Training Guide

Guide to Developing and Managing Overdose Prevention and Take Home Naloxone Projects

Module 5: Overdose Prevention and Response

Risks and Prevention Strategies

The following section highlights common overdose risks and provides prevention tips. We understood that every prevention message might not be applicable or pragmatic in every situation; we hope these tips can provide direction and messages can be shared and adapted as needed.


Risk Factor: Mixing Drugs

Drugs taken together can interact in ways that increase their overall effect. Many overdoses occur when people mix heroin or prescription opioids and/ or alcohol with benzodiazepines (such as Klonopin®, Valium®, and Xanax®). Most fatal overdoses are the result of poly-drug use.

All sedating medications carry overdose risks when taken on their own. However, when drugs are combined, the risk is substantially increased, because the drugs typically use different mechanisms in the body to create sedation. These mechanisms represent overlapping protection from the brain and respiration shutting down. This overlapping protection is diminished when multiple substances are combined. For example, the more alcohol and/or downers in someone’s system, the less heroin needed to cause an overdose.

“Speedballing” — mixing heroin and cocaine — is a common combination. While it seems intuitive that combining a stimulant and a depressant would counterbalance the drugs’ different effects, the combination does not cancel out overdose risk. Actually, people who speedball are at higher risk for overdose than people who use heroin or cocaine alone.

This is likely because:

1) the body has to process more drugs;

2) the stimulant causes vasoconstriction (which reduces blood flow to the brain) and causes the body to use more oxygen, while the depressant reduces the breathing rate;

3) people who speedball usually inject more frequently with less time between shots than people who are using only heroin.

[Download the full printable worksheet of all prevention tips]


Prevention Tips: Mixing Drugs

  • Use one drug at a time.
  • Use less of each drug.
  • Try to avoid mixing alcohol with heroin/pills — this is an incredibly dangerous combination.
  • If drinking or taking pills with heroin, do the heroin first to better gauge how high you are — alcohol and especially benzos impair judgment so you may not remember how much you have used.
  • Have a friend with you who knows what drugs you have taken and can respond in case of an emergency.


Risk Factor: Tolerance

Tolerance is your body’s ability to process a certain amount of a drug. Low tolerance means that your body can only process a small amount of a drug (i.e., it takes less drugs to feel the effects) and increased tolerance means your body has learned how to process increased amounts of the drug (i.e., it takes more drugs to feel the effects).

Tolerance develops over time, so the amount of a drug a long-time user needs to feel the drug’s effects is a lot greater than a newer user. Tolerance also wavers depending on several factors including, weight, size, illness, stress, compromised immune system, and age.

Most importantly, tolerance can decrease rapidly when someone has taken a break from using a substance whether intentionally (i.e. while in drug treatment or on methadone detox) or unintentionally (i.e. while in jail or the hospital). Research has also shown that tolerance is affected when a person uses drugs in a new or unfamiliar environment, and can therefore increase their risk for overdose.


Prevention Tips: Tolerance

  • Use less after any period of abstinence or decreased use – even a few days away can lower your tolerance.
  • If you are using after a period of abstinence, be careful and go slow.
  • Use less when you are sick and your immune system may be weakened.
  • Do a tester shot, or go slow to gauge how the shot is hitting you.
  • Use a less risky method (i.e. snort instead of inject).
  • Be aware of using in new environments, or with new people — this can change how you experience the effects of the drugs and in some cases, increase the risk of overdose.


Risk Factor: Quality

Quality refers to how pure, or strong, a drug is. The content and purity of street drugs is always unpredictable. They are often “cut” with other drugs or materials that can be dangerous. You can’t tell how pure your drugs are from looking at them, and purity levels are always changing, which means you can do a shot that’s a lot stronger than what you are used to and put yourself at risk of an overdose.

The same applies to prescription drugs — while we may know the contents of the pill and the dosage, you may not know how strong one type of pill is compared to another of a similar type. For example, an Oxycontin® is not the same as a Vicodin®, even though both are in the opioid family. Understanding strength and dosage when taking pills is as important as knowing the strength and purity of street drugs like heroin.


Prevention Tips: Quality

  • Test the strength of the drug before you do the whole amount.
  • Try to buy from the same dealer so you have a better idea of what you’re getting.
  • Talk to others who have copped from the same dealer.
  • Know which pills you’re taking and try to learn about variations in similar pills.
  • Be careful when switching from one type of opioid pill to another since their strengths and dosage will vary.


