Overdose Recognition & Response 

What is an Overdose?

Substance Categories

Opioid Overdoses

Stimulant Overdoses

Alcohol Poisoning

Complicated Overdoses from Drug Combinations

What is an Overdose?

An overdose occurs when a drug or combination of substances overwhelm the body. As a result, the central nervous system (CNS) is no longer able to control basic life functions such as breathing, heart rate, body temperature, and consciousness.

Anyone using alcohol, prescription, and/or illicit drugs can overdose.

Opioid overdoses are one of the most common types of fatal overdoses in Canada, with the number of fatal overdoses increasing over recent years. Since the overdose crisis erupted in 2016, there have been over 11,500 opioid overdose deaths in Canada, and the crisis is not slowing down.

Overdose deaths are preventable.

Risk factors include:

• Drug potency and quality - with illicit (street) drugs being the most dangerous due to drug contamination with fentanyl and other substances

• Mixing different drugs and alcohol together

• Drug tolerance

• Using alone and social context of use

• History of previous overdoses

Different classes of drugs can lead to different types of overdoses.

Substance Categories

Depressants

Slow down the Central Nervous System (CNS)

• Opioids/opiates (heroin, Fentanyl, Dilaudid, Percocet, Morphine, Methadone, Suboxone)

• Benzodiazepines (Ativan, Valium, Xanax)

• Alcohol

• GHB

Stimulants

Speed up the CNS

• Cocaine

• Crack cocaine

• Amphetamines (speed, MDMA, crystal meth)

• Methylphenidate

• Caffeine 

• Tobacco

Overdose Symptoms Compared

Opiates/Opioids

• Not breathing

• Changes in skin colour (grey, white lips, blue tinged * can vary with skin tones)

• Deep Snoring or gurgling

• Pinpoint pupils

• Unconscious

Stimulants

• Seizures

• Foaming at the mouth

• Racing pulse

• Heavy sweating

• Chest pain

Opioid Overdose

Opioids are substances derived from the opium poppy, or synthetic analogues with similar effects. Opioids/opiates include morphine, heroin, codeine (in Tylenol 2, 3 & 4), oxycodone, methadone, hydromorphone (Dilaudid) and fentanyl. Opioids are depressants that affect the part of the brain which regulates breathing, and in high doses can cause respiratory depression and death. Combining opioids with other depressants such as alcohol, sedatives, and/or anti-anxiety medication increases the risk of respiratory depression, and these drug combinations are often present in fatal overdoses.

An opioid overdose is a life-threatening oxygen emergency.

You can save a life if you learn how to recognize and respond to an overdose using naloxone.

Opioid Intoxication vs. Overdose

There is a difference between being intoxicated and having overdosed. When someone is heavily intoxicated, they should be supported and observed for signs of overdose. When someone exhibits signs of an overdose, you must act immediately to ensure they get medical help.

Opioid intoxication (really high):

• Muscles become relaxed

• Speech is slowed/slurred

• Sleepy looking

• Will respond to stimulation like yelling

• Nodding off

Opioid Overdose:

• Deep snoring, gurgling (“death rattle”), choking or wheezing

• Will not respond to stimulation (“heavy nod”)

• Breathing is very slow, irregular, or has stopped

• Clammy skin, “drained” or pale face.

• Person looks “wrong” or doesn’t look alive

• Nails, lips, or fingertips have blue undertones (on light skin) or grey/ashen undertones (dark skin)

• Pinpoint pupils

• Sclera (white part of eye) is pale or red (not vibrant white)

• May be shaking and/or sweating, confused, dizzy, and unable to stay awake

Responding to an opioid overdose

Get Trained in Naloxone Use and carry a kit

Naloxone is a medication that reverses opioid overdoses. You can get naloxone kits and training at most pharmacies and some community organizations. Call in advance to check if they’re in stock.

Get a free naloxone kit near you: ontario.ca/where-get-free-naloxone-kit

If you witness an opioid overdose, take action immediately and follow the 5-step response:

1. Check for responsiveness and vital signs

   • Shout their name and shake their shoulders

   • Check is they are responsive to voice, physical stimulation, and mild pain (try sternum rub or pen pressed across nail bed)

   • Check their breathing: Is their airway clear? Is their chest rising and falling? Does a mirror or phone under their nose fog up? Do they have a pulse?

