Overdose and Overdose Response

This section focus on the opioid and other drug overdose crises, current drug threats, and identifying and responding to an overdose emergency. Upon completion of this section learners will be able to:

  • Describe the current public health situation related to drug overdose deaths,
  • Identify and respond to an overdose emergency, and
  • Explain how up-to-date information on current drug threats can help prevent overdose.

About the Opioid Crisis

The opioid crisis was the result of illegal and unethical practices by prescription opioid manufacturers, promotors, distributers, and prescribers. Beginning in 2007, the Department of Justice charged opioid manufacturers with felony level offenses resulting in guilty plea agreement and millions I fines.  Since that time enormous sums have been paid to settle suits in federal, state, and local courts that will likely total in the hundreds of billions in damages before it’s over.

The public health impacts include reductions in life expectancy (for years that preceded the COVID-19 pandemic), nearly a million overdose deaths, and costs to taxpayers are likely to continue to accrue for the foreseeable future.

However, the most damaging effect continues to be the increased drug demand and supply of heroin, illicitly manufactured fentanyl, other deadly analogues such as carfentanil, methamphetamine, cocaine, and counterfeit pills that may contain any of the above.

The FDA approval of Oxy Contin in 1996 marks the beginning of the prescription opioid problem. Fatalities peaked around 2010.

After 2016, when opioid prescribing guidelines reduced the availability of prescription opioids, overdose deaths had the highest spike to date, as supplies of potent heroin and illicitly produced fentanyl increased.

However, in 2020 overdose deaths increased 31% in comparison to 2019. Recently, the CDC announced that overdose deaths will reach an all-time high, exceeding 104,000 deaths based on provisional data available for the most the most recent 12-month period. These data not only reflect the impact of the pandemic, but they also illustrate disproportionate increases in overdose deaths among Indigenous and African Americans (both increasing 44% in 2020).

Where are we now?

Overdose deaths continue to rise.  The annual estimates of the “economic burden” of the opioid crisis exceed a trillion dollars in loss of productivity due to mortality and morbidity, plus the costs of health care, emergency response, addiction treatment, criminal justice involvement, foster care, and other child welfare costs.

What factors might increase the likelihood of an opioid overdose?

There are many factors associated with a risk of opioid overdose.  However, development of formal overdose risk assessments is in its infancy.  Some of the risk factors include:

  • History of previous non-fatal overdose
  • Injecting illicit opioids
  • High levels of drug use, intoxication, and alcohol use
  • Lowered tolerance due to abstinence during periods of incarceration, treatment, or a return to use after a period in recovery
  • A history of combining opioids with benzodiazepines, alcohol, or other CNS depressants
  • Feelings of hopelessness and suicidal thoughts
  • Higher risk injecting behaviors, such as sharing used equipment
  • HIV positive or other chronic health problems (Zedler et al. 2015)
  • Use of opioids in combination with sedatives or alcohol – this is a critical factor (Dietzea et al. 2006)

Key Consideration: Post-Incarceration Drug Overdose Fatalities

Drug overdose is the leading cause of post-release death. A recent study found that 85% of fatalities that occurred in the first 2 weeks after release were attributable to drug overdose. (Bukten et al. 2015) Although opioid overdose deaths made up the largest share, studies show that cocaine and other stimulants are also responsible for a substantial number of deaths. (Calcaterra et al. 2012)

According to a study of recently released prisoners who survived a drug overdose, two of the most common reasons they gave for the overdose were:

  • A lack of knowledge about decreased tolerance levels after a period of limited access to drugs during incarceration, and
  • Increase potency levels of street drugs during the time they spent in custody. (Binswanger et al. 2012)

How do different types of drugs cause overdose and what are the treatment options?

The drugs most frequently involved in overdose fatalities are:

  1. Opioids (both illicit and pharmaceutically produced)
  2. Stimulants (mainly cocaine and methamphetamine), and
  3. Benzodiazepines (alprazolam or Xanax and diazepam or Valium). (Warner et al. 2016)

While there are steps people can take to prevent on opioid overdose emergency, it is important to note that there is no medication that can reverse a stimulant overdose.

