Saving Lives: How To Recognize And Reverse An Opioid Overdose

In the case of an overdose, a person stops breathing long before most of us realize what is happening. That is why our mantra is simple and urgent: call 911 and give naloxone. We walk step by step through recognizing an opioid overdose, using nasal naloxone in under a minute, and staying safe while you help. You do not need a medical degree to save a life; you need a clear plan, Naloxone, and the courage to act when someone will not wake up.

We break down how opioids shut down the brain’s breathing center and why unresponsiveness plus poor breathing should trigger immediate action. You will learn the key visual cues, when pinpoint pupils help and when mixed drugs blur the picture, and why naloxone is still a smart move even if alcohol or other substances are involved. We also confront stigma head-on, separating withdrawal management from life-saving priorities, and share a powerful ER story where Naloxone rescued a patient from an overdose in minutes.

Fentanyl demands new habits. We explain why it often takes multiple naloxone sprays, debunk fears about casual skin contact, and outline a compact PPE kit—mask, eye protection, nitrile gloves—to protect against airborne powder or accidental transfer. We cover re-overdose risks when naloxone wears off, the critical role of EMS observation, and practical tips on storage, expiration, and keeping naloxone in your glove box or bag. Along the way, we highlight Good Samaritan protections that reduce fear of calling for help, so more people step forward when it counts.

If you care about harm reduction, community safety, and giving people a second chance, this guide is for you. Hit follow, share this episode with a friend who should carry naloxone, and leave a quick review so more people learn how to act when seconds matter.

