SAMHSA

Opioid Overdose Prevention

TOOLKIT: 

Facts for Community Members

Five Essential Steps for First Responders

Information for Prescribers

Safety Advice for Patients & Family Members

Recovering From Opioid Overdose
ii

ACKNOWLEDGMENTS 

Acknowledgments

This publication was prepared for the Substance Abuse and Mental Health Services Administration 

(SAMHSA) by the Association of State and Territorial Health Officials, in cooperation with Public Health 

Research Solutions, under contract number 10-233-00100 with SAMHSA, U.S. Department of Health and 

Human Services (HHS). LCDR Brandon Johnson, M.B.A., served as the Government Project Officer.

Disclaimer

The views, opinions, and content expressed herein are those of the authors and do not necessarily reflect 

the official position of SAMHSA or HHS. Nothing in this document constitutes an indirect or direct 

endorsement by SAMHSA or HHS of any non-federal entity’s products, services, or policies, and any 

reference to a non-federal entity’s products, services, or policies should not be construed as such. No official 

support of or endorsement by SAMHSA or HHS for the opinions, resources, and medications described is 

intended to be or should be inferred. The information presented here in this document should not be 

considered medical advice and is not a substitute for individualized patient or client care and treatment 

decisions.

Public Domain Notice

All materials appearing in this volume except those taken directly from copyrighted sources are in the public 

domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the 

source is appreciated. However, this publication may not be reproduced or distributed for a fee without the 

specific, written authorization of the Office of Communications, SAMHSA, HHS. 

Electronic Access and Copies of Publication

This publication may be ordered from SAMHSA’s Publications Ordering Web page at 

http://store.samhsa.gov. Or, please call SAMHSA at 1-877- SAMHSA-7 (1-877-726-4727) (English). 

Recommended Citation

Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention 

Toolkit. HHS Publication No. (SMA) 16-4742. Rockville, MD: Substance Abuse and Mental Health Services 

Administration, 2016. 

Originating Office

Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental 

Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. 

HHS Publication No. (SMA) 16-4742. First printed 2013. Revised 2014, 2016. 
iii

TABLE OF CONTENTS

SAMHSA Opioid Overdose Prevention Toolkit 

Facts for Community Members.............................................................................................. 1 

Scope Of The Problem.......................................................................................................... 1

Five Essential Steps for First Responders............................................................................ 2

Strategies To Prevent Overdose Deaths............................................................................... 2

Resources For Communities................................................................................................. 4

Step 1: Call For Help (Dial 911) ............................................................................................ 5

Step 2: Check For Signs Of Opioid Overdose ....................................................................... 5

Step 3: Support The Person’s Breathing ............................................................................... 6

Step 4: Administer Naloxone................................................................................................. 6

Step 5: Monitor The Person’s Response............................................................................... 7

Summary .............................................................................................................................. 8

Information for Prescribers .................................................................................................... 9 

Opioid Overdose................................................................................................................... 9

Treating Opioid Overdose ...................................................................................................14

Legal And Liability Considerations ......................................................................................16

Claims Coding And Billing...................................................................................................16

Resources For Prescribers..................................................................................................17

Safety Advice for Patients & Family Members ....................................................................18

What Are Opioids?..............................................................................................................18

Preventing Overdose ..........................................................................................................18

If You Suspect An Overdose...............................................................................................18

What Is Naloxone?..............................................................................................................19

Report Any Side Effects ......................................................................................................19

Store Naloxone In A Safe Place..........................................................................................19

Summary: How To Avoid Opioid Overdose.........................................................................19

Recovering From Opioid Overdose .....................................................................................20

Resources For Overdose Survivors And Family Members ..................................................20

Finding A Network Of Support.............................................................................................20

Resources...........................................................................................................................21

References.............................................................................................................................22
1

FACTS FOR COMMUNITY MEMBERS

SCOPE OF THE PROBLEM

Opioid overdose continues to be a major public health 

problem in the United States. It has contributed 

significantly to accidental deaths among those who 

use or misuse illicit and prescription opioids. In fact, U.S. 

overdose deaths involving prescription opioid analgesics 

increased to about 19,000 deaths in 20141,2 more than three 

times the number in 2001.1 According to Centers for Disease 

Control and Prevention (CDC) data, health care providers 

wrote 259 million prescriptions for painkillers in 2012, enough 

for every American adult to have a bottle of pills.

3-4 

WHAT ARE OPIOIDS? Opioids include illegal drugs such 

as heroin, as well as prescription medications used to treat 

pain such as morphine, codeine, methadone, oxycodone 

(OxyContin®, Percodan®, Percocet®), hydrocodone 

(Vicodin®, Lortab®, Norco®), fentanyl (Duragesic®, 

Fentora®), hydromorphone (Dilaudid®, Exalgo®), and 

buprenorphine (Subutex®, Suboxone®).

Opioids work by binding to specific receptors in the brain, 

spinal cord, and gastrointestinal tract. In doing so, they 

minimize the body’s perception of pain. However, stimulating 

the opioid receptors or “reward centers” in the brain can also 

trigger other systems of the body, such as those responsible 

for regulating mood, breathing, and blood pressure.

HOW DOES OVERDOSE OCCUR? A variety of effects 

can occur after a person takes opioids, ranging from 

pleasure to nausea, vomiting, severe allergic reactions 

(anaphylaxis), and overdose, in which breathing and 

heartbeat slow or even stop.

Opioid overdose can occur when a patient deliberately 

misuses a prescription opioid or an illicit drug such as heroin. 

It can also occur when a patient takes an opioid as directed, 

but the prescriber miscalculated the opioid dose or an error 

was made by the dispensing pharmacist or the patient 

misunderstood the directions for use.

Also at risk are individuals who misuse opioids and 

combine them with sedative hypnotic agents resulting in 

sedation and respiratory depression.

5,6

WHO IS AT RISK? Anyone who uses 

opioids for long-term management of 

chronic cancer or non-cancer pain is at 

risk for opioid overdose, as are persons 

who use heroin.

7 Others at risk include 

persons who are:

 Receiving rotating opioid medication 

regimens (and thus are at risk for 

incomplete cross-tolerance).

 Discharged from emergency medical 

care following opioid intoxication or 

poisoning.

 At high risk for overdose because of 

a legitimate medical need for 

analgesia, coupled with a suspected 

or confirmed substance use disorder, 

or non-medical use of prescription or 

illicit opioids.

 Completing mandatory opioid 

detoxification or abstinent for a period 

of time (and presumably with reduced 

opioid tolerance and high risk of 

relapse to opioid use).

 Recently released from incarceration 

and who have a history of opioid use 

disorder (and presumably have

reduced opioid tolerance and high 

risk of relapse to opioid use).

Tolerance develops when someone uses

an opioid drug regularly, so that their

body becomes accustomed to the drug 

and needs a larger or more frequent

dose to continue to experience the

same effect.

Loss of tolerance occurs when someone

stops taking an opioid after long-term

use. When someone loses tolerance and

then takes the opioid drug again, they

can experience serious adverse effects,

including overdose, even if they take an

amount that caused them no problem in

the past.
2

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

STRATEGIES TO PREVENT OVERDOSE DEATHS

STRATEGY 1: Encourage providers, persons at high risk, family members, 

and others to learn how to prevent and manage opioid overdose. Providers 

should be encouraged to keep their knowledge current about evidence-based practices 

for the use of opioid analgesics to manage pain, as well as specific steps to prevent and 

manage opioid overdose.

Federally funded Continuing Medical Education courses are available to providers 

at no charge at http://www.OpioidPrescribing.com (a series of courses funded by the 

Substance Abuse and Mental Health Services Administration [SAMHSA]).