Types of substances and the mechanisms of overdose

Depressants Stimulants
Examples of substances Opioids, Benzodiazepines Cocaine, Methamphetamines
Signs of overdose
  • Falling asleep or loss of consciousness​ (person will not wake up, body is limp)​
  • Abnormal breathing (slow, shallow breathing​, choking or gurgling sounds​)
  • Other physical signs
    • Pale, blue, or cold skin​
    • Small, constricted “pinpoint pupils”​
  • Agitation (restlessness, hallucinations, rapid breathing, panic states)
  • Muscle pains an weakness
  • Heart problems (irregular heartbeat, abnormal blood pressure)
  • Stomach issues (nausea, vomiting, cramps, diarrhea)
  • Convulsions, seizures
Physiology of overdose death
  • Respiratory depression
  • Lack of oxygen to the brain can cause serious health consequences in cases of non-fatal overdose. (World Health Organization 2018)
  • Cardiovascular causes such as heart attack, stroke, seizure, and hemorrhage.
  • Pre-existing cardiovascular disease heightens fatality risk. Up to 82% of those who die of methamphetamine overdose have pre-existing cardiovascular disease. (Wagner 2017)
Treatment options
  • Naloxone (opioids)
  • Flumazenil (benzodiazepines)
  • No medication available
  • Treatment manages symptoms such as elevated blood pressure and hyperthermia


Naloxone is a short-acting opioid antagonist that immediately blocks the effects of opioids, including respiratory depression. When administered during an opioid overdose emergency, naloxone blocks the effects of opioids on the brain and can restores breathing within two to eight minutes. Naloxone has been used for more than 40 years save lives.

Key Points about Administering Naloxone

Know what to expect after administering a dose.
  • When individuals are addicted to opioids are revived with naloxone, they may experience immediate, intense withdrawal symptoms known as precipitated withdrawal. (Office of the U.S. Surgeon General, U.S. Department of Health and Human Services 2018) This typically results in a strong desire to use more opioids. Therefore, it is important to monitor individuals revived with naloxone to counter this short-term, predictable physiological response.
Give the right number of doses.
  • More than one dose of naloxone may be required to revive individuals overdosing on potent illicit opioids. It is not uncommon to have to administer 2 to 4 doses before successfully reviving an individual. (Faul et al. 2017) Also, the effects of naloxone only last for 30–90 minutes. A follow-up second dose is usually administered to prevent respiratory depression from returning as the medication wears off. Most naloxone kits contain two doses for this reason. All overdose survivors revived with naloxone should get medical attention. (European Monitoring Centre for Drugs and Addiction)
Respond quickly.
  • Naloxone cannot reverse any damage oxygen deprivation does to the brain. Performing rescue breathing until emergency medical help arrives and naloxone is administered can prevent damage from occurring.
Position the person correctly.
  • To prevent individuals from choking from vomiting, they should be placed on their side with their top arm across their torso, bottom arm under their heads, and knees slightly bent. This placement is especially crucial if overdose victims must be left for any length of time.


Flumazenil, like naloxone, is an antagonist medication that can reverse a benzodiazepine overdose and prevent respiratory depression, coma, and death.

However, nearly all benzodiazepine overdose fatalities involve alcohol or other drugs, and flumazenil may be contraindicated when multiple substances are involved.  Flumazenil may also be contraindicated for individuals who have taken high doses for extended periods. As with alcohol and opioids, tolerance to benzodiazepines occurs with regular use.

Abrupt benzodiazepine withdrawal, in these cases, can involve serious symptoms, including seizures, delirium tremens, and psychosis. (Hedegaard et al. 2018) Delirium tremens is a state of confusion that is usually related to alcohol withdrawal, and it can take several days to begin. Unlike naloxone, flumazenil cannot be legally administered by a non-medical professional.

Regional Drug Threat Information

When peer support specialists stay current on local drug threats and trends, they can alert the people they work with who may be at-risk for returning to or continuing illicit drugs use.  This harm reduction approach is becoming more important as communities deal with overdose ‘outbreaks,’ counterfeit pills, and adulterated street drugs. Some of the following resources provide information about talking to people in the community who are seeking recovery can really help peer support specialist understand what more about local drug supplies.

