Opioid Overdose and Naloxone

The signs of an opioid overdose are unconsciousness or an inability to wake the person, slow or shallow breathing or choking and gurgling sounds, fingernails or lips turning blue or purple (or skin turning pale, grayish or ashen on darker skin), and pinpoint pupils. SAMHSA's published response is four steps: check for a response, give an opioid overdose reversal medication such as naloxone, call 911 and support the person's breathing, and wait for emergency medical services to arrive.

Signs of an opioid overdose

SAMHSA's Overdose Prevention and Response Toolkit lists these as the signs and symptoms of an opioid overdose (source 1):

• Unconsciousness, or an inability to awaken the person.
• Slow or shallow breathing, or difficulty breathing — including choking sounds or a gurgling or snoring noise from a person who cannot be awakened.
• Fingernails or lips turning blue or purple. SAMHSA notes that for lighter-skinned people the skin tone may turn bluish purple, and for darker-skinned people the skin tone may turn pale, grayish or ashen.
• Pinpointed pupils, or pupils that do not react to light.

SAMHSA's instruction if an overdose is suspected is to first try to wake the person by calling their name; if that does not work, rub your knuckles on the person's upper lip or the center of the chest. If the person does not respond, or you are not sure what to do next, call 911.

SAMHSA also states plainly that there is no “type” of person who experiences opioid use disorder or opioid overdose, and that research has shown women, older people, and those without obvious signs of opioid use disorder are undertreated with reversal medications and, as a result, have a higher death rate. Its guidance is to use a reversal medication any time someone shows symptoms of overdose (source 1).

The four response steps

SAMHSA publishes these as the overdose response steps (source 1):

1. Check for a response. Call the person's name; if there is no response, rub your knuckles on the upper lip or center of the chest.
2. Give an opioid overdose reversal medication. Naloxone and nalmefene are the two SAMHSA names. If overdose is suspected and the person is unresponsive, give it as quickly as possible and then call 911. SAMHSA states these medications do not cause harm if given to a person who is not experiencing an opioid overdose.
3. Call 911 and support the person's breathing. Give rescue breaths if you can, or place the person in the recovery position — rolled onto their side with the top leg bent to support the position. SAMHSA's stated goal of overdose reversal is to restore breathing, and it puts it directly: breathing is more important than waking up. If you are not trained in rescue breathing and chest compressions, follow the 911 operator's instructions.
4. Wait for emergency medical services to arrive. SAMHSA advises encouraging the person to be treated by EMS or to go to an emergency department, because overdose symptoms can recur once the reversal medication wears off.

If the person does not start breathing or otherwise respond after 2 to 3 minutes, SAMHSA's guidance is to give a second dose, and to continue giving doses every 2 to 3 minutes until the person starts breathing (source 1).

How naloxone nasal spray is given

These are the steps as published by MedlinePlus, the National Library of Medicine's consumer drug information service, drawing on AHFS Patient Medication Information (source 2). Over-the-counter products also carry directions for use on the Drug Facts Label of the product itself (source 1) — read the label that comes with your device, because products differ.

1. Lay the person on their back.
2. Remove the nasal spray from the box and peel back the tab to open it. Do not prime the spray before using it.
3. Hold the device with your thumb on the bottom of the plunger and your first and middle fingers on either side of the nozzle.
4. Gently insert the tip of the nozzle into one nostril until your fingers on either side of the nozzle are against the bottom of the person's nose. Support the back of the person's neck with your hand to let the head tilt back.
5. Press the plunger firmly to release the medication, then remove the nozzle from the nostril.
6. Turn the person on their side into the recovery position and call for emergency medical assistance immediately after the first dose.
7. If the person does not respond — waking to voice or touch, or breathing normally — or responds and then relapses, give another dose. Repeat every 2 to 3 minutes in alternating nostrils, using a new nasal spray each time, until emergency medical assistance arrives.

Each naloxone nasal spray device contains a single dose and is used once. MedlinePlus advises being aware of the expiration date on the device and replacing it when that date passes (source 2). Separately, SAMHSA notes that studies show naloxone's stability remains at a usable standard even after multiple years of storage, and that while it may become less effective over time, research indicates it does not cause harm if used past its expiration date (source 1). Both statements are on this page because they are both true and they answer different questions: replace it when you can, use it anyway if that is what you have.

