Overdose Risk

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:

• Preventing an Opioid Overdose (PDF—1.59 MB)
• Naloxone for Opioid Overdose: Life-Saving Science (PDF—199 KB)
• Opioid Safety and How To Use Naloxone (PDF—496 KB)
• Take Care Take Charge: Safety Tips for People Who Use or Inject Drugs (PDF—427 KB)
• Opioid Prevention and Response (PDF—974 KB)

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

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.

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.