Helpful information for laypersons on how to prevent and manage overdose is 

available from Project Lazarus at http://www.projectlazarus.org or from the 

Massachusetts Health Promotion Clearinghouse at http://www.maclearinghouse.org.

STRATEGY 2: Ensure access to treatment for individuals who are misusing or 

addicted to opioids or who have other substance use disorders. Effective 

treatment of substance use disorders can reduce the risk of overdose and help 

overdose survivors attain a healthier life. Medication-assisted treatment, as well as 

counseling and other supportive services, can be obtained at SAMHSA-certified and 

Drug Enforcement Administration (DEA)-registered opioid treatment programs (OTPs), 

as well as from physicians who are trained to provide care in office-based settings with 

medications such as buprenorphine and naltrexone.

Information on treatment services available in or near your community can be obtained 

from your state health department, your state alcohol and drug agency, or SAMHSA

(see page 4).

STRATEGY 3: Ensure ready access to naloxone. Opioid overdose-related deaths 

can be prevented when naloxone is administered in a timely manner. As a narcotic 

antagonist, naloxone displaces opiates from receptor sites in the brain and reverses 

respiratory depression that usually is the cause of overdose deaths.7

On the other hand, naloxone is not effective in treating overdoses of 

benzodiazepines (such as Valium®, Xanax®, or Klonopin®), barbiturates (Seconal® or 

Fiorinal®), clonidine, Elavil®, GHB, ketamine, or synthetics. It is also not effective in 

overdoses with stimulants, such as cocaine and amphetamines (including 

methamphetamine and Ecstasy). However, if opioids are taken in combination with 

other sedatives or stimulants, naloxone may be helpful.

Naloxone injection has been approved by the United States Food and Drug 

Administration (FDA) and used for more than 40 years by emergency medical services 

(EMS) personnel to reverse opioid overdose and resuscitate persons who otherwise 

might have died in the absence of treatment.

8

Encourage

to learn

about

managing

opioid 

overdose

Ensure

access to 

treatment
3

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

Naloxone does not have the potential for abuse. It reverses the effects of 

opioid overdose.

9 Injectable naloxone is relatively inexpensive. It typically is 

supplied as a kit with two syringes10 These kits require training on how to 

administer naloxone using a syringe. The FDA has also approved an intranasal 

naloxone product, called Narcan® Nasal Spray, and a naloxone auto-injector, 

called Evzio®. The intranasal spray is a pre-filled, needle-free device that requires 

no assembly. The auto-injector can deliver a dose of naloxone through clothing, if 

necessary, when placed on the outer thigh. 

Prior to 2012, just six states had any laws that expanded access to naloxone 

or limited criminal liability.11 Today, 42 states and the District of Columbia have 

statutes that provide criminal liability protections to laypersons or first responders 

who administer naloxone. Thirty-nine states and the District of Columbia have 

statutes that provide civil liability protections to laypersons or first responders who 

administer naloxone. Thirty-eight states have statutes that offer criminal liability 

protections for prescribing or distributing naloxone. Thirty-three states have 

statutes that offer civil liability protections for prescribing or distributing naloxone. 

And 42 states have statutes that allow naloxone distribution to third parties or first 

responders via direct prescription or standing order. To find states that have 

adopted relevant laws, visit the White House website at 

www.whitehouse.gov/sites/default/files/ondcp/ 

Blog/naloxonecirclechart_january2016.pdf. 

STRATEGY 4: Encourage the public to call 911. An individual who is 

experiencing opioid overdose needs immediate medical attention. An essential 

first step is to get help from someone with medical expertise as quickly as 

possible.12-13 Therefore, members of the public should be encouraged to call 911. 

All they have to say is “Someone is not breathing” and give a clear address and 

location. Thirty-two states and the District of Columbia have “Good Samaritan” 

statutes that prevent arrest, charge, or prosecution for possession of a controlled 

substance or paraphernalia if emergency assistance is sought for someone who is 

experiencing an opioid-induced overdose.

STRATEGY 5: Encourage prescribers to use state Prescription Drug 

Monitoring Programs. State Prescription Drug Monitoring Programs (PDMPs) 

have emerged as a key strategy for addressing the misuse of prescription opioids 

and thus preventing opioid overdoses and deaths. Specifically, prescribers can 

check their state’s PDMP database to determine whether a patient is filling the 

prescriptions provided and/or obtaining prescriptions for the same or a similar 

drug from multiple prescribers. 

While nearly all states now have operational PDMPs, the programs differ from 

state to state in terms of the exact information collected, how soon that 

information is available to prescribers, and who may access the data. Therefore, 

information about the program in a particular state is best obtained directly from 

the state PDMP or from the board of medicine or pharmacy.

Encourage 

the public to 

call 911.

Encourage 

prescribers 

to use state 

Prescription 

Drug 

Monitoring 

Programs.
4

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

RESOURCES FOR COMMUNITIES

Resources that may be useful to local communities and organizations are found 

at: 

Substance Abuse and Mental Health Services Administration (SAMHSA)

 National Helpline: 

1-800-662-HELP (4357) or 1-800-487-4889 (TDD — for hearing impaired)

 Behavioral Health Treatment Locator: 

https://findtreatment.samhsa.gov to search by address, city, or zip code

 Buprenorphine Treatment Physician Locator: 

http://www.samhsa.gov/medication-assisted-treatment/physician-programdata/treatment-physician-locator

 State Substance Abuse Agencies: 

https://findtreatment.samhsa.gov/TreatmentLocator/faces/about.jspx

 Center for Behavioral Health Statistics and Quality (CBHSQ): 

http://www.samhsa.gov/data 

 SAMHSA Publications: http://store.samhsa.gov 

1-877-SAMHSA (1-877-726-4727)

Centers for Disease Control and Prevention (CDC) 

http://www.cdc.gov/drugoverdose/epidemic

http://www.cdc.gov/homeandrecreationalsafety/poisoning

White House Office of National Drug Control Policy (ONDCP)

State and Local Information: http://www.whitehouse.gov/ondcp/state-map

Association of State and Territorial Health Officials 

(ASTHO) ASTHO 214 Policy Inventory: State Action to Prevent and Treat 

Prescription Drug Abuse: http://www.astho.org/rx/profiles/Rx-Survey-Highlights 

National Association of State Alcohol and Drug Abuse Directors 

(NASADAD) 

Overview of State Legislation to Increase Access to Treatment for Opioid 

Overdose: 

http://nasadad.org/wp-content/uploads/2015/09/Opioid-Overdose-Policy-Brief2015-Update-FINAL1.pdf

American Association for the Treatment of Opioid Dependence (AATOD)

Prevalence of Prescription Opioid Abuse: 

http://www.aatod.org/projectseducational-training/prevalance-of-prescriptionopioid-abuse 

Resources 

that may be 

useful to 

local 

communities 

and 

organizations

... 
5

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

Overdose is common 

among persons who 

use illicit opioids such 

as heroin and among those 

who misuse medications 

prescribed for pain, such as 

oxycodone, hydrocodone, and 

morphine. The incidence of 

opioid overdose is rising 

nationwide. In 2014, 28,647 of 

drug overdose deaths involved 

some type of opioid, including 

heroin.14 U.S. overdose 

deaths involving prescription 

opioid analgesics increased to 

about 19,000 deaths in 20141,2

more than three times the 

number in 2001.1

 

To address the problem, 

emergency medical personnel, 

health care professionals, and 

patients increasingly are being 

trained in the use of the opioid 

antagonist naloxone 

hydrochloride (naloxone), 

which is the treatment of 

choice to reverse the 

potentially fatal respiratory 

depression caused by opioid 

overdose. (Note that naloxone 

has no effect on non-opioid 

overdoses, such as those 

involving cocaine, 

benzodiazepines, or 

alcohol.)15

The steps outlined below 

are recommended to reduce 

the number of deaths resulting 

from opioid 

overdoses2,6,10,16,17,18,19,20

STEP 1: CALL FOR HELP (DIAL 911)

AN OPIOID OVERDOSE NEEDS IMMEDIATE MEDICAL

ATTENTION. An essential step is to get someone with medical 

expertise to see the patient as soon as possible, so if no emergency 

medical services (EMS) or other trained personnel are on the scene, 

dial 911 immediately. All you have to say is “Someone is not 

breathing.” Be sure to give a clear address and/or description of your 

location.

