Heroin Overdose
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An opioid overdose is
toxicity Toxicity is the degree to which a chemical substance or a particular mixture of substances can damage an organism. Toxicity can refer to the effect on a whole organism, such as an animal, bacteria, bacterium, or plant, as well as the effect o ...
due to excessive consumption of
opioids Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...
, such as
morphine Morphine, formerly also called morphia, is an opiate that is found naturally in opium, a dark brown resin produced by drying the latex of opium poppies (''Papaver somniferum''). It is mainly used as an analgesic (pain medication). There are ...
,
codeine Codeine is an opiate and prodrug of morphine mainly used to treat pain, coughing, and diarrhea. It is also commonly used as a recreational drug. It is found naturally in the sap of the opium poppy, ''Papaver somniferum''. It is typically use ...
,
heroin Heroin, also known as diacetylmorphine and diamorphine among other names, is a morphinan opioid substance synthesized from the Opium, dried latex of the Papaver somniferum, opium poppy; it is mainly used as a recreational drug for its eupho ...
,
fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...
,
tramadol Tramadol, sold under the brand name Tramal among others, is an opioid analgesic, pain medication and a serotonin–norepinephrine reuptake inhibitor (SNRI) used to treat moderately severe pain. When taken by mouth in an immediate-release form ...
, and
methadone Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid used medically to treat chronic pain and opioid use disorder. Prescribed for daily use, the medicine relieves cravings and opioid withdrawal sym ...
. This preventable pathology can be fatal if it leads to
respiratory depression Hypoventilation (also known as respiratory depression) occurs when ventilation is inadequate (''hypo'' meaning "below") to perform needed respiratory gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapni ...
, a lethal condition that can cause hypoxia from slow and shallow breathing. Other symptoms include small pupils and
unconsciousness Unconsciousness is a state in which a living individual exhibits a complete, or near-complete, inability to maintain an awareness of self and environment or to respond to any human or environmental stimulus. Unconsciousness may occur as the r ...
; however, its onset can depend on the method of ingestion, the dosage and individual risk factors. Although there were over 110,000 deaths in 2017 due to opioids, individuals who survived also faced adverse complications, including
permanent brain damage Brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating trauma-induced damage. A common ...
. Opioid overdoses are diagnosed based on symptoms and examination. Risk factors for opioid overdose include high levels of
opioid dependence Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. ...
, use of opioids via injection, high-dose opioid usage, having a
mental disorder A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is ...
or having a predisposition for one, and use of opioids in combination with other substances, such as
alcohol Alcohol may refer to: Common uses * Alcohol (chemistry), a class of compounds * Ethanol, one of several alcohols, commonly known as alcohol in everyday life ** Alcohol (drug), intoxicant found in alcoholic beverages ** Alcoholic beverage, an alco ...
,
benzodiazepines Benzodiazepines (BZD, BDZ, BZs), colloquially known as "benzos", are a class of central nervous system (CNS) depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat co ...
, or
cocaine Cocaine is a tropane alkaloid and central nervous system stimulant, derived primarily from the leaves of two South American coca plants, ''Erythroxylum coca'' and ''Erythroxylum novogranatense, E. novogranatense'', which are cultivated a ...
. Dependence on prescription opioids can occur from their use to treat
chronic pain Chronic pain is pain that persists or recurs for longer than 3 months.https://icd.who.int/browse/2025-01/mms/en#1581976053 It is also known as gradual burning pain, electrical pain, throbbing pain, and nauseating pain. This type of pain is in cont ...
in individuals. Additionally, if following a period of
detoxification Detoxification or detoxication (detox for short) is the physiological or medicinal removal of toxic substances from a living organism, including the human body, which is mainly carried out by the liver. Additionally, it can refer to the period o ...
, which allows the tolerance level to fall, the risk of overdose upon return to use is high. Initial treatment of an overdose involves supporting the person's breathing and providing
oxygen Oxygen is a chemical element; it has chemical symbol, symbol O and atomic number 8. It is a member of the chalcogen group (periodic table), group in the periodic table, a highly reactivity (chemistry), reactive nonmetal (chemistry), non ...
to reduce the risk of hypoxia.
Naloxone Naloxone, sold under the brand name Narcan among others, is an opioid antagonist, a medication used to reverse or reduce the effects of opioids. For example, it is used to restore breathing after an opioid overdose. Effects begin within two ...
is then recommended to those who cannot reverse the opioid's effects through breathing. Giving naloxone via
nasal administration Nasal administration, popularly known as snorting, is a route of administration in which drugs are insufflated through the nose. It can be a form of either topical administration or systemic administration, as the drugs thus locally delivered ...
or as an
injection into a muscle Intramuscular injection, often abbreviated IM, is the injection of a substance into a muscle. In medicine, it is one of several methods for parenteral administration of medications. Intramuscular injection may be preferred because muscles have ...
has shown to be equally effective. Other efforts to prevent deaths from overdose include increasing access to naloxone and treatment for opioid dependence. Drug use contributes to 500,000 deaths worldwide, with opioid overdose resulting in approximately 115,000 of these deaths in 2018. This is up from 18,000 deaths in 1990. In 2018, approximately 269 million people had engaged in drug usage at least once, 58 million of which used opioids. Drug use disorders have affected around 35.6 million people worldwide in 2018. The
WHO The World Health Organization (WHO) is a specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Geneva, Switzerland, and has 6 regional offices and 15 ...
estimates that 70% of deaths due to drug use are in relation to opioids, with 30% being due to overdose. It is believed that the
opioid epidemic The opioid epidemic, also referred to as the opioid crisis, is the rapid increase in the overuse, misuse or abuse, and overdose deaths attributed either in part or in whole to the class of drugs called opiates or opioids since the 1990s. It inc ...
has partly been caused due to assurances that prescription opioids were safe, by the
pharmaceutical industry The pharmaceutical industry is a medical industry that discovers, develops, produces, and markets pharmaceutical goods such as medications and medical devices. Medications are then administered to (or self-administered by) patients for curing ...
in the 1990s. This led to unwarranted trust and a subsequent heavy reliance on opioids. Though there are treatment interventions which can effectively reduce the risk of overdose in people with opioid dependence, less than 10% of affected individuals receive it.


