, is a long acting opioid that reduces withdrawal symptoms as well as opioid craving while not providing the intense euphoria of heroin or fentanyl. Patients can get an induction dose in the ED and then are scheduled for follow up care and treatment in an addiction clinic.
Emergency Departments may keep some patients overnight, and then transport the patient directly to a treatment center the next day if there is an opening and the patient agrees to enter treatment. Some hospitals, if the patient is being discharged, will provide naloxone, as well as safe-use kits for those who are likely to continue to use drugs.
For those patients who EMS is not able to resuscitate fully, or who continue to have low oxygen saturations or other identified medical problems, they may be admitted to the hospital or if appropriate, the intensive care unit (ICU) for further care. While most patients recover within 2-15 minutes of receiving naloxone, if the person has been without oxygen for a longer period, their brains may have been stunned, and return to consciousness may take longer. Sadly a number of people may have suffered prolonged hypoxia, end up with anoxic brain injury. This is particularly a problem with patients whose hearts were stopped and needed resuscitation. It is hoped that some of these patients will gradually recover in the coming days, but brain scans may show that the damage sustained was both severe and permanent. Rather than live in a vegetative state, patients are often made comfort measures only after consultation with the patient’s family. They are given pain medicine and removed from the ventilators. Some have their organs donated to others.
Where years ago, after I resuscitated a patient I told them to just say no or they will end up dead or in jail, now I ask them if they know where they can help, and if they are not ready to quit, I tell them, if you are going to use again, please do not use alone, and always have naloxone available. This is a message that must be repeated over and over to avoid the tragedies that are occurring in our country every day.