STEP 2: CHECK FOR SIGNS OF 

OPIOID OVERDOSE

Signs of OVERDOSE, which often results in death if not treated, 

include15: 

 Extreme sleepiness, inability to awaken verbally or upon 

sternal rub. 

 Breathing problems that can range from slow to shallow 

breathing in a patient that cannot be awakened. 

 Fingernails or lips turning blue/purple. 

 Extremely small “pinpoint” pupils. 

 Slow heartbeat and/or low blood pressure. 

Signs of OVERMEDICATION, which may progress to overdose, 

include:15

 Unusual sleepiness, drowsiness, or difficulty staying awake 

despite loud verbal stimulus or vigorous sternal rub. 

 Mental confusion, slurred speech, intoxicated behavior. 

 Slow or shallow breathing. 

 Extremely small “pinpoint” pupils, although normal size pupils 

do not exclude opioid overdose. 

 Slow heartbeat, low blood pressure. 

 Difficulty waking the person from sleep.

Because opioids depress respiratory function and breathing, one 

telltale sign of a person in a critical medical state is the “death rattle.” 

If a person emits a “death rattle”—an exhaled breath with a very 

distinct, labored sound coming from the throat—emergency 

resuscitation will be necessary immediately, as such a sound almost 

always is a sign that the individual is near death.17
6

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

STEP 3: SUPPORT THE PERSON’S 

BREATHING

Ventilatory support is an important intervention and may be lifesaving on its own. Patients should be ventilated with oxygen prior to 

administration of naloxone.

2,6 In situations where oxygen is not 

available, rescue breathing can be very effective in supporting 

respiration.2 Rescue breathing for adults involves the following steps:

 Be sure the person’s airway is clear (check that nothing inside 

the person’s mouth or throat is blocking the airway).

 Place one hand on the person’s chin, tilt the head back and 

pinch the nose closed.

 Place your mouth over the person’s mouth to make a seal 

and give 2 slow breaths.

 The person’s chest should rise (but not the stomach).

 Follow up with one breath every 5 seconds.

STEP 4: ADMINISTER NALOXONE

Any patient who presents with signs of opioid overdose, or when 

this is suspected, should be administered naloxone. Naloxone 

injection is approved by the FDA and has been used for decades by 

EMS personnel to reverse opioid overdose and resuscitate 

individuals who have overdosed on opioids.

Naloxone can be given by intranasal spray, intramuscular (into 

the muscle), subcutaneous (under the skin), or intravenous 

injection.

17-19 The most rapid onset of action is achieved by 

intravenous administration, which is recommended in emergency 

situations.

17 The dose should be titrated to the smallest effective dose 

that maintains spontaneous normal respiratory drive. 

Opioid-naive patients may be given starting doses of up to 2 mg 

without concern for triggering withdrawal symptoms depending on the 

route of administration.

2,9,18

The intramuscular route of administration for naloxone may be 

suitable for patients with suspected opioid use disorder because it 

provides a slower onset of action and a prolonged duration of effect, 

which may minimize rapid onset of withdrawal symptoms.

2,5,10

DURATION OF EFFECT. The duration of effect of naloxone is 20 to 

90 minutes depending on dose and route of administration6

, and 

overdose symptoms.5,17,18 The goal of naloxone therapy should be to 

restore adequate spontaneous breathing, but not necessarily 

complete arousal.

5

 

More than one dose of 

naloxone may be needed to 

revive someone who is 

overdosing. Patients who have 

taken longer-acting opioids 

may require further 

intravenous bolus doses or an 

infusion of naloxone.21

Comfort the person being 

treated, as withdrawal 

triggered by naloxone can feel 

unpleasant. As a result, some 

persons become agitated or 

combative when this happens 

and need help to remain calm.

SAFETY OF NALOXONE. 

The safety profile of naloxone 

is remarkably high, especially 

when used in low doses and 

titrated to effect.2,9,17,22 When 

given to individuals who are 

not opioid-intoxicated or 

opioid-dependent, naloxone 

produces no clinical effects, 

even at high doses. Moreover, 

although rapid opioid 

withdrawal in tolerant patients 

may be unpleasant, it is not 

life-threatening.

Naloxone can be used in 

life-threatening opioid 

overdose circumstances in

pregnant women.23

The FDA has approved 

injectable naloxone, intranasal 

naloxone (called Narcan® 

Nasal Spray), and a naloxone 

auto-injector (called Evzio®1). 

1 http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm

The currently available 

naloxone kits that include a 

syringe and naloxone ampules 

or vials or a prefilled naloxone 
7

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

syringe and a mucosal atomizer device to enable intranasal delivery 

require the user to be trained on how to assemble all of the materials 

and administer the naloxone to the victim. The Narcan Nasal Spray is 

a pre-filled, needle-free device that requires no assembly, which can 

deliver a single dose into one nostril. The Evzio auto-injector is 

injected into the outer thigh to deliver naloxone to the muscle 

(intramuscular) or under the skin (subcutaneous). Once turned on, 

the device provides verbal instruction to the user describing how to 

deliver the medication, similar to automated defibrillators. Both 

Narcan Nasal Spray and Evzio are packaged in a carton containing 

two doses, to allow for repeat dosing if needed. 

STEP 5: MONITOR THE PERSON’S

RESPONSE 

All patients should be monitored for recurrence of signs and 

symptoms of opioid toxicity for at least 4 hours from the last dose of 

naloxone or discontinuation of the naloxone infusion. Patients who 

have overdoses on long-acting opioids should have more prolonged 

monitoring.2,10

Most patients respond by returning to spontaneous breathing. 

The response generally occurs within 3 to 5 minutes of naloxone 

administration. (Continue rescue breathing while waiting for the 

naloxone to take effect.)2,5,10

Naloxone will continue to work for 30 to 90 minutes, but after that 

time, overdose symptoms may return.

17,18Therefore, it is essential to 

get the person to an emergency department or other source of 

medical care as quickly as possible, even if he or she revives after 

the initial dose of naloxone and seems to feel better. 

SIGNS OF OPIOID WITHDRAWAL. The signs and symptoms of 

opioid withdrawal in an individual who is physically dependent on 

opioids may include, but are not limited to, the following: body aches, 

diarrhea, tachycardia, fever, runny nose, sneezing, piloerection, 

sweating, yawning, nausea or vomiting, nervousness, restlessness or 

irritability, shivering or trembling, abdominal cramps, weakness, and 

increased blood pressure. In the neonate, opioid withdrawal may also 

include convulsions, excessive crying, and hyperactive reflexes.

17

NALOXONE NONRESPONDERS. If a patient 

does not respond to naloxone, 

an alternative explanation for 

the clinical symptoms should 

be considered. The most likely 

explanation is that the person 

is not overdosing on an opioid 

but rather some other 

substance or may even be 

experiencing a non-overdose 

medical emergency. A 

possible explanation to 

consider is that the individual 

has overdosed on 

buprenorphine, a long-acting 

opioid partial agonist. Because 

buprenorphine has a higher 

affinity for the opioid receptors 

than do other opioids, 

naloxone may not be effective 

at reversing the effects of 

buprenorphine-induced opioid 

overdose.

