Passing over a man slumped against the wall of a convenience store were the polished dress shoes and scruffy sneakers of pedestrians rushing to their destinations; not an eyelash was batted at their fellow New Yorker turning blue-grey. I encountered him one day in September 2021 while conducting routine harm-reduction street outreach as a syringe-exchange peer, a type of worker that engages people who consume drugs by drawing from our own expertise developed through our lived, stigmatized drug-use experiences. I rushed over to him––let’s call him Phil––and whipped out the small zippered bag I always keep in my purse. I slid the nozzle of a white nasal spray into his nostril. Almost immediately, Phil’s eyes fluttered open as the opioid-overdose antidote rushed in.
Phil could have died in broad daylight, surrounded by thousands of people. None of the passersby needed to be medical experts or outreach workers, like myself, to know how to help a fellow human out—they simply needed to understand how to squirt Narcan into his nose. Narcan is a branded intranasal formulation of the chemical naloxone, which stops opioids like heroin or fentanyl from further suppressing breathing by breaking their bond to the brain’s opioid-specific receptors.
Yet most of us lack the training to correctly identify and respond to an overdose. Some might think they don’t need to know because they believe they don’t know people who use drugs—but unless you live under a rock, the numbers suggest that’s probably not the case. Others just might not give a shit: a survey found that 84 percent of respondents were not willing to administer Narcan (although researchers didn’t track the reasons why), and 88 percent of respondents didn’t have a Narcan kit, though half were willing to receive training.
In a world where upwards of 100,000 North Americans died preventable deaths involving opioids in 2020 alone, everyone should carry and know how to use the medication that saved Phil’s life. It’s straightforward enough, but there are nuances that people who have never touched an opioid might not know, so read on to get your harm reduction game on point!
What’s an overdose, exactly?
“Overdose” is a catch-all term for a diverse range of medical emergencies in which the body is overwhelmed by ingested substances. Perilously suppressed breathing (a.k.a. respiratory depression) and sometimes cardiac arrest are characteristic of overdoses primarily involving downers, including opioids, benzodiazepines, alcohol and GHB/GBL. For uppers, like amphetamines or cocaine, problems can range from cardiac arrest, psychosis, stroke, seizure and overheating; experts sometimes use the term “over amp” to describe stimulant overdoses.
Despite its name, overdoses are not necessarily determined by the quantity ingested. Rather, mixing multiple substances, using without tolerance and using too quickly are better predictors.
Get prepared
To effectively respond to an opioid-involved overdose, you will need naloxone, whether it comes in a little vial for injection into the muscle or the more well-known Narcan nasal spray. And you should never have to pay for either: if you live in the United States, you can have the antidote delivered to your doorstep by mail through the harm reduction organization Next DISTRO, or you can find your closest syringe service program through a curated interactive map maintained by the National Harm Reduction Coalition. For Canadians, pharmacies across provinces and territories make it available at no-cost through Take-Home Naloxone Kits.
For the layperson who cares about the lives of people who use drugs, Narcan and CPR are the best tools for responding to an opioid-involved overdose. The spray device is small and portable, the active ingredients won’t kill anyone and delivering the antidote is just a matter of pressing a button. Increasingly, organizers at queer dance spaces and raves are organizing with harm reduction groups to keep parties safer. Look up harm reduction groups operating in your city to inquire about further naloxone training. There are other techniques, like advanced airway maintenance, or medication, like buprenorphine, but those are better left to people with formal medical training.
ID-ing an OD
Before you can respond to an opioid-involved overdose, you need to properly identify it.
The sign that seems to first spark the alarm of panicking friends or concerned passerbyers is unconsciousness and unresponsiveness, a symptom that I have found to be the most telling of whether an individual is indeed overdosing. To confirm your observation, try nudging them and saying their name, if known, or just loudly ask, “Are you all right?” If you don’t get a response, try pinching them or rubbing your knuckles against the center of their chest.
