Opioid overdose: who is at risk and what to do

Anyone who takes opioids can overdose. SAMHSA’s overdose toolkit and the CDC point to certain situations where the risk is much higher.

Using again after a break

Tolerance drops when you stop, even for a short time. This applies after detox, a hospital stay, time in jail or prison, or a stretch of not using. A dose your body handled before can now be too much. MedlinePlus notes that most opioid overdose deaths occur in people who have just detoxed. Our page on relapse covers this in detail.

Fentanyl in the supply

Fentanyl is far stronger than heroin, and you cannot see, taste or smell it. It is mixed into powders and pressed into fake pills, so the strength of each dose is a guess. See what fentanyl is and why it changed the risk.

Mixing with alcohol or benzodiazepines

Alcohol and benzodiazepines, such as Xanax and Valium, also cause sedation and slow breathing. Taken with an opioid, the effects stack. NIDA reports that in 2021 nearly 14 percent of overdose deaths involving opioids also involved benzodiazepines. Opioids and benzodiazepines both carry an FDA boxed warning about being used together.

Using alone

Naloxone works, but you cannot give it to yourself once you have passed out. With no one nearby, there is no one to call for help.

A previous overdose

The CDC notes that people who have had at least one overdose are more likely to have another.

The CDC lists these signs:

• The person is unconscious or cannot be woken.
• Breathing is slow, shallow or has stopped.
• Choking sounds, or a gurgling or snoring noise from someone who will not wake.
• Discolored skin, especially lips and nails.
• Very small “pinpoint” pupils that do not react to light.

You may not see all of them. If you are not sure, the CDC’s advice is to treat it as an overdose. Acting on a false alarm costs little. Waiting can cost a life.

1. Give naloxone if you have it, and call 911. Tell the dispatcher the person is not breathing or will not wake.
2. Try to keep the person awake and breathing.
3. Lay them on their side so they do not choke.
4. Stay with them until emergency help arrives.

Naloxone is a medicine that reverses an opioid overdose. The CDC says it can restore normal breathing within 2 to 3 minutes. It will not harm someone who turns out not to have opioids in their system.

With fentanyl, one dose is sometimes not enough. NIDA notes that standard naloxone still works for most fentanyl overdoses, though some people need more doses. The CDC advises staying with the person until help arrives, or for at least four hours, to make sure their breathing returns to normal.

Most states have Good Samaritan laws that give some legal protection to the person overdosing and to the person who calls for help. The details differ by state.

Our naloxone guide for families explains where to get it and how to use it.

Call 911 if someone is not breathing or cannot be woken. Call or text 988 for a crisis or thoughts of suicide. For a free referral at any hour, the SAMHSA National Helpline is 1-800-662-4357.

You do not have to be ready to stop to make an overdose less likely. These steps are for people who are still using and for the people around them.

• Keep naloxone where it can be found, and make sure the people you live with know where it is. It is sold over the counter in all 50 states.
• Avoid using alone. If that is not possible, tell someone you trust so they can check on you.
• After any break, assume your tolerance has dropped.
• Do not mix opioids with alcohol, benzodiazepines or other sedating drugs.
• Treat any pill that did not come from a pharmacy as if it contains fentanyl.

The strongest protection is treatment itself. NIDA reports that people treated with methadone or buprenorphine are less likely to die or overdose than people who are not treated. You can read about medication for opioid use disorder, or look for a provider in the treatment directory.

If an overdose has already happened in your household, help now lists who to contact today.