Opioid Overdose Prevention: A Practical Guide to Saving Lives

Introduction

Opioid overdose is a preventable cause of death. With over 80,000 opioid overdose deaths in the United States in 2021, overdose prevention is one of the most urgent public health priorities of our time. The tools to prevent overdose deaths exist — naloxone, fentanyl test strips, harm reduction education, and expanded access to treatment — but they must be widely distributed and used. This article provides a practical, evidence-based guide to opioid overdose prevention for individuals, families, and communities.

Key Definitions

Opioid overdose: A life-threatening emergency in which opioids suppress breathing to the point of respiratory failure. Without intervention, brain damage and death occur within minutes.

Naloxone (Narcan, Kloxxado, Zimhi): An opioid antagonist that rapidly reverses opioid overdose by blocking opioid receptors. Available as nasal spray, auto-injector, and injectable formulations.

Good Samaritan laws: State laws that provide legal protection for people who call 911 during a drug overdose. Available in most states but vary in scope.

Harm reduction: Policies and practices that reduce the negative consequences of drug use without requiring abstinence. Includes naloxone distribution, fentanyl test strips, and supervised consumption sites.

Post-overdose care: Medical and psychosocial care provided after a non-fatal overdose, including assessment for opioid use disorder and initiation of treatment.

Recognizing Opioid Overdose

Recognizing opioid overdose quickly is essential for effective response. Key signs:

Classic signs:

• Unconscious or unresponsive — cannot be awakened by shouting or sternal rub
• Slow, shallow, or absent breathing (fewer than 1 breath per 5 seconds)
• Choking, gurgling, or snoring sounds (the "death rattle")
• Blue or purple lips, fingertips, or face (cyanosis) — indicating oxygen deprivation
• Pinpoint (very small) pupils
• Limp body
• Pale, clammy skin

Distinguishing overdose from being "high": A person who is very high may be difficult to wake but will respond to stimulation. A person who is overdosing will not respond to stimulation, will have very slow or absent breathing, and may have blue lips or fingertips.

Responding to Opioid Overdose: Step-by-Step

1. Try to wake the person: Call their name loudly, rub your knuckles firmly on their sternum (breastbone). If they don't respond, proceed immediately.
2. Call 911: Call immediately. Tell the dispatcher that someone is unresponsive and not breathing. Stay on the line. Most states have Good Samaritan laws that protect you from prosecution for calling 911.
3. Administer naloxone: If available, administer naloxone immediately. For nasal spray: place the tip in one nostril and press the plunger. For auto-injector: follow the voice instructions. Repeat every 2-3 minutes if there is no response, up to 3 doses.
4. Perform rescue breathing: If the person is not breathing, perform rescue breathing — tilt the head back, lift the chin, and give one breath every 5 seconds. If trained, perform CPR if there is no pulse.
5. Place in recovery position: If the person is breathing but unconscious, place them on their side (recovery position) to prevent aspiration of vomit.
6. Stay with the person: Stay until emergency services arrive. Naloxone wears off in 30-90 minutes — if the person received a large dose of fentanyl, they may re-overdose when naloxone wears off.

Naloxone: What Everyone Needs to Know

Availability: Naloxone is available without a prescription in most states. It can be obtained at pharmacies, community health centers, harm reduction programs, and through mail-order programs. Many states have standing orders that allow pharmacists to dispense naloxone without an individual prescription.

Formulations:

• Narcan nasal spray (4mg): The most widely used formulation. Easy to use, no needles required. One spray per nostril.
• Kloxxado nasal spray (8mg): Higher-dose formulation, may be more effective for high-potency fentanyl overdoses.
• EVZIO auto-injector: Provides voice instructions for use. Injected into the outer thigh.
• Injectable naloxone: Used by healthcare providers and trained first responders.

Dosing for fentanyl overdose: Fentanyl's high potency means that standard naloxone doses may be insufficient. The current recommendation is to administer 2-4mg (one or two doses of the 4mg nasal spray) and repeat every 2-3 minutes if there is no response. Multiple doses may be needed.

Safety: Naloxone is safe to administer even if you are not sure whether the person has taken opioids. It will not harm someone who has not taken opioids. It has no effect on non-opioid overdoses.

Fentanyl Test Strips

Fentanyl test strips can detect the presence of fentanyl in drugs before use, allowing people to make informed decisions about their drug use. They are inexpensive (approximately $1 per strip), easy to use, and have been shown to change drug use behavior — people who test positive for fentanyl are more likely to use less, use with others, or not use at all.

Fentanyl test strips are legal in most states, though some states still classify them as drug paraphernalia. Advocacy for their legalization is an important harm reduction priority.

Good Samaritan Laws

Fear of legal consequences is a major barrier to calling 911 during an overdose. Good Samaritan laws — available in most states — provide legal protection for people who call 911 during a drug overdose. The scope of protection varies by state — some protect only the person who calls, while others protect all people present. Know your state's law, and advocate for stronger protections if your state's law is limited.

Post-Overdose Care: A Critical Opportunity

A non-fatal overdose is a critical opportunity for intervention. Research has shown that people who survive an overdose are at extremely high risk for subsequent overdose — the period immediately following an overdose is one of the highest-risk periods for fatal overdose. Post-overdose care should include:

• Assessment for opioid use disorder
• Offer of medication-assisted treatment (buprenorphine can be initiated in the emergency department)
• Naloxone prescription and education
• Connection to recovery support services
• Follow-up care

Frequently Asked Questions

Can I get in trouble for calling 911 during an overdose?
Most states have Good Samaritan laws that protect people who call 911 during a drug overdose from prosecution for drug possession. Check your state's law. Even in states without Good Samaritan laws, calling 911 is always the right thing to do — a person's life is more important than legal risk.

How do I get naloxone?
Naloxone is available without a prescription at most pharmacies in the United States. It can also be obtained through harm reduction programs, community health centers, and mail-order programs. NEXT Distro and other organizations provide free naloxone by mail in many states.

What if naloxone doesn't work?
If naloxone doesn't work after 2-3 doses, the overdose may not be opioid-related, or the fentanyl dose may be very high. Continue rescue breathing and CPR if needed, and wait for emergency services. Do not give up — continue administering naloxone every 2-3 minutes.

Key Takeaways

• Opioid overdose is recognizable by unconsciousness, slow or absent breathing, blue lips, and pinpoint pupils.
• The response to overdose: call 911, administer naloxone, perform rescue breathing, place in recovery position, stay with the person.
• Naloxone is available without a prescription in most states and should be widely distributed to anyone at risk of opioid overdose.
• Fentanyl test strips can detect fentanyl in drugs before use and are an important harm reduction tool.
• A non-fatal overdose is a critical opportunity for intervention — post-overdose care should include assessment and offer of treatment.

Additional Resources

Related articles on Sobriety Navigator: Opioid Use Disorder, Fentanyl and the Opioid Crisis, Medication-Assisted Treatment.