18

In all cases, support of 

ventilation, oxygenation, and 

blood pressure should be 

sufficient to prevent the 

complications of opioid 

overdose and should be given 

priority if the response to 

naloxone is not prompt.
8

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

SUMMARY 

Do’s and Don’ts in Responding to Opioid Overdose

 DO support the person’s breathing by administering oxygen or performing rescue breathing.

 DO administer naloxone.

 DO put the person in the “recovery position” on the side, if he or she is breathing independently.

 DO stay with the person and keep him/her warm.

 DON’T slap or try to forcefully stimulate the person—it will only cause further injury. If you are unable 

to wake the person by shouting, rubbing your knuckles on the sternum (center of the chest or rib 

cage), or light pinching, he or she may be unconscious.

 DON’T put the person into a cold bath or shower. This increases the risk of falling, drowning, or 

going into shock.

 DON’T inject the person with any substance (saltwater, milk, “speed,” heroin, etc.). The only safe 

and appropriate treatment is naloxone.

 DON’T try to make the person vomit drugs that he or she may have swallowed. Choking or inhaling 

vomit into the lungs can cause a fatal injury.

NOTE: All naloxone products have an expiration date, so it is important to check the expiration date and 

obtain replacement naloxone as needed.
9

INFORMATION FOR PRESCRIBERS 

Opioid overdose is a major public health problem. In 2014, 

28,647 of drug overdose deaths involved some type of

opioid, including heroin.

14,19 Overdose involves both men

and women of all ages, ethnicities, and demographic and 

economic characteristics, and involves both illicit opioids such as 

heroin and, increasingly, prescription opioid analgesics such as 

oxycodone, hydrocodone, fentanyl, and methadone.4

Physicians and other health care providers can make a 

major contribution toward reducing the toll of opioid overdose 

through the care they take in prescribing opioid analgesics and 

monitoring patients’ response, as well as through their acuity in 

identifying and effectively addressing opioid overdose. Federally 

funded Continuing Medical Education (CME) courses are 

available at no charge at http://www.OpioidPrescribing.com (a 

series of courses funded by the Substance Abuse and Mental 

Health Services Administration [SAMHSA])2. 

2 For additional educational material for extended-release and long-acting opioid analgesics, see 

http://www.er-la-opioidrems.com/IwgUI/rems/faq.action and the FDA Blueprint for Prescriber 

Education for Extended- Release and Long-Acting Opioid Analgesics, 

http://www.accessdata.fda.gov/drugsatfda_docs/rem

s/ERLA_opioids_2015-10-23_FDA_Blueprint.pdf

OPIOID OVERDOSE

The risk of opioid overdose can be minimized through 

adherence to the following clinical practices, which are supported 

by a considerable body of evidence. 2,10,22,24

ASSESS THE PATIENT. Obtaining a history of the patient’s 

past use of drugs (either illicit drugs or prescribed medications 

with misuse potential) is an essential first step in appropriate 

prescribing. Such a history should include very specific 

questions. For example:

 “In the past 6 months, have you taken any medications to 

help you calm down, keep from getting nervous or upset, 

raise your spirits, make you feel better, and the like?”

 “Have you been taking any medications to help you sleep? 

Have you been using alcohol for this purpose?”

 “Have you ever taken a medication to help you with a drug 

or alcohol problem?”

 “Have you ever taken a medication for a nervous 

stomach?”

 “Have you taken a medication to give you more energy or 

to cut down on your appetite?”

 “Have you ever been treated for a possible or suspected 

opioid overdose?” 

 

The patient history should also 

include questions about use of 

alcohol and over-the- counter 

(OTC) preparations. For example, 

the ingredients in many common 

cold preparations include alcohol 

and other central nervous system 

(CNS) depressants, so these 

products should not be used in 

combination with opioid analgesics.

Positive answers to any of 

these questions warrant further 

investigation.

TAKE SPECIAL PRECAUTIONS 

WITH NEW PATIENTS. Many 

experts recommend that additional 

precautions be taken in prescribing opioid analgesics for new 

patients.22 These might involve the 

following:

1.Assessment: In addition to doing 

the patient history and 

examination, the physician 

should determine who has been 

caring for the patient in the past, 

what medications have been 

prescribed and for what 

indications, what substances 

(including alcohol, illicit drugs, 

and OTC products) the patient 

has reported using, and when 

and what amount was last used 

and by what route. Medical 

records should be obtained (with 

the patient’s consent).

2.Emergencies: In emergency 

situations, the physician should 

prescribe the smallest possible 

quantity, typically not exceeding 

3 days’ supply, and arrange for a 

.
10

INFORMATION FOR PRESCRIBERS 

return visit the next day. In addition, consider prescribing 

naloxone to help mitigate risk associated with these emergent 

situations. At a minimum, the patient’s identity should be 

verified by asking for proper identification.

3.Non-emergencies: In non-emergency situations, only enough 

of an opioid analgesic should be prescribed to meet the 

patient’s needs until the next appointment. The patient should 

be directed to return to the office for additional prescriptions, 

as telephone orders do not allow the physician to reassess the 

patient’s continued need for the medication.

STATE PRESCRIPTION DRUG MONITORING 

PROGRAMS. State Prescription Drug Monitoring Programs 

(PDMPs) have emerged as a key strategy for addressing the 

misuse of prescription opioids and thus preventing opioid 

overdoses and deaths. Specifically, prescribers can check their 

state’s PDMP database to determine whether a patient is filling 

the prescriptions provided and/or obtaining prescriptions for the 

same or similar drugs from multiple physicians.

While nearly all states now have operational PDMPs, the 

programs differ from state to state in terms of the exact 

information collected, how soon that information is available to 

physicians, and who may access the data. Therefore, 

information about the program in a particular state is best 

obtained directly from the PDMP or from the state board of 

medicine or pharmacy.

SELECT AN APPROPRIATE MEDICATION. Rational drug 

therapy demands that the efficacy and safety of all potentially 

useful medications be reviewed for their relevance to the 

patient’s disease or disorder.2,22

When an appropriate medication has been selected, the 

dose, schedule, and formulation should be determined. These 

choices often are just as important in optimizing 

pharmacotherapy as the choice of medication itself. Decisions 

involve (1) dose (based not only on age and weight of the 

patient, but also on severity of the disorder, possible loadingdose requirement, and the presence of potentially interacting 

drugs); (2) timing of administration (such as a bedtime dose to 

minimize problems associated with sedative or respiratory 

depressant effects); (3) route of administration (chosen to 

improve compliance/adherence as well as to attain peak drug 

concentrations rapidly); and (4) formulation (e.g., selecting a 

patch in preference to a tablet, or an extended-release product 

rather than an immediate-release formulation).

Even when sound medical 

indications have been established, 

physicians typically consider three 

additional factors before deciding 

to prescribe an opioid analgesic2,22: 

1. The severity of symptoms, in 

terms of the patient’s ability to 

accommodate them. Relief of 

symptoms is a legitimate goal 

of medical practice, but using 

opioid analgesics requires 

caution.

2. The patient’s reliability in taking 

medications, noted through 

observation and careful historytaking. The physician should 

assess a patient’s history of 

and risk factors for substance 

use disorders before 

prescribing any psychoactive 

drug and weigh the benefits 

against the risks. The likely 

development of physical 

dependence in patients on 

long-term opioid therapy should

be monitored through periodic 

checkups.