If the individual responds to your efforts, through mutters, movements or any other physical or verbal response, they do not need naloxone at that time. That said, their condition may worsen and they may become unresponsive and unconscious, at which point naloxone may be needed. But as long as they can respond, they are likely just enjoying what’s called a ‘nod,’ a deep intoxication usually rendering the consumer limp. (It feels really, really good.) If you can, stay with them until they are lucid, or arrange for someone else to monitor their condition.
If nothing gives, it’s safe to say they are unresponsive. Go ahead and check for signs of disrupted breathing: the abdomen or chest hardly, or no longer, rising and falling; the individual is making snoring or gurgling noises; their fingertips or lips are discoloured, usually blue for lighter complexions and gray for darker complexions).
A hallmark of a fentanyl-involved overdose is extreme stiffness and the inability to bend appendages, departing from the usual slouching or limpness associated with other opioid overdoses.
To Narcan or not to Narcan?
When in doubt, administer Narcan. A life is at stake, so it’s better to do it even if you later realize it wasn’t necessary than to hold back and let someone die. For non-overdosers who rarely—if ever—use opioids, Narcan is inconsequential, posing no potential side effect for those who don’t need it. But for their less fortunate peers, it can mean everything.
With that said, it’s important for responders, especially those who have never used opioids, to understand that naloxone can prompt extremely uncomfortable and even unbearable withdrawal symptoms for people who need opioids to function (a quality termed “physical dependence”). Blissful euphoria is likely the last thing the individual knew until being revived and being hit with headaches, changes in blood pressure, rapid heart rate, sweating, nausea, vomiting and tremors as the opioids are stripped from their receptors. So if you are sure they are just very high and not overdosing, no need to subject them to pain.
There’s no one-size-fits-all method for knowing whether to administer Narcan. Since you likely won’t have access to advanced medical instruments to stabilize an overdosing individual, you may need to give the antidote when a nurse in an emergency room might otherwise not. The best you can do is to evaluate all the available information and to act swiftly.
Narcan-ing 101
Once you’ve decided the individual is unresponsive and perhaps has other signs of breathing difficulties, it’s time to give them the antidote.
If you have the Narcan nasal sprayer, unpackage it and use your index and middle finger to hold either side of the nozzle. Insert the nozzle into either nostril until your fingers touch their nose, and then press the red plunger. The Narcan nasal spray has one dose and it has now been emptied.
Wait two minutes to see if the individual regains consciousness or their breathing improves. During this time, initiate CPR if you are trained. If the individual is still out, administer a second dose. Repeat as needed, or until your supply runs out.
Cops are not our friends
Medical experts recommend calling emergency medical services (EMS) immediately upon identifying an opioid overdose, as, in rare cases, overdoses can resume once the Narcan wears off. Over the past decade, many have done so with hospitalizations for serious complications associated with opioid overdoses having rapidly accelerated. Besides saving a life, hospital visits can connect survivors with resources that can prevent future overdoses and support them if they are struggling with their relationships with opioids. Seeking professional help is likely necessary if naloxone is not available at the scene of the overdose or if the individual’s condition does not improve after administering the medication.
If the survivor recovers and appears to be stabilized, they can self-determine what they most need. While there is evidence that heroin overdoses or those linked to some prescription opioids may not require EMS intervention and hospitalization, scientists believe this may not apply to those involving fentanyl, other highly-potent synthetic opioids or other depressants, like benzodiazepines.
Unless you live in Kansas, Texas, Wyoming or the five U.S. territories, responders and survivors have varying degrees of protection from arrest and prosecution for liability relating to potential medical complications and some drug charges, thanks to Good Samaritan laws. The Public Health Law Network has created a chart for you to learn the protections available to you in your state. In Canada, thanks to the Good Samaritan Drug Overdose Act, people who experience or witness an overdose are protected from possession charges when they seek emergency help.
Nonetheless, the decision to call 911 before a survivor awakens should not be taken lightly: criminalization and other harms may be a consequence. Cops continue to make arrests at the scenes of overdoses and run warrant checks on survivors when doing post-overdose home visits. One local prosecutor in Indiana used a successful naloxone administration as evidence to pursue simple possession criminal charges against the survivor. In addition, if the overdoser ends up dying, the supplier of the drugs involved––someone who is often the friend or family member of the deceased––can be charged with homicide in 22 states, the District of Columbia, Guam and the U.S. Virgin Islands.