Signs and symptoms

Opiate overdose symptoms and signs can be referred to as the "opioid
toxidrome A toxidrome (a portmanteau of ''toxic'' and ''syndrome'', coined in 1970 by Mofenson and Greensher) is a syndrome caused by a dangerous level of toxins in the body. It is often the consequence of a drug overdose. Common symptoms include dizziness, ...
triad": decreased level of consciousness, pinpoint pupils, and
respiratory depression Hypoventilation (also known as respiratory depression) occurs when ventilation is inadequate (''hypo'' meaning "below") to perform needed respiratory gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapni ...
. Other signs and symptoms include
seizure A seizure is a sudden, brief disruption of brain activity caused by abnormal, excessive, or synchronous neuronal firing. Depending on the regions of the brain involved, seizures can lead to changes in movement, sensation, behavior, awareness, o ...
s and
muscle spasm A spasm is a sudden involuntary contraction of a muscle, a group of muscles, or a hollow organ, such as the bladder. A spasmodic muscle contraction may be caused by many medical conditions, including dystonia. Most commonly, it is a musc ...
s. Sometimes, an opiate overdose can lead to such a decreased level of consciousness that the person will not wake up. Because of their effect on the part of the brain that regulates breathing,
opioid Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...
s can cause very slow or stopped breathing during overdoses, leading to hypoxia or death if left untreated. Hypoxia is typically caused by respiratory depression. The brain uses oxygen to regulate the
homeostasis In biology, homeostasis (British English, British also homoeostasis; ) is the state of steady internal physics, physical and chemistry, chemical conditions maintained by organism, living systems. This is the condition of optimal functioning fo ...
of the body. In animal studies, it was found that opioids act on specific regions of the
central nervous system The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain, spinal cord and retina. The CNS is so named because the brain integrates the received information and coordinates and influences the activity o ...
associated with respiratory regulation, including the medulla and
pons The pons (from Latin , "bridge") is part of the brainstem that in humans and other mammals, lies inferior to the midbrain, superior to the medulla oblongata and anterior to the cerebellum. The pons is also called the pons Varolii ("bridge of ...
. During cerebral hypoxia, the brain lacks sufficient oxygen supply. Prolonged lack of oxygenation from
respiratory depression Hypoventilation (also known as respiratory depression) occurs when ventilation is inadequate (''hypo'' meaning "below") to perform needed respiratory gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapni ...
can lead to detrimental damage to the brain and spinal cord and can leave the person unable to walk or function normally, even if treatment with naloxone is given.
Alcohol Alcohol may refer to: Common uses * Alcohol (chemistry), a class of compounds * Ethanol, one of several alcohols, commonly known as alcohol in everyday life ** Alcohol (drug), intoxicant found in alcoholic beverages ** Alcoholic beverage, an alco ...
also causes respiratory depression and, therefore, when taken with opioids, can increase the risk of
respiratory depression Hypoventilation (also known as respiratory depression) occurs when ventilation is inadequate (''hypo'' meaning "below") to perform needed respiratory gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapni ...
and death. In young children, opioid overdose may not be apparent right away. This is due to absorption, distribution, and metabolism differences between young children and adults and the higher amount of opioid ingestion per kilogram of body weight.


Causes

Risk factors for opioid overdose include
opioid dependence Opioid use disorder (OUD) is a substance use disorder characterized by cravings for opioids, continued use despite physical and/or psychological deterioration, increased tolerance with use, and withdrawal symptoms after discontinuing opioids. ...
, injecting opioids, using high doses of opioids, and use together with
alcohol Alcohol may refer to: Common uses * Alcohol (chemistry), a class of compounds * Ethanol, one of several alcohols, commonly known as alcohol in everyday life ** Alcohol (drug), intoxicant found in alcoholic beverages ** Alcoholic beverage, an alco ...
,
benzodiazepines Benzodiazepines (BZD, BDZ, BZs), colloquially known as "benzos", are a class of central nervous system (CNS) depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat co ...
, or
cocaine Cocaine is a tropane alkaloid and central nervous system stimulant, derived primarily from the leaves of two South American coca plants, ''Erythroxylum coca'' and ''Erythroxylum novogranatense, E. novogranatense'', which are cultivated a ...
. The risk is particularly high following
detoxification Detoxification or detoxication (detox for short) is the physiological or medicinal removal of toxic substances from a living organism, including the human body, which is mainly carried out by the liver. Additionally, it can refer to the period o ...
. Dependence on prescription opioids can occur from their use to treat
chronic pain Chronic pain is pain that persists or recurs for longer than 3 months.https://icd.who.int/browse/2025-01/mms/en#1581976053 It is also known as gradual burning pain, electrical pain, throbbing pain, and nauseating pain. This type of pain is in cont ...
. In young children, an overdose is usually due to opioids that are intended for their parents, older siblings, or grandparents. In mothers who take
codeine Codeine is an opiate and prodrug of morphine mainly used to treat pain, coughing, and diarrhea. It is also commonly used as a recreational drug. It is found naturally in the sap of the opium poppy, ''Papaver somniferum''. It is typically use ...
during breastfeeding, opioid overdoses have occurred in their baby. Codeine is, therefore, not recommended for those who are breastfeeding.