What naloxone does and does not do

The FDA describes naloxone as a lifesaving emergency treatment that reverses opioid overdose, states that it is a medicine with no abuse potential and is not a controlled substance, and that it can be administered by individuals with or without medical training. The FDA approved the first over-the-counter naloxone nasal spray in March 2023, and the first nalmefene hydrochloride nasal spray, which is available by prescription, in May 2023 (source 3).

What it works on. SAMHSA states that all opioid overdose reversal medications are effective in reversing opioid overdose, including overdose caused by fentanyl, and that they can be used in both youth and adult populations. Its guidance is to use them even if you are not sure what drugs someone took (source 1).

Where it is limited. SAMHSA states that these medications may be less effective if someone has used multiple different drugs, especially other drugs with a sedating effect such as alcohol or benzodiazepines. It also notes that xylazine — an active ingredient in a sedative that the FDA has approved for use in animals but not in humans — is increasingly being mixed into the unregulated drug supply, and that these drugs may make overdose reversal more challenging (source 1). Separately, MedlinePlus notes that naloxone nasal spray may not reverse the effects of certain opioids such as buprenorphine and pentazocine, and may require additional doses with a new nasal spray each time (source 2).

What it does not do. Naloxone is an emergency measure. It is not treatment for opioid use disorder, and nothing on this page should be read as saying otherwise.

Where to get naloxone

SAMHSA states that opioid overdose reversal medications are available in all 50 states, territories, and Tribal Nations and communities, and that they are available to the public by prescription, through standing orders, or without a prescription over the counter at pharmacies and other retail outlets — or at no charge from local community-based organizations that provide them. It notes that training is typically not required to obtain one (source 1).

SAMHSA lists several no-cost routes: asking your local health department, visiting a community-based organization, and noting that many state and local health departments and behavioral health agencies now offer these medications through vending machines, street outreach, and at fairs, festivals and other local events. Some programs deliver by mail. SAMHSA also describes the “NaloxBox” — an emergency kit that can sometimes be found alongside public defibrillators (source 1).

SAMHSA's position is that everyone should keep one of these medications on hand, and especially those who use opioids or other drugs, or who have friends or family members who do (source 1).

After the reversal

SAMHSA notes that when a person who has developed physical dependence on opioids is given a reversal medication, they may start breathing again but may also develop signs and symptoms of opioid withdrawal — which it lists as including body aches, diarrhea, fast heart rate, fever, runny nose, sneezing, gooseflesh, sweating, yawning, nausea or vomiting, nervousness, restlessness or irritability, shivering or trembling, abdominal cramps, weakness, tearing, insomnia, opioid craving, and dilated pupils (source 1).

This is worth knowing in advance, because a person who wakes up in withdrawal may be distressed, confused or angry. SAMHSA's guidance to encourage EMS treatment or an emergency department visit does not change because of that reaction: symptoms can recur when the reversal medication wears off.

Good Samaritan laws

SAMHSA advises familiarizing yourself with your state's Good Samaritan laws, and describes them as laws that provide limited immunity from certain civil or criminal consequences of drug use, or of rendering assistance in response to drug use, in the event of an overdose. These laws differ by state. SAMHSA points readers to the Network for Public Health Law for state-level detail (source 1).

We are not summarizing any individual state's law here. The wording and the limits vary, and a paraphrase is exactly the kind of thing that gets a detail wrong on a page where a wrong detail matters. Read your own state's, through the link SAMHSA gives: Network for Public Health Law — Overdose Good Samaritan Laws.

Keep going

• Which level of care applies?
• Detox, inpatient, outpatient or MAT — which one is me?
• The first 72 hours in detox: what actually happens
• What to bring to detox
• Questions to ask a treatment facility
• How to talk to a family member about addiction
• Browse treatment facilities by state

This page is informational and is not medical advice or a substitute for overdose response training. Brief training on administering these medications can be obtained from the provider of the kit, or from your pharmacist or medical provider — SAMHSA's own recommendation (source 1).