CA Opioid Surveillance Dashboard

High Intensity Drug Trafficking Areas

Local Emergency Responders and Law Enforcement Agencies


[1] Zedler B et al. LB010. “Validation of a Screening Risk Index for Overdose or Serious Prescription Opioid-Induced Respiratory Depression.” Presented at: AAPM 2015. March 19-22, 2015; National Harbor, Maryland.

[2] Dietzea, P. et al. (2006). When is a Little Knowledge Dangerous? Circumstances of recent heroin overdose and links to knowledge of overdose risk factors. Alcohol and Drug Dependence, Vol. 84 No 3, pp 223-230.

National Institute on Drug Abuse (NIDA). (2018, June). Drug Facts: Prescription Stimulants. National Institutes of Health. https://nida.nih.gov/sites/default/files/drugfacts-prescriptionstimulants.pdf

15 Bukten, A., Lund, I. O., Rognli, E. B., Stavseth, M. R., Lobmaier, P., Skurtveit, S., . . . Kunøe, N. (2015). The Norwegian Offender Mental Health and Addiction study—Design and implementation of a national survey and prospective cohort study. Substance Abuse: Research and Treatment, 2015:9(S2), 59–66. doi:10.4137/SART.S23546

16 Calcaterra, S., Blatchford, P., Friedmann, P., & Binswanger, I. (2012). Psychostimulant-related deaths among former inmates. Journal of Addiction Medicine, 6(2), 97–105. doi:10.1097/ADM.0b013e318239c30a

17 Binswanger, I. A., Nowels, C., Corsi, K. F., Glanz, J., Long, J., Booth, R. E., & Steiner, J. F. (2012). Return to drug use and overdose after release from prison: A qualitative study of risk and protective factors. Addiction Science & Clinical Practice. doi:10.1186/1940-0640-7-3

33 Warner, M., Trinidad, J. P., Bastian, B. A., Miniño, A. M., & Hedegaard, H. (2016). Drugs most frequently involved in drug overdose deaths: United States, 2010–2014. National Vital Statistics Report, 10(65). Retrieved from Centers for Disease Control and Prevention website https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_10.pdf

34 World Health Organization (August 2018). Information sheet on opioid overdose [Webpage]. Retrieved from http://www.who.int/substance_abuse/information-sheet/en/

35 Heard, K., Palmer, R., & Zahniser, N. R. (2008). Mechanisms of acute cocaine toxicity. The Open Pharmacology Journal, 2(9), 70–78. doi:10.2174/1874143600802010070 36 Pittman, H. J. (2005). Methamphetamine overdose. Nursing, 35(4), 88.

37 Wagner, G. (2017). County of San Diego Department of the Medical Examiner 2016 annual report. Retrieved from https://www.sandiegocounty.gov/content/dam/sdc/me/docs/SDME%20Annual%20Report%202016.pdf

47 Office of the U.S. Surgeon General, U.S. Department of Health and Human Services. (2018). U.S. Surgeon General’s advisory on naloxone and opioid overdose. Retrieved from https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html

48 U.S. Department of Justice Drug Enforcement Administration. (2017, October). National drug threat assessment (DEA-DCT-DIR-040-17). Retrieved from https://www.dea.gov/sites/default/files/docs/DIR-040-17_2017-NDTA.pdf

49 Rosenberg, M., Chai, G., Mehta, S., & Schick, A. (2018). Trends and economic drivers for United States naloxone pricing, January 2006 to February 2017. Addictive Behaviors, 86, 86–89. doi: 10.1016/j.addbeh.2018.05.006.

50 Faul, M., Lurie, P., Kinsman, J. M., Dailey, M. W., Crabaugh, C., & Sasser, S. M. (2017). Multiple naloxone administrations among emergency medical service providers is increasing. Prehospital Emergency Care, 21(4), 411–419. doi:10.1080/10903127.2017.1315203

51 European Monitoring Centre for Drugs and Drug Addiction. (n.d.). Harm reduction topics page. Retrieved from http://www.emcdda.europa.eu/topics/harm-reduction.

52 Hedegaard, H., Miniño, A., & Warner, M. (2018). Drug Overdose Deaths in the United States, 1999–2017 (National Center for Health Statistics Data Brief No. 329). Retrieved from the Centers for Disease Control and Prevention website https://www.cdc.gov/nchs/data/databriefs/db329- h.pdf.