Co-ingestion

Opioid overdoses are often associated with
benzodiazepines Benzodiazepines (BZD, BDZ, BZs), colloquially known as "benzos", are a class of central nervous system (CNS) depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat co ...
, tranquilisers (e.g.
xylazine Xylazine is a structural analog of clonidine and an α2-adrenergic receptor, α2-adrenergic receptor agonist, sold under many trade names worldwide, most notably the Bayer brand name Rompun, as well as Anased, Sedazine and Chanazine. Xylazine ...
) or
alcohol Alcohol may refer to: Common uses * Alcohol (chemistry), a class of compounds * Ethanol, one of several alcohols, commonly known as alcohol in everyday life ** Alcohol (drug), intoxicant found in alcoholic beverages ** Alcoholic beverage, an alco ...
use. Other central nervous system depressants, muscle relaxers, pain relievers, anti-convulsants,
anxiolytics An anxiolytic (; also antipanic or anti-anxiety agent) is a medication or other intervention that reduces anxiety. This effect is in contrast to anxiogenic agents which increase anxiety. Anxiolytic medications are used for the treatment of anxie ...
, treatment drugs of a psychoactive or epileptic variety or any other such drug with its active function meant to calm or mitigate neuronal signaling (
barbiturate Barbiturates are a class of depressant, depressant drugs that are chemically derived from barbituric acid. They are effective when used medication, medically as anxiolytics, hypnotics, and anticonvulsants, but have physical and psychological a ...
s, etc.) can additionally cause a worsened condition with less likelihood of recovery cumulative to each added drug. This includes drugs less immediately classed to a slowing of the metabolism such as with GABAergic like GHB or glutamatergic antagonists like PCP or
ketamine Ketamine is a cyclohexanone-derived general anesthetic and NMDA receptor antagonist with analgesic and hallucinogenic properties, used medically for anesthesia, depression, and pain management. Ketamine exists as its S- (esketamine) a ...
.


Risk factors

End organ dysfunction (liver disease), which may lead to decreased drug clearance, is a risk factor for opioid overdose. Other risk factors for opioid overdose include
sleep disordered breathing When we sleep, our breathing changes due to normal biological processes that affect both our respiratory and muscular systems. Physiology Sleep Onset Breathing changes as we transition from wakefulness to sleep. These changes arise due to biologi ...
disorders such as
sleep apnea Sleep apnea (sleep apnoea or sleep apnœa in British English) is a sleep-related breathing disorder in which repetitive Apnea, pauses in breathing, periods of shallow breathing, or collapse of the upper airway during sleep results in poor vent ...
, pulmonary diseases (such as
asthma Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wh ...
or
chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation. GOLD defines COPD as a heterogeneous lung condition characterized by chronic respiratory s ...
) which may reduce ventilation and concomitant use of sedating medications such as benzodiazepines, gabapentinoids,
muscle relaxants A muscle relaxant is a drug that affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeu ...
and other central nervous system depressants. Benzodiazepine use with opioids increases the risk of overdose death by four-fold, whereas concomitant use with gabapentintoids such as
gabapentin Gabapentin, sold under the brand name Neurontin among others, is an anticonvulsant medication primarily used to treat neuropathic pain and also for partial seizures of epilepsy. It is a commonly used medication for the treatment of neuropath ...
or
pregabalin Pregabalin, sold under the brand name Lyrica among others, is an anticonvulsant, analgesic, and anxiolytic amino acid medication used to treat epilepsy, neuropathic pain, fibromyalgia, restless legs syndrome, opioid withdrawal, generalized anx ...
increases the risk of overdose death by nearly two-fold. Higher doses of prescription opioids, as well as long-acting formulations, are associated with an increased risk of overdose. In those on long-term opioid treatment for chronic pain, daily morphine equivalents greater than 200 mg were associated with death from opioid related causes (including overdose) in 3.8% of men and 2.2% of women. Opioids are the most common cause for serious accidental poisonings of children in the UK.