Risk Factor: Using Alone

While using alone isn’t necessarily a cause of overdose, it increases the chance of dying from an overdose because there is no one there to call for help or take care of you if you go out. Many fatal overdoses have occurred behind closed or locked doors where the victims could not be found and no one was there to intervene.


Prevention Tips: Using Alone

  • Develop an overdose plan with your friends or partners.
  • Leave the door unlocked or slightly ajar whenever possible.
  • Call or text someone you trust and have them check on you.
  • Some people can sense when they are about to go out. This is rare, but if you are one of the people can do this, have a loaded syringe or nasal naloxone ready. People have actually given themselves naloxone before!


Risk Factor: Age and Physical Health

Your age and physical health impact your body’s ability to manage drugs. While having more experience with substances is probably protective (and can increase tolerance), the cumulative effects of long-term substance use—which could include illnesses like viral hepatitis or HIV or infections, kidney, heart, lung, or circulation problems, or infections like endocarditis or cellulitis — may hinder resiliency. Older people who overdose are less likely than younger people to survive their overdose.

If you have a compromised immune system, you’ve been sick, or if you have a current infection, like an abscess, this also puts you at higher risk for overdose because your body is weakened. Dehydration and not eating or sleeping enough also puts you at greater risk for overdose. If you are a stimulant user, you are more at risk for a seizure, stroke, or heart attack if you also have other health issues like high blood pressure, heart disease, diabetes, high cholesterol or if you smoke cigarettes.

Liver and lung health, negatively impacted by hepatitis and smoking respectively, play an important role in overdose. The liver filters substances in the body and is involved in their metabolism; a poorly functioning liver means less capacity to metabolize substances in a timely manner. In other words, when your liver is not working well it can’t process drugs and alcohol as easily, leading to “build-up” of drugs in your system; this can be toxic and make the effects of certain drugs last longer than they should.

Since downers cause your breathing to slow down, asthma or other breathing problems can put you at higher risk for overdose. Poor lung function decreases the body’s capacity to replenish oxygen supply, which is essential to survive an overdose. Using less when you are sick or recovering from an illness can reduce the risk of overdose. It is important to rely more on what you know about your own body, tolerance and experience, as opposed to what partners or friends may experience because there is substantial variability in how different substances are processed by different people.

Anyone who uses opioids, including people who take opioids for pain, should be aware of increased overdose risk if they:

  • Smoke or have COPD, emphysema, asthma, sleep apnea, respiratory infection or other respiratory illness
  • Have kidney or liver disease or dysfunction, cardiac illness or HIV/AIDS
  • Drink alcohol heavily
  • Are currently taking benzodiazepines, other sedative prescription or antidepressant medication


Prevention Tips: Age and Physical Health

  • Stay hydrated! Drink plenty of water or other fluids.
  • Eat regularly.
  • Get enough sleep and rest when you feel worn down.
  • Pharmaceuticals (like opioids and benzos) — especially those with Tylenol® (acetaminophen) in them — are harder for your liver to break down. If you have liver damage, stay away from pharmaceuticals with a lot of acetaminophen in them, like Vicodin® and Percocet®.
  • Carry your inhaler if you have asthma, tell your friends where you keep it and explain what to do if you have trouble breathing.
  • Go slow (use less at first) if you’ve been sick, lost weight, or have been feeling under the weather or weak — this can affect your tolerance.
  • Try to find a good, nonjudgmental doctor and get checked out for any health factors that may increase your risk for a stroke, seizure, respiratory problems or heart attack.


Risk Factor: Mode of Administration

There are many ways to use drugs, including swallowing, snorting, plugging (drug-water solution introduced rectally with a needleless syringe — aka booty bumping), intramuscular injection, and intravenous injection. Regardless of the mode of administration, if someone uses enough drugs in a short enough period of time, overdose is possible.

Methods that deliver the drug quicker to the brain and are more likely to create a rush (such as intravenous injection and smoking) are linked to higher risk for overdose. Transition periods (i.e. changing modes of administration) can be dangerous, too. When someone switches the mode of administration that they are used to, it is harder to anticipate the effects. Similarly, when someone migrates to a different drug of preference or temporarily substitutes a different primary drug, there can also be a period of heightened risk. Some examples include: Going from swallowing methadone to injecting methadone; switching from swallowing oxycodone (OxyContin®, Roxicodone®, Percocet®) to swallowing oxymorphone (Opana®); or moving from injecting heroin to injecting Dilaudid®; these are all periods when heightened overdose prevention techniques are important.


