Overdose Risk

The risk of overdose poses a distinct threat to the safety and survival of individuals with opioid use disorders. In 2017, more than 47,000 individuals died from an opioid-related drug overdose. Further, the overdose death rate from synthetic opioids, including fentanyl, increased more than 45 percent from 2016 to 2017.1

While participation in medication-assisted treatment (MAT) decreases opioid-related and all-cause mortality in general, patients who begin using opioids again after a period of abstinence are at heightened risk for overdose as their tolerance may have changed. Therefore, it is important that providers and other staff address the risk of overdose throughout the course of treatment and are adequately prepared to respond.

High-risk behaviors include consuming large volumes of opioids; taking opioids in combination with other respiratory depressants (e.g., alcohol, benzodiazepines); and using opioids in which the contents of the substance are unknown (e.g., heroin potentially laced with fentanyl).2

In addition, as the earlier section on Suicidality described, individuals experiencing suicidal thoughts, ideation, or planning may be at greater risk for overdose. Providers should teach patients and their families how to reduce risk of overdose and how to intervene when an overdose occurs, including providing naloxone. It is also important for providers to understand that rapid access to low-barrier MAT can also serve as an overdose mitigation strategy.

North Star

The clinical care team understands the risk of overdose among patients with opioid use disorder, has been trained on how to identify signs of an overdose and respond accordingly, and provides education and other support, including naloxone, to patients at risk.

How Do You Do It?

Train Providers, Patients, and Families About Overdose

When beginning a MAT program, all providers and staff should be trained on how to recognize an overdose and respond by administering naloxone. It is also important that providers educate patients and families about these risks and appropriate responses and make naloxone available to them so they can intervene to save a loved one who has overdosed.

Signs and symptoms of an overdose include3:

  • 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.

Providers need to provide basic education to patients and families about the importance of naloxone.

  • What is naloxone? It is a medication that, when administered in a timely manner, can reverse the effects of an opioid overdose, including respiratory depression, that may lead to death.4
  • How does naloxone work? It is an opioid antagonist, meaning it displaces opioids from the receptor sites in the brain, which then blocks the effects of other opioids in the bloodstream. While it may cause uncomfortable withdrawal symptoms, naloxone is safe to use.4
  • How is naloxone administered? Naloxone is available in several forms: an injectable, a nasal spray (Narcan), and an autoinjector (Evzio). Instructions for use depend on the type of product.

Examples of educational materials include the following:

The Institute for Research, Education, and Training in Addictions (IRETA) also highlights several opportunities for providers to address the risk of overdose throughout the course of treatment5:

  • Waitlists—Individuals on program waitlists should receive information about the risks of and appropriate responses to an overdose. Programs should also consider giving patients at higher risk of an overdose priority for participating in the program if capacity is limited.
  • Screening and Assessments—Programs should consider including items on initial screening and assessments, such as history of overdose or exposure to trauma, that may indicate a patient’s increased risk.
  • Induction and Orientation— Initial stages of treatment may present a higher risk of overdose as individuals are just beginning to stabilize on their medications. Education about the risk of overdose can be incorporated into all early treatment sessions and medication management visits.
  • Counseling—Behavioral health providers can deliver psychoeducation about preventing relapse and overdose to both patients and families or discuss past experiences with overdose.
  • Positive Drug Screens—When urine drug test results screen positive for illicit opioid use, providers can use the opportunity to discuss the risks of overdose associated with continued use. Providers can emphasize that these are safety concerns for the patient, rather than judgment.
  • Discharge—Before patients are discharged from the MAT program, it is important to do extensive relapse planning and overdose prevention, even if they are in recovery. Providers should be sure to give their patients all of the skills, information, and tools they will need to continue to be safe.

Providers should also regularly check their State’s Prescription Drug Monitoring Program to see if a patient is obtaining prescription opioids from another prescriber, as it may indicate a return to use.2

Increase Access to Naloxone and Promote Its Use

In recent years, Federal and State governments have worked to increase access to naloxone. However, restrictions may still exist in terms of whether a prescription is needed, who can obtain naloxone prescriptions, and who can administer the medication. In addition, States have moved to enact laws that offer liability and criminal protections to bystanders or first responders who witness an overdose or administer naloxone. Learn more about laws related to naloxone in your State (PDF—1.29 MB).

