Training Guide

Getting Off Right: A Safety Manual for Injection Drug Users

Overdose & Other Medical Emergencies

This chapter covers:

  • What  Is  an  Overdose?
  • How Do Overdoses Happen?
  • How Can You Tell if Someone Has  Overdosed?
  • Naloxone
  • What to Do if Someone Overdoses
  • What You Should Not Do if Someone Overdoses
  • Accidental Needlestick Injuries

Whether or not an individual survives an over- dose depends mostly on what those present do or don’t do to help.
One  of  the  most  serious  health  consequences associated with using illicit drugs is the risk of overdose. While overdose is indeed serious, it doesn’t have to be fatal. Anyone who uses illicit drugs should take the time to talk with friends and develop an overdose plan in the event that something happens. Whether or not an individual survives an overdose depends mostly on what those present do or don’t do to help. People who use drugs should learn how to perform rescue breathing and CPR, for example, and be aware of the necessary steps they should take if someone they’re with overdoses. Many overdoses occur in the presence of another person, so often we have the opportunity to help our friends and loved ones survive if  we know what to do. Read the following section carefully and do what you need to do to feel confident that you could help someone who has overdosed survive. We owe it to ourselves and to each other.


Drugs that people take to get high work by affecting the brain. Because the brain controls other parts and functions of the body (like the lungs which enable oxygen to get to the blood, the kid- neys and liver which remove toxins from the body, and the heart which pumps blood to all parts of the body), using drugs can affect one or more of these crucial activities in addition to making you high. For example, cocaine speeds up your heart rate and heroin slows down your breathing. A person’s body can usually adjust to these changes, but if you take too much of a particular drug, such changes may overwhelm the body’s ability to adjust to them and very dangerous side effects can occur.
Some side effects that occur from taking a lot of drugs are often serious but not immediately life-threatening, such as the damage that can result to the liver and kidneys from making them work hard to remove drugs from the body over a period of years. But if too much of a drug gets to the brain or other organs too fast, dangerous side effects such as unconsciousness, stopped breathing, heart failure, or seizures may occur — any of which can be deadly. This is what is known as a drug overdose (o.d.).
This chapter will help you or someone you love avoid overdosing in the first place and give you some basic information about what to do in case you’re with someone who overdoses. There is no reason you should die just because you get high!

How do overdoses happen?

Anyone who uses drugs can overdose, from the first-time user to the person with many years’ experience. There are numerous reasons a person can overdose:

  • One of the effects of drugs being illegal is that there is no quality control; in other words, you don’t know what you’re getting. Drugs you buy on the street — especially drugs like heroin that, unlike pills, are not made by drug companies — can be a different strength from day to day. Sometimes a drug may be cut a lot, and sometimes it’s hardly cut at all and therefore much stronger. If you’re using drugs of unknown strength (and you are every time you purchase from a different dealer or new batch), do a tester shot first to see how strong they are. You can always do more later. Many people overdose when they do a full hit of a strong drug.
  • Sometimes dope, speed, and coke are cut with other, cheaper drugs which can be dangerous and unpredictable and increase your chances of overdosing.  Fentanyl is an example of a very cheap and extremely potent opioid often used to cut heroin.   Fentanyl has also been found in pressed pills sold as Xanax, as well as cocaine, crack, and meth.   Fentanyl test strips can be purchased online in small amounts (https://dancesafe.org/product/fentanyl-test-strips-pack-of-10-free-shipping/) or wholesale (https://www.btnx.com/HarmReduction) and are offered at many syringe service programs.  These are a helpful tool for detecting if there is fentanyl in your drugs, but unfortunately do not tell you how much fentanyl is present.  In addition, in many places it may be impossible to purchase “heroin” that does not contain fentanyl, so this might not be a useful tool for people who use opioids regularly.  For those who are stimulant users with no tolerance for opioids, this information might be more useful.
  •  If possible, try to purchase your drugs from a regular source that, to the extent possible given the situation, you can trust. Establish a relationship with a dealer who you feel you can talk to about his or her product.
  • Some people overdose because they simply do too many drugs in one session. Let your drugs work first before you do more, and perhaps plan to use only a certain amount (maybe even purchasing just the amount you’re going to use at a given time). Take your time to prepare your drugs right, even if you’re in withdrawal or in a hurry. Minimize uncertainty by thinking through each step of your drug-taking. Deep breathing may help focus you, and sniffing or smoking a little bit of the drug may help calm you before preparing your injection.
  • Take control of your own drug preparation and intake. Different people have different tolerances to drugs, so a dose that’s fine for one person could be lethal to someone else. Make sure you know what you’re putting into your own body.
  • A person can overdose if they haven’t used for a while, even for a short time. After detoxing or spending some time in a rehabilitation center, your body is no longer used to the same amount of drugs. One of the consequences of jail time is that your tolerance decreases and you’re a lot more sensitive to dope, so be careful if you’re getting high after release. Take a smaller dose if you’re using after a break until you figure out how much you need. Someone who’s using a drug for the first time should also be extremely careful, since they will have no tolerance to it at all. You might try using the drug in a way that makes it come on more slowly (sniffing heroin or cocaine rather than injecting it, for example). And make sure you use with someone who knows what they’re doing and has experience with the drug.
  • Mixing drugs like heroin, pills, and alcohol can be very dangerous. One of the most common reasons for death from an o.d. is mixing drugs, since drugs that are taken together can be much stronger than if they’re taken alone. You may get a stronger high

