Mitigating Overdose Risk

Educate patients and families about factors that increase the risk of overdose and how naloxone can reverse overdose so they can be prepared to respond if an overdose occurs.

People with OUD are most at risk of overdose when they use opioids following periods of abstinence or significantly diminished use.⁶ During these times, their opioid tolerance is likely to decrease so use of previous quantity of opioids can be enough to trigger an overdose. This increased risk of overdose is more common in the following situations:

• After leaving a controlled environment such as inpatient or residential stay or release from prison or jail;
• After discontinuing a medication for OUD or trying to remain opioid-free without medication;
• When using opioids, such as illicit fentanyl, where the opioid dose and the other substances included are unknown;
• When taking opioids in combination with other respiratory depressants (e.g., alcohol, benzodiazepines);⁷ and
• In individuals experiencing suicidal thoughts, ideation, or planning.

Actively encourage patients and families to obtain and carry naloxone. Prompt administration of naloxone can reverse an overdose and save lives.¹⁰ Indeed, meta-analysis shows that naloxone distribution programs are associated with higher overdose survival rates.¹⁰ But this depends on people with OUD and those around them having naloxone readily available. Ideally, hand a naloxone kit to each patient with OUD.

Since 2023, naloxone has been available without a prescription in all 50 states and the District of Columbia, yet access to the medication remains imperfect. Challenges include knowledge, availability in some areas, and cost. Many treatment-seeking adults with OUD do not know where to obtain naloxone, and only about half of them carry it.¹¹ Though sometimes health insurance may help defray the cost of naloxone, the cost can be prohibitive for some people. A two-pack kit of over-the-counter naloxone costs approximately $45, and fewer naloxone kits are sold in lower income areas.¹²

Providers can play a significant role in promoting naloxone. For example, youth (aged 10-19) access to naloxone (based on prescriptions filled) increased 395% nationwide from 2017 to 2022. Primary care and pediatricians were among the highest prescribers and increased their rate of naloxone prescriptions filled by 952% and 991%, respectively, over the 6-year study period.¹³

People are interested in carrying naloxone. For example, one program used naloxone distribution boxes (akin to newspaper boxes) in hospital and other healthcare settings that were available at all hours and readily visible. The number of kits distributed via these boxes vastly exceeded physician-directed naloxone distribution (2,383 vs. 17 kits, respectively) in 6 months).¹⁴

Depending on availability in your state, you may find free or low-cost naloxone kits. Naloxone can be obtained free-of-charge from some public spaces such as libraries, community health centers, and vending machines, and it is also available at many stores and online. 

Learn more about state naloxone laws in the Naloxone Access Summary of State Laws (PDF - 6.4 MB).

Train providers, staff, patients, and families on how to recognize an opioid overdose and respond by administering naloxone. Keep naloxone available in the office, and ideally, provide it to patients and their families. See Resources section for patient education materials.

Signs and symptoms of an overdose include:⁸

• Small or constricted pupils;
• Loss of consciousness or inability to awaken;
• Shallow breathing or slow heart rate;
• Choking or gurgling sounds;
• Limpness; and
• Pale, blue, or cold skin.

Make sure all staff know what to do in the event of an overdose. Ensure staff are trained in naloxone administration including rescue breathing and that naloxone kits are readily available onsite. Consider printing and laminating a tip card such as the following: Preventing an Opioid Overdose: Know the Signs. Save a Life. | Overdose Resource Exchange (ORE) | CDC. If someone appears to be experiencing an overdose, take the following steps:⁸

1. Administer naloxone.
2. Call 911 immediately to enlist the help of first responders.
3. Aim to keep the affected person awake and breathing. Provide rescue breathing as needed.
4. Place the person on their side to avoid choking.
5. Stay with the person until emergency personnel arrive.

If one of your patients has an overdose, review their treatment plan to determine whether changes and additional services are needed. This may mean transitioning them to a higher level of care.

Individuals who have survived an overdose may continue to experience intense emotions such as shame, guilt, or anger. Encourage them to find a network of support through family, friends, and community-based organizations.⁷ As discussed in the section on Suicidality, it is also important to recognize that an overdose may have been intentional.

Consider regularly checking your state's Prescription Drug Monitoring Practice to see if a patient is obtaining prescription opioids from another prescriber, as it may indicate a return to use.⁷