3. The dependence-producing 

potential of the medication. The 

physician should consider 

whether a product with less 

potential for misuse, or even a 

non-drug therapy, would 

provide equivalent benefits. 

Patients should be warned 

about possible adverse effects 

caused by inter- actions 

between opioids and other 

medications or substances, 

including alcohol. At the time a 

drug is prescribed, patients 

should be informed that it is 

illegal to sell, give away, or 

otherwise share their 

medication with others, 
11

INFORMATION FOR PRESCRIBERS 

including family members. The patient’s obligation extends to 

keeping the medication in a locked cabinet or otherwise 

restricting access to it and to safely disposing of any unused 

supply (visit http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm for advice from the United States 

Food and Drug Administration (FDA) on how to safely 

dispose of unused medications).

EDUCATE THE PATIENT AND OBTAIN INFORMED 

CONSENT. Obtaining informed consent involves informing the 

patient about the risks and benefits of the proposed therapy and

of the ethical and legal obligations such therapy imposes on 

both physician and patient.

22 Such informed consent can serve 

multiple purposes: (1) it provides the patient with information 

about the risks and benefits of opioid therapy; (2) it fosters

adherence to the treatment plan; it limits the potential for

inadvertent drug misuse; and (4) it improves the efficacy of the 

treatment program.

Patient education and informed consent should specifically 

address the potential for physical dependence and cognitive 

impairment as side effects of opioid analgesics.3

3 An important source of patient information is the FDA package insert. The medication guides

that accompany all extended-release or long-acting as well as oral solution opioids should be 

reviewed as part of the FDA Risk Evaluation and Management Strategy (REMS). For links to 

medication guides, please visit http://www.er-la-opioidrems.com/IwgUI/rems/products.action

For a general patient counseling document on opioid 

analgesics, available in English or Spanish, please 

visit: http://www.er-laopioidrems.com/IwgUI/rems/pcd.action. . 

Other issues that should be addressed in the informed consent 

or treatment agreement include the following22: 

 The agreement instructs the patient to stop taking all other

pain medications, unless explicitly told to continue by the

physician. Such a statement reinforces the need to adhere to

a single treatment regimen.

 The patient agrees to obtain the prescribed medication from

only one physician and, if possible, from one designated

pharmacy.

 The patient agrees to take the medication only as prescribed

(for some patients, it may be possible to offer latitude to

adjust the dose as symptoms dictate).

 The agreement makes it clear that the patient is responsible

for safeguarding the written prescription and the supply of

medications, and arranging refills during regular office hours.

This responsibility includes planning ahead so as not to run

out of medication during weekends or vacation.

 The agreement specifies the consequences for failing to adhere to the treatment plan, which may include

discontinuation of opioid 

therapy if the patient’s actions 

compromise his or her safety.

Both patient and physician 

should sign the informed con- sent 

agreement, and a copy should be 

placed in the patient’s medical 

record. It also is helpful to give the 

patient a copy of the agreement to 

carry with him or her, to document 

the source and reason for any 

controlled drugs in his or her 

possession.

Some physicians provide a 

laminated card that identifies the 

individual as a patient of their 

practice. This is helpful to other 

physicians who may see the 

patient and in the event the patient 

is seen in an emergency 

department.

EXECUTE THE PRESCRIPTION 

ORDER. Careful execution of the 

prescription order can prevent 

manipulation by the patient or 

others intent on obtaining opioids 

for non-medical purposes. For 

example, federal law requires that 

prescription orders for controlled 

substances be signed and dated 

on the day they are issued. Also 

under federal law, every 

prescription or der must include at 

least the following information:

 Name and address of the

patient

 Name, address, and DEA

registration number of the

physician
12

INFORMATION FOR PRESCRIBERS 

 Signature of the physician

 Name and quantity of the drug prescribed

 Directions for use

 Refill information

 Effective date if other than the date on which the prescription 

was written

Many states impose additional requirements, which the 

physician can determine by consulting the state medical 

licensing board. In addition, there are special federal 

requirements for drugs in different schedules of the federal 

Controlled Substances Act (CSA), particularly those in Schedule 

II, where many opioid analgesics are classified.

Blank prescription pads as well as information such as the 

names of physicians who recently retired, left the state, or died 

all can be used to forge prescriptions. Therefore, it is a sound 

practice to store blank prescriptions in a secure place rather than 

leaving them in examining rooms.

NOTE: The physician should immediately report the theft or loss 

of prescription blanks to the nearest field office of the federal 

Drug Enforcement Administration and to the state board of 

medicine or pharmacy.

MONITOR THE PATIENT’S RESPONSE TO TREATMENT.

Proper prescription practices do not end when the patient 

receives a prescription. Plans to monitor for drug efficacy and 

safety, compliance, and potential development of tolerance must 

be documented and clearly communicated to the patient.2

Subjective symptoms are important in monitoring, as are 

objective clinical signs (such as body weight, pulse rate, 

temperature, blood pressure, and levels of drug metabolites in 

the bloodstream). These can serve as early signs of therapeutic

failure or unacceptable adverse drug reactions that require 

modification of the treatment plan.

Asking the patient to keep a log of signs and symptoms gives 

him or her a sense of participation in the treatment program and 

facilitates the physician’s review of therapeutic progress and 

adverse events.

Simply recognizing the potential for non-adherence, 

especially during prolonged treatment, is a significant step 

toward improving medication use25. Steps such as simplifying 

the drug regimen and offering patient education also improve 

adherence, as do phone calls to patients, home visits by nursing 

personnel, convenient packaging of medication, and periodic 

urine testing for the prescribed 

opioid as well as any other 

respiratory depressant.

Finally, the physician should 

convey to the patient through 

attitude and manner that any 

medication, no matter how helpful, 

is only part of an overall treatment 

plan.

When the physician is 

concerned about the behavior or 

clinical progress (or lack thereof) of 

a patient being treated with an 

opioid analgesic, it usually is 

advisable to seek a consultation 

with an expert in the disorder for 

which the patient is being treated 

and an expert in addiction. 

Physicians place themselves at risk 

if they continue to prescribe opioids 

in the absence of such 

consultations.22

CONSIDER PRESCRIBING 

NALOXONE ALONG WITH THE 

PATIENT’S INITIAL OPIOID 

PRESCRIPTION. Naloxone 

competitively binds opioid 

receptors and is the antidote to 

acute opioid toxicity. With proper 

education, patients on long-term 

opioid therapy and others at risk for 

overdose may benefit from being 

prescribed (1) a naloxone kit 

containing naloxone, syringes, and 

needles; (2) Narcan® Nasal Spray, 

which delivers a single dose of 

naloxone into one nostril via a prefilled intranasal spray; or (3) 
13

INFORMATION FOR PRESCRIBERS 

Evzio®,4 which delivers a single dose of naloxone to the outer 

thigh via a hand-held auto-injector. 5,9

4 For further information about Evzio® visit 

http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm.

Patients who are candidates for such kits include those who are:

 Taking high doses of opioids for long-term management of 

chronic malignant or non-malignant pain.

 Receiving rotating opioid medication regimens (and thus are 

at risk for incomplete cross-tolerance).

 Discharged from emergency medical care following opioid 

intoxication or poisoning.

 At high risk for overdose because of a legitimate medical 

need for analgesia, coupled with a suspected or confirmed 

history of substance use disorder or non-medical use of 

prescription or illicit opioids.

 On certain opioid preparations that may increase risk for 

opioid overdose such as extended release/long-acting 

preparations.

 Completing mandatory opioid detoxification or abstinence 

programs.

 Recently released from incarceration and with a history of 

opioid use disorder (and presumably with reduced opioid 

tolerance and high risk of relapse to opioid use).