when you mix, but you’re also putting yourself at much greater risk of having an overdose. Mixing drugs also increases the risk of passing out and vomiting, and vomit can block your airways and cause you to suffocate.

  • Finally, some pharmaceuticals may interact with “street” drugs in dangerous ways. If you feel comfortable doing so, you might want to talk to your doctor about this issue.
  • Changes in your health may cause you to be at higher risk for an o.d. If you have lost a lot of weight, a smaller amount of a drug will get you high; and if your liver or kidneys aren’t working well, you can overdose easier. Your body is less able to protect itself after you’ve been sick, so help it out by using less and giving it a chance to recover. Eat and sleep well, always drink a lot of fluids, and get that annual physical.
  • Using drugs alone increases the chance that if you overdose, it will be fatal because you can’t take care of yourself or call for help. If you find yourself alone in an overdose situation and have called 911, remember to unlock your door so that the paramedics can get inside. If possible, use with people who care about you and who you trust, and sit down and talk with them about an overdose plan. Try to put together a support system for yourself of people who know you use and will be there for you if something happens.


STIMULANT DRUGS, such as cocaine and speed, can cause a person who has overdosed to have a heart attack or experience cardiac arrest, collapse from exhaustion, have a seizure, or become so disoriented that they accidentally hurt themselves.
DEPRESSANT DRUGS like opiates (e.g., heroin and Dilaudid) and sedatives (e.g., Valium and alcohol) slow down the body’s functions. A person who overdoses on a depressant will experience respiratory arrest—that is, their breathing will become life-threateningly slow or stop altogether, leading to heart failure.
Since an opioid related overdose causes issues with breathing, some common signs are that they are breathing but very slowly and shallowly, with a gurgling snore, or not at all.  Their lips or face may turn blue/purple due to a lack of oxygen.  They may also be pale, their body may be limp, they may be able to breathe and look at you, but not be able to talk and they may have a slow pulse (heartbeat) or no pulse at all.  Someone may also suddenly collapse and become unconscious.
Some other signs that an overdose or other medical emergency is happening is if they foam at the mouth, vomit, are shaking or having a seizure, complain of chest pain, pressure, tightness, or shortness of breath.
A person who is overdosing isn’t usually aware of what is happening because of the effects of the drug they’re on. They need someone to act quickly. If a person stops breathing, it can take only a few minutes for them to die. Just waiting for them to “get over it” is the worst thing you can do if someone is overdosing. Immediate action must be taken to help them survive.


How Naloxone Works

Naloxone (also referred to by its brand name Narcan®) is an opioid antagonist,  which means that it binds to the same receptors in the brain as opioids, pushes opioids off receptors, and blocks them, reversing the effects of an overdose,  allowing the person overdosing to breathe normally.
Naloxone may be injected in the muscle, vein or under the skin, or sprayed into the nose and wears off in 30-90 minutes.  Naloxone only works if a person has opioids in their system; the medication has no effect if opioids are absent.
Naloxone causes temporary acute and severe withdrawal symptoms in people who are opioid dependent.  This means that the person’s body is thrown into severe withdrawal almost immediately, causing them extreme discomfort. The person who was overdosing may be very confused, disoriented or even frustrated.  Remember that there were no signs to them that they were overdosing, they were feeling good and now are waking up to this chaotic and scary scene.
You cannot overdose or get high from naloxone, and it is a nonscheduled, prescription medication.  The laws surrounding naloxone vary state by state, in some, Naloxone is restricted for use by medical and health professionals only, and in others, you can get naloxone at the pharmacy or from a social service provider without a prescription.


Five- Steps for Overdose Response

Rule of thumb: if the naloxone is readily available, use that first then dial 911, or if the phone is closest dial 911 first then find, assemble, and administer the naloxone.  Remember that opioid related overdose is not the only medical emergency someone can experience.  If the person is conscious and breathing but experiencing nausea, chest tightness, shortness of breath, or other such symptoms they may not need naloxone, but they still need medical attention, convince them to call 911 or call 911 for them.

  1. Assess
  2. 911
  3. Naloxone
  4. Rescue Breathe
  5. Monitor

Assess the person

  • Is the person unconscious?
  • To check, try stimulation like a sternal rub or pinching their fingertip if you don’t have access to their sternum.