Medical responders who show up after a 911 call do not always provide the compassionate care a caller may be seeking. Stigma against people who use drugs by health care providers is pervasive and has been shown to hinder care-seeking when needed. When it comes to overdose, people of colour have received inequitable treatment: according to a 2018 study, the odds that emergency room staff will give a desperately-needed life-saving overdose antidote, like naloxone, to Black and Latinx patients is one-half and one-quarter, respectively, that of their white peers. Other researchers have found that, once stabilized, fewer Black ED patients received behavioural counselling than white and Latinx peers. In Canada, systemic racism against Indigenous patients in emergency rooms is well documented.
It is up to you to decide whether to immediately call EMS or let the survivor choose after administering naloxone.
What you need to know about after-care
Upon waking, the OD survivor will likely feel like shit—especially if withdrawal symptoms are setting in. They may be confused, frustrated or angry. Research has shown that staying calm, being kind and providing clear communication can help soothe the survivor’s understandably tumultuous emotions.
Make sure to briefly bring them up to speed, and let them know that you administered Narcan. If you haven’t called EMS yet, ask them if they would like an ambulance, and inform them that the police may arrive if called. Respect their agency to decline medical treatment.
It is recommended that survivors not be alone for at least two hours after the overdose in case they slip into a rare second overdose. For survivors declining medical attention and with whom you are unfamiliar, encourage them to link up with trusted friends, family or others who can respond if anything goes south. It can be lifesaving. If you know them, hang out if you can. If no one, including yourself, is available, and they don’t want to seek medical attention, invite them to call a 24/7 hotline where listeners will stay on the line with them as they use and will contact EMS if they become unresponsive. Americans can call Never Use Alone (+1 800-484-3731), and Canadians can call the National Overdose Response Service (1-888-688-6677).
Before you part with the survivor, let them know about the prevention strategies I’ve listed below. Once the naloxone has worn off (within 90 minutes), and as potentially-excruciating withdrawal symptoms persist, the survivor may want to re-dose. Suffering a subsequent overdose in the following hours and days is a significant risk.
Preventing overdose
Overdoses are not an inevitable feature of drug use. Take a moment to consider how you can adapt your own consumption practices or encourage others to do the same to avoid experiencing unnecessary harm.
- Avoid mixing psychoactive substances, especially those sourced from unregulated supplies;
- Use with others. If you can’t, or don’t want to, call one of the hotlines listed above;
- Sample a small amount of a new batch to see how it hits, ideally while you’re around others. Go slow and take breaks;
- Check what’s in your drugs with fentanyl test strips, available at some syringe exchanges, and with reagent test kits sold by DanceSafe and Bunk Police.
Far from predestined, overdose risk is inflated by government policy. As long as consumers have no other option but an unregulated supply—one that is constantly destabilized by law enforcement interventions, rendering it ever more volatile, unpredictable and potent—naloxone and fentanyl test strips can only do so much. To truly prevent overdoses, structural transformation is needed, including:
- the decriminalization of the entire supply chain, from cultivation to production to trafficking to distribution to sales to possession;
- the low-cost provision of medical-grade versions of consumers’ street drugs of choice, as Britain did for most of the 20th century, and as disparate countries, from Colombia to Iran to the United States, did for shorter periods, and as Canada currently maintains;
- and low-barrier, consumer- and worker-run supervised consumption sites.
Like many of his peers, Phil is surviving the reality of the prohibition-driven overdose crisis. Its gratuity of suffering was made all too clear when I saw him next, just a week after his OD. Apparently, only a few hours after I had resuscitated him, his friend went under. If the bag of Narcan I had given to him was not strapped to his backpack, the crisis would have likely claimed yet another life. Individual-level harm reduction is not going to transform the world but for drug users living in a society at odds with their very existence, it makes a world of difference.
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