Metabolic disorders

Opioid Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...
s are primarily metabolized in the
liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...
, before being excreted through urine. Opioids are metabolized by phase 1 and/or phase 2
metabolism Metabolism (, from ''metabolē'', "change") is the set of life-sustaining chemical reactions in organisms. The three main functions of metabolism are: the conversion of the energy in food to energy available to run cellular processes; the co ...
, which can lead to the activation or inhibition of these drugs. Phase 1 metabolism is the CYP pathway which consists of different
cytochrome P450 Cytochromes P450 (P450s or CYPs) are a Protein superfamily, superfamily of enzymes containing heme as a cofactor (biochemistry), cofactor that mostly, but not exclusively, function as monooxygenases. However, they are not omnipresent; for examp ...
s – a set of enzymes that catalyze
hydrolysis Hydrolysis (; ) is any chemical reaction in which a molecule of water breaks one or more chemical bonds. The term is used broadly for substitution reaction, substitution, elimination reaction, elimination, and solvation reactions in which water ...
, reduction, and
oxidation Redox ( , , reduction–oxidation or oxidation–reduction) is a type of chemical reaction in which the oxidation states of the reactants change. Oxidation is the loss of electrons or an increase in the oxidation state, while reduction is ...
reactions – to create an active
metabolite In biochemistry, a metabolite is an intermediate or end product of metabolism. The term is usually used for small molecules. Metabolites have various functions, including fuel, structure, signaling, stimulatory and inhibitory effects on enzymes, c ...
. In contrast, Phase 2 metabolism causes the opioids to undergo conjugation, with little to no interaction with the CYP pathway. The opioids undergo phase 1 and phase 2 metabolism until they are
hydrophilic A hydrophile is a molecule or other molecular entity that is attracted to water molecules and tends to be dissolved by water.Liddell, H.G. & Scott, R. (1940). ''A Greek-English Lexicon'' Oxford: Clarendon Press. In contrast, hydrophobes are n ...
enough to be
renally In humans, the kidneys are two reddish-brown bean-shaped blood-filtering organs that are a multilobar, multipapillary form of mammalian kidneys, usually without signs of external lobulation. They are located on the left and right in the retrope ...
excreted. Various factors play a role in how an opioid is metabolized. In phase 1 metabolism, the CYP family has several polymorphisms, which can account for the difference in
therapeutic A therapy or medical treatment is the attempted remediation of a health problem, usually following a medical diagnosis. Both words, ''treatment'' and ''therapy'', are often abbreviated tx, Tx, or Tx. As a rule, each therapy has indications an ...
responses within each individual. This diversification leads to opioids being modified at varying rates, which can cause the drug to remain in the
bloodstream In vertebrates, the circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of the heart an ...
for either a longer or shorter period. Therefore, these polymorphisms control opioid tolerance and facilitate
overdose A drug overdose (overdose or OD) is the ingestion or application of a drug or other substance in quantities much greater than are recommended. Retrieved on September 20, 2014.
.


Mental health

Evidence suggests that mental health can be a significant facilitator for opioid use disorder. Given that opioids are prescribed for pain management, mental health disorders, such as depression, have been shown to increase use of opioids when treating conditions associated with
chronic pain Chronic pain is pain that persists or recurs for longer than 3 months.https://icd.who.int/browse/2025-01/mms/en#1581976053 It is also known as gradual burning pain, electrical pain, throbbing pain, and nauseating pain. This type of pain is in cont ...
. Evidence has shown that individuals with mood and
anxiety disorder Anxiety disorders are a group of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause phys ...
s have an increased likelihood of being prescribed opioids and continuing usage for lengthy periods of time, consequently increasing likelihood for dependence. As such, affected individuals have almost double the risk of using opioids for pain relief in the long-term. Additionally, mental health challenges associated with trauma, economic depression, social environments conducive to substance use and risk-taking behaviours have been shown to increase opioid misuse. Furthermore, mental health challenges associated with
cardiovascular disease Cardiovascular disease (CVD) is any disease involving the heart or blood vessels. CVDs constitute a class of diseases that includes: coronary artery diseases (e.g. angina, heart attack), heart failure, hypertensive heart disease, rheumati ...
,
sleep disorder A sleep disorder, or somnipathy, is a medical disorder affecting an individual's sleep patterns, sometimes impacting physical, mental, social, and emotional functioning. Polysomnography and actigraphy are tests commonly ordered for diagnosing sle ...
s, and
HIV The human immunodeficiency viruses (HIV) are two species of '' Lentivirus'' (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the im ...
can cause opioid dependence and subsequent overdose. Notably, cyclic behaviours can be observed between mental illness and opioid use disorder where individuals with mental health diagnoses engage in opioid use which further perpetuates mental health challenges and increased drug usage.