Call 911

  • Tell the emergency operator you found someone unconscious and not breathing, and give the location, such as street address or cross streets.
  • Describe what you see, avoid guessing and speculating or mentioning drugs or overdose; it’s okay to say, “I don’t know.”

Administer Naloxone

  • Wait 2-3 minutes before giving another dose.  It is important to wait this time because the medication needs time to work.  We do not want to overload their system with naloxone that they do not need since it will make their withdrawal more severe
  • Rescue breathe in the meanwhile.

Rescue Breathe

  • Put the person on their back, face up
  • Tilt their neck
  • Pinch their nostrils and seal your mouth over theirs
  • Breathe into their mouth
  • Count to 5 seconds
  • Repeat
  • There are options if someone is unwilling or unable to put their mouth on another person’s to Rescue Breathe:
    • Find someone who can Rescue Breath while the first bystander stays with the person who is unconscious.
    • Use a mouth shield.
    • Put two holes in a cup and breathe through that.
    • Put a shirt or bandana over the person’s mouth and breathe through that.
    • Apply the one-use ‘Ambi-bag’ that is a hand-held gadget and acts as a rescue breathing device. This is a good option for drop-in centers, fixed site facilities and SSP vans.

Monitor and Support

  • When they come to, give the person space (if there are multiple people present have one person talk to them).  Let them know that they were overdosing and that  you administered naloxone.
  • There is a myth that all people who are given naloxone awaken and are violent.  In the rare cases that people do act violently, it is usually because they are disoriented, and being treated in an aggressive way by bystanders or first responders.  This myth is dangerous because it perpetuates stigma towards people who use drugs and means that people may hesitate to reverse overdoses.
  • If you called 911 tell them.   If they do not want to wait for the ambulance and can walk away, it is their prerogative to do so.  Do not restrain the person.
  • Since naloxone is short acting and wears off in 30-90 minutes, the person can revert back to a state of euphoria and, if they still have enough drugs in their system, begin to overdose again.  It is important that this person does not take any more drugs for a few hours because this would increase the chances of having another overdose.  Try to have someone stay with the person for the next 2-3 hours 30-60min and make sure that you have more naloxone in case they do slip back into overdose.

Intramuscular vs. Intranasal Naloxone
Injectable naloxone is in a lower concentration (0.4mg/1mL). Intranasal naloxone is sprayed up the nose (4mg/.1mL).  People have asked if intranasal (IN) naloxone is more effective than intramuscular (IM) naloxone, or vice versa. The answer is they are both effective, and are as effective, when used properly. IN naloxone should be administered when an individual is on their back, mouth-up, with their head tilted back, otherwise you run the risk of the naloxone dripping out of their nose. IM naloxone has to be pulled from the vial and if it happens to be a glass vial and cracks, do not use this particular vial of naloxone. There are studies coming out on IM vs. IN efficacy but in general, administering naloxone by squirting or misting up someone’s nose or injecting into the meat of their arm, thigh, or buttocks, will be a viable life saving measure either way.


There are also some things you should NOT do if someone you’re with has overdosed:

  • Do NOT inject a person who has overdosed with salt water. This is an old myth and will do nothing to help revive the person.
  • Do NOT inject a person who has overdosed on heroin with cocaine or speed, or vice versa. It will just waste valuable time and probably make them worse.
  • Do NOT give CPR (this is the heart compression part—the pumping the chest) unless they have no pulse and you know how to. You may do more harm than good. Mouth to mouth resuscitation is okay.
  • Do NOT put the person in a cold water bath because it may cause them to go into shock or to drown. You can put them in a cool shower to wake them up, but you must stay there with them. Do NOT put ice on their genitals (down their pants).
  • Again, do NOT leave someone alone who has overdosed, even after you’ve called an ambulance. Your friend will need you to see them through this very scary experience.


There is a remote chance of being infected with HIV if you are pricked or scratched with a used needle. The risk of infection from hepatitis and tetanus are far greater if the needle was contaminated with either of these pathogens, both of which are much more infectious than HIV. If you are accidentally stuck with a needle that was used by someone else, try not to panic and take the following precautions:

  1. Wash the wound with soap and water as soon as possible.
  2. Apply an antiseptic and a sterile bandage.
  3. Seek medical attention from an emergency room. You will likely be given a one-month  prescription for PEP, and you may also be offered a tetanus shot. If not, you may want to request one if your vaccination is not current.
  4. If you’re around needles and syringes regularly, you may want to get a tetanus booster every five years and be vaccinated against hepatitis-B.

There is no reason that accidental needlesticks should happen.

  • IIf at all possible, never handle injection equipment that was used by someone else, especially if it is uncapped.
  • NEVER try to re-cap a needle that was used by someone else.
  • ALWAYS re-cap your own needle immediately after use.
  • Do NOT break the needle off with your fingers.
  • Always store your used needles and syringes safely (see chapter 5).