Prevention Tips: Mode of Administration of the Substance

  • Be mindful that injecting and smoking can lead to increased risk.
  • Consider snorting, especially in cases when you’re using alone or may have decreased tolerance.
  • If you inject, try and remove the tie after registering and before injecting — this will allow you to better taste your shot and inject less if it feels too strong.
  • Be careful when changing modes of administration since you may not be able to handle the same amounts.


Risk Factor: Previous Nonfatal Overdose

People who have had a nonfatal overdose in the past may be at increased risk for overdose in the future. It is believed that this is related to drug use patterns and potentially risky behavior. Experiencing a nonfatal overdose may cause damage to the body, even if the person survives the overdose. One study found that many people who had experienced a nonfatal overdose also experienced other harms, including physical injury sustained when falling at overdose, burns, assault while unconscious, peripheral neuropathy (nerve damage, numbness/tingling), vomiting, temporary paralysis of limbs, chest infections and seizure.


Prevention Tips: Previous Nonfatal Overdose

  • Always use with a friend or around other people.
  • Use less at first, especially if you are using a new product.
  • Make an overdose plan with friends or drug partners.


Overdose Recognition

If someone is using downers, like heroin or pills, and they are very high but not necessarily experiencing overdose, they may exhibit certain symptoms.

If a person seems too high or on the verge of overdose but is still conscious, walk them around, keep them awake, and monitor their breathing. If a person is experiencing an overdose emergency, their symptoms will be more severe than when they are high.

If someone is making unfamiliar sounds while “sleeping” it is worth trying to wake him or her up. Unfortunately, many loved ones of users have thought a person was snoring, when in fact the person was overdosing. These situations are a missed opportunity to intervene and save a life.

Important: It is rare for someone to die immediately from an overdose. When people survive, it’s because someone was there to respond. The most important thing is to act right away!


High vs. Overdose

How do you tell the difference between someone who is really high or overdosing? 


  • Pupils will contract and appear small
  • Muscles are slack and droopy
  • They might “nod out” (but remain responsive to stimulus)
  • Scratch a lot due to itchy skin
  • Speech may be slurred
  • They may be out of it, but they will respond to outside stimulus like loud noise or a light shake from a concerned friend


  • Awake, but unable to talk
  • Body is very limp
  • Face is very pale or clammy
  • Fingernails and lips turn blue or purplish black
  • For lighter skinned people, the skin tone turns bluish purple, for darker skinned people, it turns grayish or ashen
  • Breathing is very slow and shallow, erratic, or has stopped
  • Pulse (heartbeat) is slow, erratic, or not there at all
  • Choking sounds, or a snore-like gurgling noise
  • Vomiting
  • Loss of consciousness
  • Unresponsive to outside stimulus

Responding to Opioid or Depressant Overdose 


Assess the Signs: 

  • Is the person breathing?
  • Is the person responsive?
  • Does the person answer when you shake them and call their name?
  • Can the person speak? What is the skin color (especially lips and fingertips)?



If the person is unconscious or in a heavy nod, try and wake them up first by calling their name. You can also say something that they might not want to hear, like “I’m going to call 911” or “I’m going to give you naloxone (Narcan®).”

  • If they remain unresponsive, try  to stimulate them with mild pain by rubbing your knuckles into the sternum (the place in the middle of your chest where your ribs meet) or rubbing your knuckles on their upper lip. The sternal rub is preferable over the upper lip because the person may have dental problems, or prosthetic teeth that may cause pain or unnecessary  discomfort when rubbed vigorously. However, if the person is in a position where you cannot get to their sternum easily, or if they are wearing multiple layers of heavy clothing, rub the upper lip area.
  • If this causes the person to wake up, try to get them to focus. Can they speak to you? Check their breathing. Continue to monitor them, especially their breathing and pulse and try to keep them awake and alert. If their breathing is shallow, they tell you that they feel short of breath, or they are experiencing chest tightness — call 911. 
  • If the person does not respond to stimulation and remains unconscious or the condition appears to get worse, do not try a different or alternative form of stimulation. Treat this as an emergency and call 911 immediately.


Recovery Position 

If you have to leave the overdosing person at any time — even for a minute to phone 911 — make sure you put them in the Recovery Position: lay the person slightly on their side so that their body is supported by a bent knee, with their face turned to the side. This will help to keep their airway clear and prevent them from choking on their own vomit if they begin to throw-up.