Mechanism

Opioids bind with neural opioid receptors to provoke
analgesic An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...
,
sedative A sedative or tranquilliser is a substance that induces sedation by reducing irritability or Psychomotor agitation, excitement. They are central nervous system (CNS) Depressant, depressants and interact with brain activity, causing its decelera ...
, and
euphoric Euphoria ( ) is the experience (or affect) of pleasure or excitement and intense feelings of well-being and happiness. Certain natural rewards and social activities, such as aerobic exercise, laughter, listening to or making music and danci ...
effects. Opioids function by stimulating specific
G-protein coupled receptors G protein-coupled receptors (GPCRs), also known as seven-(pass)-transmembrane domain receptors, 7TM receptors, heptahelical receptors, serpentine receptors, and G protein-linked receptors (GPLR), form a large group of evolutionarily related ...
distributed throughout the body—including the brain, skin and spinal cord. Three of the major opioid receptors include mu, kappa, delta, and nociception, each playing a role in eliciting the effects associated with opioids. An opioid overdose results from over-activation of these receptors, which can cause permanent brain damage from cerebral hypoxia or
neurotoxicity Neurotoxicity is a form of toxicity in which a biological, chemical, or physical agent produces an adverse effect on the structure or function of the central and/or peripheral nervous system. It occurs when exposure to a substance – specifical ...
. Mu receptors have an
analgesic An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...
effect on the brain, and are found in various parts of the nervous system including the
cerebral cortex The cerebral cortex, also known as the cerebral mantle, is the outer layer of neural tissue of the cerebrum of the brain in humans and other mammals. It is the largest site of Neuron, neural integration in the central nervous system, and plays ...
and
thalamus The thalamus (: thalami; from Greek language, Greek Wikt:θάλαμος, θάλαμος, "chamber") is a large mass of gray matter on the lateral wall of the third ventricle forming the wikt:dorsal, dorsal part of the diencephalon (a division of ...
. They can be found in the
nucleus accumbens The nucleus accumbens (NAc or NAcc; also known as the accumbens nucleus, or formerly as the ''nucleus accumbens septi'', Latin for ' nucleus adjacent to the septum') is a region in the basal forebrain rostral to the preoptic area of the hypo ...
, the pleasure centre of the brain, as well as the
amygdala The amygdala (; : amygdalae or amygdalas; also '; Latin from Greek language, Greek, , ', 'almond', 'tonsil') is a paired nucleus (neuroanatomy), nuclear complex present in the Cerebral hemisphere, cerebral hemispheres of vertebrates. It is c ...
. Kappa receptors, in the
hypothalamus The hypothalamus (: hypothalami; ) is a small part of the vertebrate brain that contains a number of nucleus (neuroanatomy), nuclei with a variety of functions. One of the most important functions is to link the nervous system to the endocrin ...
, produce a similar
analgesic An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...
effect. They bind with
dynorphin Dynorphins (Dyn) are a class of opioid peptides that arise from the precursor protein prodynorphin. When prodynorphin is cleaved during processing by proprotein convertase 2 (PC2), multiple active peptides are released: dynorphin A, dynorphin ...
s to stimulate anti-reward effects —
dysphoria Dysphoria (; ) is a profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation. In psychiatry Intense states of distress and uneas ...
— and other negative effects of withdrawal. While mu receptors are the source of addiction, kappa receptors contribute to continued use. They generate
dysphoria Dysphoria (; ) is a profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation. In psychiatry Intense states of distress and uneas ...
in response to increasing stress levels via corticotropin-releasing factor (CRF). This increases erratic shifts in mood during the withdrawal period and can prompt relapse. Delta receptors, found in the
basal ganglia The basal ganglia (BG) or basal nuclei are a group of subcortical Nucleus (neuroanatomy), nuclei found in the brains of vertebrates. In humans and other primates, differences exist, primarily in the division of the globus pallidus into externa ...
of the
limbic system The limbic system, also known as the paleomammalian cortex, is a set of brain structures located on both sides of the thalamus, immediately beneath the medial temporal lobe of the cerebrum primarily in the forebrain.Schacter, Daniel L. 2012. ''P ...
, have been shown to reduce
anxiety Anxiety is an emotion characterised by an unpleasant state of inner wikt:turmoil, turmoil and includes feelings of dread over Anticipation, anticipated events. Anxiety is different from fear in that fear is defined as the emotional response ...
by binding with
enkephalin An enkephalin is a pentapeptide involved in regulating nociception (pain sensation) in the body. The enkephalins are termed endogenous ligands, as they are internally derived (and therefore endogenous) and bind as ligands to the body's opioid ...
s, although this requires further research. The most recent addition to these receptors are
nociception In physiology, nociception , also nocioception; ) is the Somatosensory system, sensory nervous system's process of encoding Noxious stimulus, noxious stimuli. It deals with a series of events and processes required for an organism to receive a pai ...
opioid receptors. Although they have been determined to be receptors to certain
ligand In coordination chemistry, a ligand is an ion or molecule with a functional group that binds to a central metal atom to form a coordination complex. The bonding with the metal generally involves formal donation of one or more of the ligand's el ...
s from opioids, their role is not yet fully understood. When opioids are ingested, the
ligand In coordination chemistry, a ligand is an ion or molecule with a functional group that binds to a central metal atom to form a coordination complex. The bonding with the metal generally involves formal donation of one or more of the ligand's el ...
binds to these constitutively active receptors to reduce
neural activity Neurotransmission (Latin: ''transmissio'' "passage, crossing" from ''transmittere'' "send, let through") is the process by which signaling molecules called neurotransmitters are released by the axon terminal of a neuron (the presynaptic neuron) ...
. This is accomplished by inhibiting
adenylyl cyclase Adenylate cyclase (EC 4.6.1.1, also commonly known as adenyl cyclase and adenylyl cyclase, abbreviated AC) is an enzyme with systematic name ATP diphosphate-lyase (cyclizing; 3′,5′-cyclic-AMP-forming). It catalyzes the following reaction: :A ...
and
cyclic AMP Cyclic adenosine monophosphate (cAMP, cyclic AMP, or 3',5'-cyclic adenosine monophosphate) is a second messenger, or cellular signal occurring within cells, that is important in many biological processes. cAMP is a derivative of adenosine triph ...
, which are necessary for communication within the
central nervous system The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain, spinal cord and retina. The CNS is so named because the brain integrates the received information and coordinates and influences the activity o ...
. There is research indicating that opioids reduce pain by disrupting
ion channel Ion channels are pore-forming membrane proteins that allow ions to pass through the channel pore. Their functions include establishing a resting membrane potential, shaping action potentials and other electrical signals by Gating (electrophysiol ...
s and vesicle fusion. Prolonged exposure to opioids can cause these receptors to become internalized, leading to increased tolerance and increased opioid use.