Whether or not the State requires clinicians to provide a prescription for naloxone, it is important that providers actively encourage patients and families to obtain naloxone. Naloxone should be made freely available to all patients being treated for opioid use disorder as well as their families and caregivers. When resources are limited, naloxone should be given to patients at higher risk of overdose, including those who:

  • Have a history of overdose;
  • Report taking benzodiazepines;
  • Are at risk of returning to a higher dose for which they no longer have the tolerance; and
  • Report taking higher doses of opioids (e.g., more than 50 morphine milligram equivalents per day).2

Some patients and families may be concerned about the cost associated with purchasing naloxone at the pharmacy. Given the increased grant funding to combat the opioid epidemic, other naloxone distribution initiatives or programs may be available in their State or community.

Learn more about guidance for prescribing naloxone in primary, chronic pain, or palliative care settings.

Respond to an Overdose

After someone recognizes the warning signs and believes someone may be experiencing an overdose, he or she should take the following steps3:

  1. Call 911 immediately to enlist the help of first responders.
  2. Administer naloxone.
  3. Aim to keep the person possibly experiencing an overdose awake and breathing.
  4. Place the person on his or her side to avoid choking.
  5. Stay with the person until emergency personnel arrive.

If providers witness or learn that one of their patients is having an overdose, they should ensure that their patient is connected with the appropriate treatment as followup. This treatment might mean a higher intensity of treatment or recovery supports or transitioning patients to a higher level of care. If patients have recently stopped participating in treatment, providers should do their best to encourage them to re-engage, using motivational interviewing techniques.

In other cases, the patient experiencing an overdose may be part of the primary care practice but not already a participant in the MAT program. In this situation, providers should do a followup screening and diagnosis for an opioid use disorder, start the patient on medications for opioid use disorder, and connect him or her other treatment services, as appropriate.

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 other community-based organizations.2 As discussed in the section on Suicidality, it is also important to recognize that this overdose may or may not have been accidental. Providers should screen patients for suicide risk and conduct brief interventions, as needed.

What Not To Do

  • Don’t create barriers to access to naloxone.


Opioid Overdose Prevention Toolkit

Equips healthcare providers, communities, and local governments with material to develop practices and policies to help prevent opioid-related overdoses and deaths. Addresses issues for healthcare providers, first responders, treatment providers, and those recovering from opioid overdose.

Behavioral Health Providers
Medical Providers
Policymakers and Payers
Substance Abuse and Mental Health Services Administration
  1. Scholl L, Seth P, Kariisa M, et al. Drug and opioid-involved overdose deaths — United States, 2013–2017. MMWR Morb Mortal Wkly Rep 2019;67:1419-27. https://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1.htm?s_cid=mm675152e1_w. Accessed June 12, 2019.
  2. Substance Abuse and Mental Health Services Administration. Opioid Overdose Prevention Toolkit. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. Publication No. SMA18-4742. https://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA18-4742. Accessed June 12, 2019.
  3. Centers for Disease Control and Prevention. Preventing an Opioid Overdose. Atlanta, GA: Centers for Disease Control and Prevention; n.d. https://www.cdc.gov/ore/search/pages/Preventing-an-Opioid-Overdose-Tip-Card-a.html. Accessed June 12, 2019.
  4. National Institute on Drug Abuse. Naloxone for Opioid Overdose: Life-Saving Science. Bethesda, MD: National Institutes of Health; 2017. https://nida.nih.gov/publications/naloxone-opioid-overdose-life-saving-science. Accessed June 12, 2019.
  5. Institute for Research, Education & Training in Addiction. Opportunities To Address Overdose in Treatment. Pittsburgh, PA: Institute for Research, Education & Training in Addiction; 2018. https://ireta.org/resources/opportunities-to-address-overdose-in-treatment/. Accessed June 12, 2019.