2. Call 911 if the person is unresponsive

   • Sample Script: “I am calling from (location). We have a person here with (nature of emergency, e.g. not breathing, non-responsive)”

   • Specify location: “1st floor, entrance on the right-hand side of the lobby doors

3. Administer Naloxone

   • 1 spray in nostril or 1 ampule into arm or leg

   • See naloxone administration page for instructions

   • See needle naloxone administration for detailed instructions

4. Start CPR

   • Rescue breathing and/or chest compressions if trained

   • See CPR and Rescue Breath page for detailed instructions

5. Assess: Is it Working?

   • If NO improvements in 2-3 minutes, repeat steps 3 & 4

   • Administer another dose of naloxone and administer CPR/rescue breaths until paramedics arrive

If at any point you need to leave the person alone, place them in the recovery position

• This aids in the clearance of physical obstruction of the airway by the tongue, and also gives a clear route by which fluid can drain from the airway and prevent choking

Stimulant Overdose

Stimulants or "uppers" speed the body up. They include amphetamines, crystal meth, cocaine, MDMA (Ecstasy), Ritalin and caffeine.

Signs of a Stimulant Overdose:

• Rigid, jerking limbs or seizures

• In and out of consciousness

• Fast pulse or chest pains

• Skin feels hot, sweating, and headaches

• Psychological distress, such as anxiety, paranoia, confusion, panic, hallucination, or agitation

Responding to a stimulant overdose

There is no antidote to stimulant overdose.

Naloxone will not work for a stimulant overdose, but it will not cause harm. If in doubt use Naloxone.

• Call 911 immediately

• If the heart has stopped give CPR

• While waiting for the ambulance to arrive:

• Stay with the individual for support, encourage hydration, and stay calm.

• Do not give them anything by mouth if they are unconscious.

• If they are having a seizure make sure there is nothing around them that can hurt them. Do not put anything in their mouth or restrain them.

If the individual is concious they may be experiencing "over-amping", or mental distress (i.e crashing, anxiety, paranoia) linked to stimulant use and sleep deprivation from stimulant use. 

How to Respond:

• stay calm, remain with them, encourage them not to take any more substances, and move away from activity and noise.

• be careful not to over-hydrate, but give water or other non-sugary, non-caffeinated drink to help replace lost electrolytes

• place cool wet cloths on forehead, back of neck, armpits.

(Toward the Heart, 2019)

Alcohol Poisoning

Alcohol is a depressant drug that can slow down the parts of the brain that affect thinking, behaviour, breathing and heart rate.

A severely intoxicated person may “black out,” and have no memory of what was said or done while drinking. Effects of extreme intoxication include inability to stand, vomiting, stupor, coma and death.

Death may result when a person “passes out,” vomits and chokes. A person who has been drinking heavily and is unconscious should be laid on his or her side and watched closely. Clammy skin, low body temperature, slow and laboured breathing and incontinence are signs of acute alcohol poisoning, which can be fatal.

Take action if someone shows signs of alcohol poisoning:

• Try to keep the person awake and sitting up

• If they cannot sit up or if you have to leave to get help, put person in recovery position

• Call 911

Naloxone will NOT reverse alcohol poisoning, although it will help if the person has taken an opioid in conjunction with alcohol.

Complicated Overdoses

Mixing drugs (polysubstance use) can lead to unpredictable effects and overdoses. When substances are taken together, they combine to create additive effects, which are unique and can be more severe than the separate effects of each drug.

Overdoses from multiple drugs can be hard to assess and treat. While people may take multiple drugs on purpose, such as heroin/fentanyl and benzodiazepines, people often suffer complicated overdoses from street drugs that are contaminated with other substances.

Opioids and other street drugs are being mixed with fentanyl, carfentanyl, caffeine, etizolam, and cannabinoid analogues - leading to overdoses that may simultaneously resemble both depressant and stimulant poisonings. People may have symptoms of an opioid overdose, while also flailing, being rigid, or remaining unconscious for a long period of time. Note that CPR and rescue breaths may be hard to administer in someone who is rigid.

Call 911 in the event of a complicated overdose.

Naloxone may treat some of the symptoms of a polysubstance overdose (if an opioid has been taken), while failing to address others. When in doubt, administer naloxone.

References

Content adapted from: Toronto Public Health. (2019). Opioid overdose education, prevention and response. [PowerPoint slides].

IMAGES Sources:

Heroin, fentanyl, and carfentanyl. Labonco. (2019). Retrieved from https://www.labconco.com/articles/the-problem-with-fentanyl