Prevention

Opioid overdoses can often be prevented.In press Clear protocols for staff at emergency departments and urgent care centers can reduce opioid prescriptions for individuals presenting in these settings who engage in drug seeking behaviors or who have a history of a substance use disorder. Drug seeking behaviors include but are not limited to obsessiveness or impatience when it comes to attaining medications, seeking multiple pain adjunct medications, and inconsistent physiological presentation. A
prescription monitoring program In the United States, prescription monitoring programs (PMPs) or prescription drug monitoring programs (PDMPs) are state-run programs which collect and distribute data about the prescription and dispensation of federally controlled substances and, ...
may help determine if an individual is receiving a high doses of opioids or combinations of medications such as benzodiazepines and opioids that put them at high risk. Limited amount of evidence suggests opioid therapy with extended-release or long-acting formulations may increase the risk of an unintentional overdose compared to shorter-acting agents. Routinely screening using tools such as the CAGE-AID and the Drug Abuse Screening Test (DAST-10) in adults and the CRAFFT in those aged 14–18 years is recommended. The revised risk index for overdose or severe opioid induced respiratory depression (RIOSORD) is a validated screening tool that may be used to estimate the risk of overdose in people using opioids, or the rapid opioid dependence screen may be used as a more rapid and succinct method to screen for opioid use disorder. Other "drug seeking" behaviors and physical indications of drug use should be used as clues to perform formal screenings. There are several medication-assisted treatments available for people with opioid use disorder or opioid dependence who are at higher risk for opioid overdose. The selection of treatment depends on various factors, such as a person's preference, accessibility, and history of treatment. Examples of medication-assisted treatments are
buprenorphine Buprenorphine, sold under the brand name Subutex among others, is an opioid used to treat opioid use disorder, acute pain, and chronic pain. It can be used under the tongue (sublingual), in the cheek (buccal), by injection (intravenous a ...
(with or without naloxone),
naltrexone Naltrexone, sold under the brand name Revia among others, is a medication primarily used to manage alcohol use or opioid use disorder by reducing cravings and feelings of euphoria associated with substance use disorder. It has also been ...
, and
methadone Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid used medically to treat chronic pain and opioid use disorder. Prescribed for daily use, the medicine relieves cravings and opioid withdrawal sym ...
. Methadone and buprenorphine are associated with reduced mortality in those with opioid use disorder as well as higher drug treatment program retention, lower illicit drug use, and decreased overdose deaths. The mortality benefit of long-term naltrexone use in those with opioid use disorder is less well-established. After a non-fatal opioid overdose, subsequent methadone or buprenorphine initiation and use reduce the risk of overdose death by 59% and 38%, respectively. Initiating buprenorphine in the emergency department is associated with lower mortality and increased adherence to opioid use disorder treatment programs. Peer support groups have tentative evidence of benefit. There is also some evidence indicating benefits in community-based overdose education and naloxone distribution programs. Buprenorphine and methadone can help decrease drug cravings. Combining pharmacologic treatments with behavioral therapy, such as support or recovery groups, can increase the likelihood of overcoming addiction and reduce the risk of an opioid overdose. Individuals diagnosed with opioid dependence should be prescribed naloxone to prevent overdose. They should be directed to one of the treatment options available, such as needle exchange programs and treatment centers. A naloxone prescription is also recommended when risk factors for opioid overdose are present, such as a history of overdose, substance use disorder, or higher doses of opioids. With the CDC recommending naloxone be provided to all people on long term opioids who have risk factors for overdose, including a history of a substance use disorder, daily morphine equivalents greater than 50 mg or concurrent benzodiazepine use. Brief
motivational interviewing Motivational interviewing (MI) is a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centered counseling style for eliciting behavior change by helping clients to e ...
can also be performed and has been shown to improve people's motivation to change their behavior. Despite these opportunities, the dissemination of prevention interventions in the US has been hampered by the lack of coordination and sluggish federal government response. Unused or old opioids should not be stored in the home as there is a risk of people using the drugs for non-medical purposes. Among adolescents and young-adults, non-medical use of prescription opioids is associated with a subsequent 13-fold increased risk of heroin use later in life. Opioids that are no longer being used may be taken to drug take back programs at local pharmacies, healthcare facilities or law enforcement agencies for safe disposal. The United States
Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respo ...
also has a "flush list"; a list of medications that may be safely disposed of by flushing down the toilet. In the United States, 49 states and the District of Columbia have expanded naloxone access at a pharmacy level via standing order, protocol order, naloxone-specific collaborative practice agreement, or pharmacist prescriptive authority.