It may also be advisable to suggest that the at-risk patient 

create an “overdose plan” to share with friends, partners, and/or 

caregivers. Such a plan would contain information on the signs 

of overdose and how to administer naloxone or otherwise 

provide emergency care (as by calling 911).

DECIDE WHETHER AND WHEN TO END OPIOID 

THERAPY. Certain situations may warrant immediate cessation 

of prescribing. These generally occur when out-of-control 

behaviors indicate that continued prescribing is unsafe or 

causing harm to the patient.2 Examples include altering or selling 

prescriptions, accidental or intentional overdose, multiple 

episodes of running out early (due to excessive use), doctor 

shopping, or engaging in threatening behavior.

When such events arise, it is important to separate the 

patient as a person from the behaviors caused by the disease of 

addiction, as by demonstrating a positive regard for the person 

but no tolerance for the aberrant behaviors.

In such a situation, the essential steps are to (1) stop 

prescribing, (2) tell the patient that continued prescribing is not 

 

clinically supportable (and thus not 

possible), (3) urge the patient to 

accept a referral for assessment by 

an addiction specialist, (4) educate 

the patient about signs and 

symptoms of spontaneous 

withdrawal and urge the patient to 

go to the emergency department if 

withdrawal symptoms occur, (5) 

retrain on the risks and the signs of 

opioid overdose and on the use of 

naloxone and consider prescribing 

naloxone if deemed appropriate, 

and (6) assure the patient that he 

or she will continue to receive care 

for the presenting symptoms or 

condition.22

Identification of a patient who is 

misusing a prescribed opioid 

presents a major therapeutic 

opportunity. The physician should 

have a plan for managing such a 

patient, typically involving work with 

the patient and the patient’s family, 

referral to an addiction expert for 

assessment and placement in a 

formal addiction treatment 

program, long-term participation in 

a 12-Step mutual-help program 

such as Narcotics Anonymous, and 

follow-up of any associated 

medical or psychiatric 

comorbidities.2

Providing training on use of 

naloxone and prescribing a 

naloxone kit or FDA-approved 

naloxone should be considered.

In all cases, patients should be 

given the benefit of the physician’s 

concern and attention. It is 

important to remember that even 

drug-seeking patients often have 
14

INFORMATION FOR PRESCRIBERS 

very real medical problems that demand and deserve the same 

high-quality medical care offered to any patient.2,22

TREATING OPIOID OVERDOSE

In the time it takes for an overdose to become fatal, it is 

possible to reverse the respiratory depression and other effects 

of opioids through respiratory support and administration of the 

opioid antagonist naloxone. 17 Naloxone is approved by the FDA 

and has been used for decades to reverse overdose and 

resuscitate individuals who have overdosed on opioids. The 

routes of administration for naloxone are intravenous, intranasal, 

intramuscular, and subcutaneous.

The safety profile of naloxone is remarkably high, especially 

when used in low doses and titrated to effect.6,17 If given to 

individuals who are not opioid-intoxicated or opioid-dependent, 

naloxone produces no clinical effects, even at high doses.

Moreover, while rapid opioid withdrawal in tolerant patients may 

be unpleasant, it is not typically life-threatening.

Naloxone should be part of an overall approach to known or 

suspected opioid overdose that incorporates the steps below.

RECOGNIZE THE SIGNS OF OVERDOSE. An opioid 

overdose requires rapid diagnosis. The most common signs of 

overdose include2

: 

 Extreme sleepiness, inability to awaken verbally or upon 

sternal rub.

 Breathing problems that can range from slow to shallow 

breathing in a patient who cannot be awakened.

 Fingernails or lips turning blue/purple.

 Extremely small “pinpoint” pupils.

 Slow heartbeat and/or low blood pressure.

Signs of OVERMEDICATION, which may progress to overdose, 

include2

: 

 Unusual sleepiness, drowsiness, or difficulty staying awake 

despite loud verbal stimulus or vigorous sternal rub.

 Mental confusion, slurred speech, intoxicated behavior.

 Slow or shallow breathing.

 Pinpoint (small) pupils; normal size pupils does not exclude 

opioid overdose.

 Slow heartbeat, low blood pressure.

 Difficulty waking the person from sleep.

Because opioids depress 

respiratory function and breathing, 

one telltale sign of an individual in 

a critical medical state is the “death 

rattle.” This is an exhaled breath 

with a very distinct, labored sound 

coming from the throat. It indicates 

that emergency resuscitation is 

needed immediately.26

SUPPORT RESPIRATION. 

Supporting respiration is the single 

most important intervention for 

opioid overdose and may be lifesaving on its own. Ideally, 

individuals who are experiencing 

opioid overdose should be 

ventilated with oxygen before

naloxone is administered to reduce 

the risk of acute lung injury.

2,6 In 

situations where oxygen is not 

available, rescue breathing can be 

very effective in supporting 

respiration until naloxone becomes 

available.27 Rescue breathing 

involves the following steps: 

 Verify that the airway is clear.

 With one hand on the patient’s 

chin, tilt the head back and 

pinch the nose closed.

 Place your mouth over the 

patient’s mouth to make a seal 

and give 2 slow breaths (the 

patient’s chest should rise, but 

not the stomach).

 Follow up with 1 breath every 5 

seconds. 

ADMINISTER NALOXONE. 

Naloxone competitively binds 

opioid receptors and is the 

antagonist of choice for the 

reversal of acute opioid toxicity. 

Any patient who presents with 

signs of opioid overdose, or when 
15

INFORMATION FOR PRESCRIBERS 

this is suspected, should be administered naloxone.9 Naloxone 

can be given intranasally intramuscularly, subcutaneously, or by 

intravenous injection.

9,17,18

PREGNANT PATIENTS. Naloxone can be used in lifethreatening opioid overdose circumstances in pregnant women.

9

MONITOR THE PATIENT’S RESPONSE. Patients should be 

monitored for re-emergence of signs and symptoms of opioid 

toxicity for at least 4 hours following the last dose of naloxone 

(however, patients who have overdosed on long-acting opioids 

require more prolonged monitoring).

6

Most patients respond to naloxone by returning to 

spontaneous breathing, with mild withdrawal symptoms.6 The 

response generally occurs within 3 to 5 minutes of naloxone 

administration. (Continue rescue breathing while waiting for the 

naloxone to take effect.)

The duration of effect of naloxone is 20 to 90 minutes depending on dose and route of administration. Patients should be 

observed after that time for re-emergence of overdose 

symptoms. The goal of naloxone therapy should be restoration of 

adequate spontaneous breathing, but not necessarily complete 

arousal.18,19

More than one dose of naloxone may be required to revive 

the patient. Those who have taken longer-acting opioids or 

opioid partial agonists may require further doses or may require 

further intravenous bolus doses or an infusion of naloxone.22

Therefore, it is essential to get the person to an emergency 

department or other source of acute care as quickly as possible, 

even if he or she revives after the initial dose of naloxone and 

seems to feel better.

SIGNS OF OPIOID WITHDRAWAL. Withdrawal triggered by 

naloxone can feel unpleasant. As a result, some persons 

become agitated or combative when this happens and need help 

to remain calm.

The signs and symptoms of opioid withdrawal in an individual 

who is physically dependent on opioids may include (but are not 

limited to) the following: body aches, diarrhea, tachycardia, fever, 

runny nose, sneezing, piloerection, sweating, yawning, nausea 

or vomiting, nervousness, restlessness or irritability, shivering or 

trembling, abdominal cramps, weakness, and increased blood 

pressure.17 Withdrawal syndromes may be precipitated by as 

little as 0.05 to 0.2 mg intravenous naloxone in a patient taking 

24 mg per day of methadone.