Call for Help

It is recommended that you call 911 in the case of an overdose because it is important to have trained medical professionals assess the condition of the overdosing person. Even though naloxone can address the overdose, there may be other health problems going on. Also, people who survive any type of overdose are at risk of experiencing other health complications as a result of the overdose; such as pneumonia and heart problems. Getting checked out by a medical professional is an important part of reducing harms associated with overdose.

What to say when calling 911 will depend somewhat on how local responders typically handle overdose emergencies. In every situation, it is important to report certain key information including that the person’s breathing has slowed or stopped, that they are unresponsive, and to clearly state the exact location. In many communities, the police respond along with the ambulance to all 911 calls. In other cases, police are only dispatched in cases where illegal activity is suspected, or if the dispatcher is concerned about the safety of first responders. In some communities, when the police respond they do not routinely arrest bystanders or victims at the scene of an overdose. However, in other places, it is common for police to arrest people at the scene of an overdose, and they have been known to charge people with everything from drug possession, to manslaughter (if the overdosing person dies and the bystander is proven to be the supplier of drugs). Fear of arrest and police involvement when calling 911 is substantial. Agencies should talk to participants about perceived and real risks associated with calling 911 and work with police and emergency personnel to address the fear of arrest and police involvement.

If calling 911 is not an option (some people will not call), it is important to make alternative plans in case your rescue attempts are not working. Can someone else in the vicinity call? Can you leave to alert someone else to call (even a passerby) after providing rescue breathing, administering naloxone, and/or putting the person in the recovery position? If you do need to leave the person, do your best to make sure they are in a place where they can be found, with doors unlocked and/or open. Remember, doing something is better than doing nothing. 


Tips When Calling 911

[Download printable checklist] 

It is important to educate participants about the safest and most effective ways to communicate with emergency dispatchers and personnel.

  • Tell the paramedics exactly where you and the overdosing person are. Give them as much information as possible so that they can find you quickly (i.e. 3rd floor, or in the bathroom).
  • When speaking with the dispatcher on the phone, avoid using words like drugs or overdose — stick to what you see: “The person is not breathing, turning blue, unconscious, non-responsive, etc.” This makes the call a priority because it will be identified as a life-threatening emergency. The dispatcher does not need to know the details of the situation, only that there is an emergency that requires immediate assistance.
  • When calling 911, keep loud noise in background to a minimum — if it sounds chaotic, they will surely dispatch police to secure the scene and protect the paramedics.
  • When the paramedics arrive, it is important to give them as much information as possible; tell them what you know about what drugs the person may have been using, when they used them, whether naloxone was administered, etc. If the paramedics suspect opioid use, they will give the victim an injection or intranasal dose of naloxone. Remember: paramedics’ main goal is to address the health of the individual and respond to the medical emergency.


Poison Control Centers

Poison Control Centers (PCC) are another resource available. Poison centers provide poison expertise and treatment advice by phone. PCC can answer a wide variety of questions about medications and street drugs and can help decide if it is necessary to go to the hospital or if a problem can be managed at home. The centers are completely confidential; specifically they never call law enforcement.

All poison centers can be reached by calling the same telephone number 1-800-222-1222, 24 hours a day. They are staffed by pharmacists, physicians, nurses and poison information providers who are toxicology specialists. They are not only available to the 50 states and Puerto Rico, but also to The Federated States of Micronesia, American Samoa, and Guam.


Perform Rescue Breathing

For a person whose breathing is severely impaired, rescue breathing is one of the most important steps in preventing an overdose death. 

When someone has extremely shallow and intermittent breathing (around one breath every 5-10 seconds) or has stopped breathing and is unresponsive, rescue breathing should be done as soon as possible; it is the quickest way of getting oxygen to someone who has stopped breathing. If you are performing rescue breathing, you are getting much needed air into someone’s body who will die without it; the difference between survival and death in an opioid overdose depends on how quickly enough oxygen gets into the person’s body.

You may have heard that new CPR guidelines recommend “hands-only CPR” or the use of chest compressions only instead of both rescue breathing and chest compressions. However, these guidelines refer to layperson response to cardiac arrest, and not overdose. Rescue breathing is still recommended when responding to an overdose, where the primary issue is respiratory depression, and not cardiac arrest.

If you are alone with the overdosing person and have naloxone, give the person a few breaths first, then put them in the Recovery Position and go get your naloxone kit. If there is more than one of you there to respond to the overdose, DIVIDE DUTIES — have one person perform rescue breathing while another goes to get the naloxone kit and/or call 911.