Treatments

If someone is suspected to have overdosed on opioids, call for medical attention, administer
naloxone Naloxone, sold under the brand name Narcan among others, is an opioid antagonist, a medication used to reverse or reduce the effects of opioids. For example, it is used to restore breathing after an opioid overdose. Effects begin within two ...
, and provide
basic life support Basic life support (BLS) is a level of medical care which is used for patients with life-threatening condition of cardiac arrest until they can be given full medical care by advanced life support providers (paramedics, nurses, physicians or any ...
as soon as possible.


Naloxone

Naloxone works by temporarily blocking the effects of opioids, including respiratory depression and sedation. Naloxone is safe and side effects are rare, generally limited to allergic reactions. It should be given if there is any suspicion of an opioid overdose. Naloxone is available to the public in the United States in two routes of administration:
intranasal Nasal administration, popularly known as snorting, is a route of administration in which drugs are insufflation (medicine), insufflated through the nose. It can be a form of either topical administration or systemic administration, as the drugs t ...
and
intramuscular Intramuscular injection, often abbreviated IM, is the injection of a substance into a muscle. In medicine, it is one of several methods for parenteral administration of medications. Intramuscular injection may be preferred because muscles hav ...
/ subcutaneous. Intranasal forms include Narcan, approved in 2015, and Kloxxado, approved in 2021. Formulations that are injectable into the intramuscular or subcutaneous spaces include Evzio, approved in 2014, and Zimhi, approved in 2021. The doses are approved for both children and adults and may be repeated every 2–3 minutes. Synthetic opioids like
fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...
and
carfentanil Carfentanil or carfentanyl, formerly sold under the brand name Wildnil, is an extremely potent opioid analgesic used in veterinary medicine to anesthetize large animals such as elephants and rhinoceroses. It is a structural analogue of the ...
are much more potent than prescription opioids and
heroin Heroin, also known as diacetylmorphine and diamorphine among other names, is a morphinan opioid substance synthesized from the Opium, dried latex of the Papaver somniferum, opium poppy; it is mainly used as a recreational drug for its eupho ...
. There is some debate about whether increased doses of naloxone are required to reverse overdose from synthetic opioids; however, this concern has prompted FDA approval of higher dose naloxone formulations such as Kloxxado and Zimhi. The effects of naloxone last for approximately 30-90 minutes, at which point opioids present in the body may begin to take effect again depending on the specific opioids duration of action. Therefore, transport to a hospital is indicated after naloxone administration, and the medication may need to be re-administered.


Access to Naloxone

Opioid overdose should be reversed as soon as possible. To shorten the time between overdose and naloxone administration, multiple programs have been enacted to improve naloxone access for drug users, caregivers, and first responders. In the US, these efforts include FDA approval of intranasal and injectable naloxone over the counter, professional organizations recommending physicians to co-prescribe naloxone when opioids are used for pain management, free community overdose education and naloxone distribution (OEND) programs, and efforts to train non-medical first responders such as firefighters and police to use naloxone. These actions have reduced opioid-related deaths at the state and national levels and are cost-effective. In the UK, naloxone is a prescription-only medicine, but drug treatment services can supply it without a prescription. In an emergency, anyone can use it as a life-saving measure. In August 2024, a new device was developed by researchers at
MIT The Massachusetts Institute of Technology (MIT) is a private research university in Cambridge, Massachusetts, United States. Established in 1861, MIT has played a significant role in the development of many areas of modern technology and sc ...
and
Brigham and Women’s Hospital Brigham and Women's Hospital (BWH or The Brigham) is a teaching hospital of Harvard Medical School and the largest hospital in the Longwood Medical Area in Boston, Massachusetts. Along with Massachusetts General Hospital, it is one of the two ...
that can be implanted under the skin, which rapidly releases naloxone when an overdose is detected.


Basic Life Support

Opioid overdose leads to death when people stop breathing. Bystanders trained in first aid can evaluate people who have overdosed and provide basic life support including rescue breathing via
bag valve mask A bag valve mask (BVM), sometimes known by the proprietary name Ambu bag or generically as a manual resuscitator or "self-inflating bag", is a hand-held device commonly used to provide Modes of mechanical ventilation, positive pressure ventilation ...
or mouth to mouth. If the person who has overdosed does not have a pulse, rescuers should begin
CPR Cardiopulmonary resuscitation (CPR) is an emergency procedure used during cardiac or respiratory arrest that involves chest compressions, often combined with artificial ventilation, to preserve brain function and maintain circulation until sp ...
.


Other Treatments

Another medication that can be used to treat opioid overdoses is
Nalmefene Nalmefene, sold under the brand name Revex among others, is a medication that is used in the treatment of opioid overdose and alcohol dependence. Nalmefene belongs to the class of opioid antagonists and can be taken by mouth, administered by ...
, which is an opioid derivative structurally similar to
Naltrexone Naltrexone, sold under the brand name Revia among others, is a medication primarily used to manage alcohol use or opioid use disorder by reducing cravings and feelings of euphoria associated with substance use disorder. It has also been ...
. It works similarly to Naloxone but has a longer half-life. It is approved for intravenous, intramuscular, and subcutaneous administration by prescription only, unlike the over the counter formulations of naloxone.