In neonates, opioid withdrawal 

may also produce convulsions, 

excessive crying, and hyperactive 

reflexes.17 Additionally, in 

neonates, opiate withdrawal may 

be life- threatening if not 

recognized and properly treated.

NALOXONE NONRESPONDERS. If a patient does 

not respond to naloxone, an 

alternative explanation for the 

clinical symptoms should be 

considered. The most likely 

explanation is that the person is not 

over- dosing on an opioid but 

rather some other substance or 

may even be experiencing a nonoverdose medical emergency. 

Another possible explanation to 

consider is that the individual has 

overdosed on buprenorphine, a 

long-acting opioid partial agonist. 

Because buprenorphine has a 

higher affinity for the opioid 

receptors than do other opioids, 

naloxone may not be effective at 

reversing the effects of 

buprenorphine-induced opioid 

overdose5

. 

In all cases, support of 

ventilation, oxygenation, and blood 

pressure should be sufficient to 

prevent the complications of opioid 

overdose and should be given the 

highest priority if the patient’s 

response to naloxone is not 

prompt.

NOTE: All naloxone products have 

an expiration date. It is important to 

check the expiration date and 

obtain replacement naloxone as 

needed.
16

INFORMATION FOR PRESCRIBERS 

LEGAL AND LIABILITY 

CONSIDERATIONS

Health care professionals who are concerned about legal risks 

associated with prescribing naloxone may be reassured by the 

fact that prescribing naloxone to manage opioid overdose is 

consistent with the drug’s FDA-approved indication, resulting in 

no increased liability so long as the prescriber adheres to 

general rules of professional conduct. Many state laws and 

regulations now permit physicians to prescribe naloxone to a 

third party, such as a caregiver.

11 More information on state 

policies is available at http://www.prescribetoprevent.org or from 

individual state medical boards.

CLAIMS CODING AND BILLING

Most private health insurance plans, Medicare, and Medicaid 

cover naloxone for the treatment of opioid overdose, but policies 

vary by state. The cost of take-home naloxone should not be a 

prohibitive factor. Not all community pharmacies stock naloxone 

routinely, but they can always order it. If you are caring for a 

large population of patients who are likely to benefit from 

naloxone, you may wish to notify the pharmacy when you 

implement naloxone prescribing as a routine practice.

The codes for Screening, Brief Intervention, and Referral to 

Treatment (SBIRT) can be used to bill time for counseling a 

patient about how to recognize overdose and how to administer 

naloxone. Billing codes for SBIRT are as follows:

 Commercial Insurance: CPT 99408 (15 to 30 minutes)

 Medicare: G0396 (15 to 30 minutes) 

 Medicaid: H0050 (per 15 minutes)

For counseling and instruction 

on the safe use of opioids, 

including the use of naloxone 

outside of the context of SBIRT 

services, the provider should 

document the time spent in 

medication education and use the 

E&M code that accurately captures 

the time and complexity. For 

example, for new patients deemed 

appropriate for opioid 

pharmacotherapy and when a 

substantial and appropriate amount 

of additional time is used to provide 

a separate service such as 

behavioral counseling (e.g., opioid 

overdose risk assessment and 

naloxone administration training), 

consider using modifier–25 in 

addition to the E&M code.

In addition, when using an 

evidence-based opioid use 

disorder or overdose risk factor 

assessment tool/screening 

instrument, CPT Code 99420 

(Administration and interpretation 

of health risk assessment 

instrument) can be used for 

patients with commercial 

insurance.
17

INFORMATION FOR PRESCRIBERS 

RESOURCES FOR PRESCRIBERS

Additional information on prescribing opioids for chronic pain is available at the following websites: 

http://www.opioidprescribing.com. 

Sponsored by the Boston University School of Medicine, with support from SAMHSA, this site presents 

course modules on various aspects of prescribing opioids for chronic pain. To view the list of courses and to 

register, go to http://www.opioidprescribing.com/overview. CME credits are available at no charge.

http://pcss-o.org or www.pcssmat.org. Sponsored by the American Academy of Addiction Psychiatry in 

collaboration with other specialty societies and with support from SAMHSA, the Providers’ Clinical Support 

System offers multiple resources related to opioid prescribing and the diagnosis and management of opioid 

use disorder.

http://www.er-la-opioidrems.com/IwgUI/rems/home.action. As required by the FDA under a risk management 

program for extended-release and long-acting opioid analgesics, this website provides physician training 

and patient education on the use of such medications.

http://www.medscape.com. One course module sponsored by SAMHSA on Screening, Brief Intervention, 

and Referral to Treatment (SBIRT) can be accessed at http://www.medscape.org/viewarticle/830331. 

CME/CE credits are available at no charge.

http://prescribetoprevent.org. Compiled by prescribers, pharmacists, public health workers, lawyers, and 

researchers working on overdose prevention and naloxone access, this privately funded site provides 

resources to help health care providers educate their patients to reduce overdose risk and provide naloxone 

rescue kits to patients.
18

SAFETY ADVICE FOR PATIENTS & FAMILY MEMBERS

WHAT ARE OPIOIDS?

Opioids include illicit drugs such as heroin 

and prescription medications used to treat 

pain such as morphine, codeine, 

methadone, oxycodone, hydrocodone, fentanyl, 

hydromorphone, and buprenorphine.

Opioids work by binding to specific receptors 

in the brain, spinal cord, and gastrointestinal tract. 

In doing so, they minimize the body’s perception 

of pain. However, stimulating the opioid receptors 

or “reward centers” in the brain can also trigger 

other systems of the body, such as those 

responsible for regulating mood, breathing, and 

blood pressure.

A variety of effects can occur after a person 

takes opioids, ranging from pleasure to nausea

and vomiting, from severe allergic reactions 

(anaphylaxis) to overdose, in which breathing and 

heartbeat slow or even stop.

Opioid overdose can occur when a patient 

misunderstands the directions for use, 

accidentally takes an extra dose, or deliberately 

misuses a prescription opioid or an illicit drug 

such as heroin.

Also at risk is the person who takes opioid 

medications pre- scribed for someone else, as is 

the individual who combines opioids—prescribed 

or illicit—with alcohol, certain other medications, 

and even some over-the-counter products that 

depress breathing, heart rate, and other functions 

of the central nervous system5

. 

PREVENTING OVERDOSE 

If you are concerned about your own use of 

opioids, don’t wait! Talk with the health care 

professional(s) who prescribed the medications 

for you. If you are concerned about a family 

member or friend, urge him or her to talk to 

whoever prescribed the medication. 

Effective treatment of opioid use disorder can 

reduce the risk of overdose and help a person 

who is misusing or addicted to opioid medications 

attain a healthier life. An evidence-based practice 

for treating opioid addiction is the use of United 

States Food and Drug Administration (FDA)-

approved medications, along with counseling and 

other supportive services. These services are 

available at SAMHSA-certified and DEAregistered opioid treatment programs (OTPs).28,29

In addition, physicians who are trained to provide 

treatment for opioid addiction in office-based and 

other settings with medications such as 

buprenorphine/naloxone and naltrexone may be 

available in your community.30

IF YOU SUSPECT AN 

OVERDOSE

An opioid overdose requires immediate 

medical attention. An essential first step is to get 

help from some- one with medical expertise as 

soon as possible. Call 911 immediately if you or 

someone you know exhibits any of the symptoms 

listed below. All you have to say: “Some- one is 

unresponsive and not breathing.” Give a clear 

address and/or description of your location.

Signs of OVERDOSE, which is a lifethreatening emergency, include the following: 

 The face is extremely pale and/or clammy to 

the touch. 