Epidemiology

In 2016, the World Health Organization estimated that 34 million people used opioids and 19 million used opiates. Of these, about 27 million people had opioid dependence, with the majority—but a decreasing number—using illicit heroin. In 2015, 118,000 people died from opioid use disorders, causing almost one-third of all drug-related deaths.


United States

Of the 70,200 overdose deaths in the US in 2017, opioids were involved in 47,600, with three male deaths for each female death. This is an increase from 2016 where over 64,000 died from drug overdose, and opioids were involved in over 42,000. Source lists US totals for 2015 and 2016 and statistics by state. In 2017, the five states with the highest rates of death due to drug overdose were
West Virginia West Virginia is a mountainous U.S. state, state in the Southern United States, Southern and Mid-Atlantic (United States), Mid-Atlantic regions of the United States.The United States Census Bureau, Census Bureau and the Association of American ...
(57.8 per 100,000),
Ohio Ohio ( ) is a U.S. state, state in the Midwestern United States, Midwestern region of the United States. It borders Lake Erie to the north, Pennsylvania to the east, West Virginia to the southeast, Kentucky to the southwest, Indiana to the ...
(46.3 per 100,000),
Pennsylvania Pennsylvania, officially the Commonwealth of Pennsylvania, is a U.S. state, state spanning the Mid-Atlantic (United States), Mid-Atlantic, Northeastern United States, Northeastern, Appalachian, and Great Lakes region, Great Lakes regions o ...
(44.3 per 100,000),
Kentucky Kentucky (, ), officially the Commonwealth of Kentucky, is a landlocked U.S. state, state in the Southeastern United States, Southeastern region of the United States. It borders Illinois, Indiana, and Ohio to the north, West Virginia to the ...
(37.2 per 100,000), and
New Hampshire New Hampshire ( ) is a U.S. state, state in the New England region of the Northeastern United States. It borders Massachusetts to the south, Vermont to the west, Maine and the Gulf of Maine to the east, and the Canadian province of Quebec t ...
(37.0 per 100,000).Drug Overdose Deaths
Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) is the National public health institutes, national public health agency of the United States. It is a Federal agencies of the United States, United States federal agency under the United S ...
,
National Center for Injury Prevention and Control The U.S. Centers for Disease Control and Prevention's National Center for Injury Prevention and Control's mission is to provide leadership in preventing and controlling injuries, i.e., reducing the incidence, severity, and adverse outcomes of inj ...
. Click on a map year. The data table is below the map. Number of deaths for each state, and the age-adjusted death rates for each state. Also, place the cursor on the map states to get data.
Concerning the 2017 data in the charts below, deaths from the various drugs add up to more than 70,200 because multiple substances are involved in many of the deaths. According to the
National Safety Council The National Safety Council (NSC) is a 501(c)(3) nonprofit, public service organization promoting health and safety in the United States. Headquartered in Itasca, Illinois, NSC is a member organization, founded in 1913 and granted a congress ...
, the lifetime odds of dying from an overdose in the United States is 1 in 96. File:US timeline. Opioid deaths.jpg, US yearly deaths from all opioid drugs. Included in this number are opioid analgesics, along with
heroin Heroin, also known as diacetylmorphine and diamorphine among other names, is a morphinan opioid substance synthesized from the Opium, dried latex of the Papaver somniferum, opium poppy; it is mainly used as a recreational drug for its eupho ...
and illicit
synthetic opioids Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...
. File:US timeline. Deaths involving other synthetic opioids, predominately Fentanyl.jpg, US yearly deaths involving other
synthetic opioids Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...
, predominately
Fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...
. File:US timeline. Prescription opioid pain reliever deaths.jpg, US yearly deaths involving prescription opioids. Non-methadone synthetics is a category dominated by illegally acquired
fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...
, and has been excluded. File:Timeline of US overdose deaths involving heroin, by other opioid involvement.jpg, US yearly overdose deaths involving heroin.


Awareness

The
Substance Abuse and Mental Health Services Administration The Substance Abuse and Mental Health Services Administration (SAMHSA; pronounced ) is a branch of the U.S. Department of Health and Human Services (HHS). SAMHSA is charged with improving the quality and availability of treatment and rehabilitati ...
hosts an annual health observance known as National Prevention Week. Every third week of May, they encourage communities across the country to unite to share stories about positive mental and behavioral health and the importance of implementing prevention methods. They also sponsor Recovery Month every September. Recovery Month aims to raise awareness about mental and substance use disorders and to honor individuals who recover, promoting the positive message that prevention works and that treatment is effective. International Overdose Awareness Day is on 31 August to remember those who have died from an overdose, to decrease the stigma of drug-related deaths, and to promote the prevention of overdose.


See also

*
Harm reduction Harm reduction, or harm minimization, refers to a range of intentional practices and public health policies designed to lessen the negative social and/or physical consequences associated with various human behaviors, both legal and illegal. H ...
* List of deaths from drug overdose and intoxication *
Responsible drug use Responsible drug use seeks to maximize the benefits and minimize the risks associated with psychoactive drug use. For illegal psychoactive drugs that are not diverted prescription controlled substances, some critics believe that illegal recreationa ...


Notes


References


External links


WHO fact sheet on opioid overdose
* {{Opioidergics Poisoning by drugs, medicaments and biological substances Drug overdose Opioids Medical emergencies Wikipedia medicine articles ready to translate Causes of death