 The body is limp. 

 Fingernails or lips have a blue or purple cast. 

 The person is vomiting or making gurgling 

noises. 

 He or she cannot be awakened from sleep or 

is unable to speak. 

 Breathing is very slow or stopped. 

 The heartbeat is very slow or stopped.

Signs of OVERMEDICATION, which may 

progress to overdose, include:

 Unusual sleepiness or drowsiness. 

 Mental confusion, slurred speech, or 

intoxicated behavior. 

 Slow or shallow breathing. 

 Extremely small “pinpoint” pupils. 

 Slow heartbeat or low blood pressure. 

 Difficulty in being awakened from sleep.
19

SAFETY ADVICE FOR PATIENTS & FAMILY MEMBERS 

WHAT IS 

NALOXONE? 

Naloxone is an antidote to 

opioid overdose. It is an opioid 

antagonist that is used to 

reverse the effects of opioids. 

Naloxone works by blocking 

opiate receptor sites. It is not 

effective in treating overdoses of 

benzodiazepines (such as Valium®, Xanax®, or Klonopin®), 

barbiturates (Seconal® or 

Fiorinal®), clonidine, Elavil®, 

GHB, or ketamine. It is also not 

effective in treating overdoses of 

stimulants such as cocaine and 

amphetamines (including 

methamphetamine and Ecstasy). 

However, if opioids are taken in 

combination with other sedatives 

or stimulants, naloxone may be 

helpful.

IMPORTANT SAFETY

INFORMATION. Naloxone may 

cause dizziness, drowsiness, or 

fainting.

These effects may be worse if it 

is taken with alcohol or certain 

medicines. For more information, 

see 

http://www.fda.gov/drugs/drugsaf

ety/postmarketdrugsafetyinforma

tionforpatientsandproviders/ucm

472923.htm. 

REPORT ANY 

SIDE EFFECTS

Get emergency medical help 

if you or someone has any signs 

of an allergic reaction after 

taking naloxone, such as hives, 

difficulty breathing, or swelling of 

your face, lips, tongue, or throat.

Call your doctor or 911 at once if 

you have a serious side effect 

such as:

 Chest pain, or fast or 

irregular heartbeats. 

 Dry cough, wheezing, or 

feeling short of breath. 

 Sweating, severe nausea, or 

vomiting. 

 Severe headache, agitation, 

anxiety, confusion, or ringing 

in your ears. 

 Seizures (convulsions). 

 Feeling that you might pass 

out. 

 Slow heart rate, weak pulse, 

fainting, or slowed breathing.

If you are being treated for 

opioid use disorder (either an 

illicit drug like heroin or a 

medication prescribed for pain), 

you may experience the 

following symptoms of opioid 

withdrawal after taking naloxone:

 Feeling nervous, restless, or 

irritable. 

 Body aches. 

 Dizziness or weakness. 

 Diarrhea, stomach pain, or 

mild nausea. 

 Fever, chills, or 

goosebumps. 

 Sneezing or runny nose in 

the absence of a cold.

This is not a complete list of 

side effects, and others may 

occur. Talk to your doctor about 

side effects and how to deal with 

them.

STORE 

NALOXONE IN A 

SAFE PLACE

Naloxone is usually handled and 

stored by a health care provider.

If you are using naloxone at 

home, store it in a locked cabinet 

or other space that is out of the 

reach of children or pets.

SUMMARY: 

HOW TO AVOID 

OPIOID 

OVERDOSE 

1. Take medicine only if it has 

been prescribed to you by 

your doctor.

2. Do not take more medicine 

or take it more often than 

instructed.

3. Call a doctor if your pain 

gets worse.

4. Never mix pain medicines 

with alcohol, sleeping pills, 

or any illicit substance.

5. Store your medicine in a 

safe place where children or 

pets can- not reach it.

6. Learn the signs of overdose 

and how to use naloxone to 

keep it from becoming fatal.

7. Teach your family and 

friends how to respond to an 

overdose.

8. Dispose of unused 

medication properly.

READ MORE AT 

http://www.fda.gov/drugs/drugsafety/p

ostmarketdrugsafetyinformationforpati

entsandproviders/ucm472923.htm.
20

RECOVERING FROM OPIOID OVERDOSE

RESOURCES FOR OVERDOSE 

SURVIVORS AND FAMILY MEMBERS

Survivors of opioid overdose have experienced a life- changing 

and traumatic event. They have had to deal with the emotional 

consequences of overdosing, which can involve 

embarrassment, guilt, anger, and gratitude, all accompanied by the 

discomfort of opioid withdrawal. Most need the support of family and 

friends to take the next steps toward recovery.

While many factors can contribute to opioid overdose, it is almost always an accident. Moreover, the underlying problem that led 

to opioid use—most often pain or substance use disorder—still exists 

and continues to require attention.2

Moreover, the individual who has experienced an overdose is not 

the only one who has endured a traumatic event. Family members 

often feel judged or inadequate because they could not prevent the 

overdose. It is important for family members to work together to help 

the overdose survivor obtain the help that he or she needs.

FINDING A NETWORK OF SUPPORT

As with any disease, it is not a sign of weakness to admit that a 

person or a family cannot deal with the trauma of overdose with- out 

help. It takes real courage to reach out to others for support and to 

connect with members of the community to get help.

Health care providers, including those who specialize in treating 

substance use disorders, can provide structured, therapeutic support 

and feedback.

If the survivor’s underlying problem is pain, referral to a pain 

specialist may be in order. If it is addiction, the patient should be 

referred to an addiction specialist for assessment and treatment, 

either by a physician specializing in the treatment of opioid addiction, 

in a residential treatment program, or in a federally certified Opioid 

Treatment Program (OTP). In each case, counseling can help the 

individual manage his or her problems in a healthier way. Choosing 

the path to recovery can be a dynamic and challenging process, but 

there are ways to help.

In addition to receiving support 

from family and friends, 

overdose survivors can access 

a variety of community-based 

organizations and institutions, 

such as:

 Health care and behavioral 

health providers. 

 Peer-to-peer recovery 

support groups such as 

Narcotics Anonymous. 

 Faith-based organizations. 

 Educational institutions. 

 Neighborhood groups. 

 Government agencies. 

 Family and community 

support programs.
21

RECOVERING FROM OPIOID OVERDOSE

RESOURCES

Information on opioid overdose and helpful advice for overdose survivors and their families can be found at:

Substance Abuse and Mental Health Services Administration (SAMHSA)

 National Helpline 1-800-662-HELP (4357) or 1-800-487-4889 

(TDD—for hearing impaired)

 Behavioral Health Treatment Services Locator: https://findtreatment.samhsa.gov to search by 

address, city, or zip code

 Buprenorphine Treatment Physician Locator: http://www.samhsa.gov/medication-assistedtreatment/physician-program-data/treatment-physician-locator 

 State Substance Abuse Agencies: 

https://findtreatment.samhsa.gov/TreatmentLocator/faces/about.jspx

Centers for Disease Control and Prevention (CDC):

http://www.cdc.gov/drugoverdose/epidemic

National Institutes of Health (NIH), National Center for Biotechnical Information: 

http://www.ncbi.nlm.nih.gov

Partnership for Drug-Free Kids: 

http://www.drugfree.org/join-together/opioid-overdose-antidote-being-more-widely-distributed-to-thosewho-use-drugs 

Project Lazarus: 

http://www.projectlazarus.org 

Harm Reduction Coalition: 

http://www.harmreduction.org 

Overdose Prevention Alliance:

http://www.overdosepreventionalliance.org 

Toward the Heart: 

http://www.towardtheheart.com/naloxne
22

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