To contact Dr. Grover: ammadeeasy@fastmail.com

Transcript

Host Intro And Purpose

SPEAKER_00 0:08

Hi, I'm Dr. Casey Grover. I spent years practicing emergency medicine before shifting my focus to addiction medicine. This podcast grew out of caring for patients, hearing their stories, and wanting to do better. Here we talk about recovery, medicine, and compassion. This is Addiction Medicine Made Easy. This episode is on how to use naloxone. And just to clarify, as we've talked about naloxone previously on this podcast, this episode is how to respond to an opioid overdose outside of a medical setting when you are using naloxone as a community member before 911 arrives. I am the medical director for a drug and alcohol treatment program near me, and they asked me to do a naloxone training for the staff. Now I've been giving naloxone trainings for over a decade, and each training is a little bit different. I adapt the training for each audience, whether it's police officers, doctors, the community, or students and teachers. But no matter who the audience is, the overall message and training is the same. If you think someone is overdosing on opioids, call 911 and give naloxone. This lecture was given to staff who work at drug and alcohol treatment programs, but it's applicable for anyone who wants to carry naloxone and be ready to respond to an overdose. And naloxone can be given in many forms, but nasal naloxone is by far the most common form currently available and the easiest to use, so that's what I was training on. I forgot to make one point during the lecture, so I wanted to include it here. As we discuss in this episode, opioids are dangerous because they suppress breathing. And when breathing stops, that is what makes an overdose fatal. Once a person stops breathing from an opioid overdose, we only have five minutes to administer naloxone before the brain starts getting damaged from lack of oxygen. And we only have eight minutes to administer naloxone before the heart stops. So giving naloxone as soon as possible makes all the difference in the world. If you carry naloxone, thank you. Before we dive in, a quick reminder that leaving me a rating on your Podcatcher helps more people find this podcast. So thank you if you are able to give me a rating. And with that, here we go. All right, so happy to see you all today. And we're gonna be going through a naloxone training, specifically nasal naloxone. And I think everybody's pretty familiar with this, but just in case, we're just gonna go real slow and go through the fundamentals. And then we're gonna talk about how rescuing people with naloxone is different in the era of fentanyl. So naloxone is a medication that wakes people up from an opioid overdose. And the way it works is it blocks the opiate receptor in the brain and it prevents opioids from binding to the opiate receptor while the drug is active. And so let's say somebody is using morphine. That morphine molecule fits to the opiate receptor and binds. It activates the opiate receptor, and the person feels the effects of the morphine. When a person is given naloxone, the naloxone binds tighter at the opiate receptor than the morphine. So it actually kicks out the morphine, which is how it works to wake somebody up. And then it sits there on the opiate receptor so that the morphine cannot bind again. And this group, I know, knows this, but again, just to make sure we're all on the same page. Opioids are a class of downers. They can be medication, they can be illicit substances. And all downers have a particular risk of overdose, which is if they sedate a person enough, eventually a person stops breathing. Now, with alcohol, it's actually fairly hard to truly overdose on alcohol because most often people fall asleep before they've consumed enough to suppress their breathing. Unfortunately, opioids are different. So opioids work directly on the breathing centers of the brain and turn that off fairly early, which means that an opioid overdose is more likely to happen compared to other downers. Here are some of the names of opioids, just so we're all on the same page: heroin, codeine, hydrocodone, fentanyl, hydromorphone, demerol, oxycodone, morphine, oxymorphone, tramadol, buprenorphine. And if you didn't know, the antidiarrheamed laperamide, also known as amodium, is a very weak opioid, and if people take enough of it, they can overdose as well. Opioids have a particular appearance when there's an overdose. The opioids also affect the pupil size. So usually a person's pupils will narrow down to very small pupils. We call them pinpoint pupils. In the case of an opioid overdose, that doesn't always happen. In a mixed drug overdose, the drugs will do different things. So a person who mixes an upper and an opioid may have fairly normal pupils. And some opioids, a very small number, do not affect the pupils as much, but that's something that you can look for. But generally, it's going to look like any downer overdose. The person's going to be unresponsive, you can't wake them up, and then you're going to see signs of them not breathing adequately, whether they're breathing very slowly, they're gurgling, they've turned purple around the lips and in the nail beds. But in general, when I train this for a non-clinical audience, I just say if somebody's not waking up, if they're unresponsive, they clearly need medical help. So call 911 and it could be an opioid overdose, in which case you would give naloxone. Other things that might suggest an opioid overdose is if it's one of your clients and they're in the programming, they have a history using opioids. If you're in the community and you hear someone saying, Oh my gosh, my friend overdosed, come help. If you come up to someone and they're unresponsive, and there's signs of drug use, either through drug paraphernalia, an empty prescription drug bottle, or like a medical patch, like a fentanyl patch on the body, would also suggest that a person has been using opioids. And again, in our world in drug and alcohol treatment, it's usually going to be somebody that we know that has a history of substance use, and we're obviously going to be more likely to suspect an overdose. Now, people always ask me, will naloxone wake somebody up from an alcohol overdose? Or what if they overdose on cannabis? And unfortunately, naloxone only works on opioids. But as we all know, people with substance use disorders often mix different substances together, whether that's intentionally or unintentionally because the drug is laced. So, in general, because the drug supply is so tainted and people do potentially mix substances, if you heard that somebody drank too much and you're worried it could be an overdose, go ahead and give the naloxone, anyways. Because, as we talked about, opioids suppress the breathing the most. So if they mixed fentanyl and alcohol and cannabis, if you at least reverse the opioid, you're likely to get them breathing again. They still have alcohol and cannabis in their system, but at least they're breathing. So, my usual recommendation is any suspicion of any type of overdose, naloxone's a good idea. A brief story from one of the trainings I did and some follow-up. Gosh, about 10 years ago, I was training one of our local police departments on how to use naloxone, and they went through the training. In fact, I think I used this same slide deck. And literally the next week, they had a 911 call to a person who was unresponsive by Robert's Lake in Monterey. That's that big lake over by the Embassy Suites Hotel. And they went out, it was a person that was unresponsive. They'd had contact with this person before, and they knew that this person had an alcohol use disorder, and they said, it's probably not worth giving naloxone. Let's just wait till the paramedics get here. So the ambulance shows up and the paramedics go ahead and start an IV and give intravenous naloxone, and the person wakes right up. Turns out it was the first day trying an opiate and mixing it with alcohol. So again, any possibility of overdose involving opioids, go ahead and give naloxone. When, if you have your naloxone, would be the reason to give it. If a person is actively telling you, I'm not overdosing, don't give me naloxone, they don't need naloxone. And this is really sad to say, and I'm not proud to say this, but when I was in my training at Stanford, I was actually taught that people with opioid addiction deserve to suffer. And so we should give them naloxone just because it would make them withdraw and they deserved it. And I'll never forget, I was in the pediatric emergency department at Stanford, and a young man had come in. He had taken, I can't remember what prescription opioid it was, but people called 911 because he was sleepy. And I just remember him being wheeled into the emergency department and him yelling, please don't narcan me, please don't narcane me. And my supervising doctor said, he deserves it. Just go ahead and give it. And I bring that up to just share, as we all know, how much stigma there is around addiction. And fortunately, we've made a lot of progress there, but I didn't know any better at the time. I was just uh newly in my medical training. Uh and you hear some patients talk about this. Oh, yeah, I went to the ER, they forced me to take naloxone because they thought I deserved a withdrawal if someone is speaking, they don't need naloxone. The only reason you need to give naloxone is you can't wake somebody up. Don't even worry about whether or not they're breathing. Don't worry about assessing that. If you come up on somebody and you can't wake them up, assume it could be an overdose and give naloxone. Now, I mentioned Narcan. That is one of the brand names of this medication. A lot of times people use narcan and naloxone interchangeably. It's literally like Tylenol and acetamenophane. It's the same substance, just one's a brand. Now, let's imagine that later today I'm out grocery shopping and I see someone unresponsive in the parking lot. If I go ahead and give them naloxone and I don't call 911, what if they're having a stroke? Or what if they've just had a seizure? What if their blood sugar is low? Really, the only way I could hurt them is to not call 911 and give them naloxone because then that medical condition's not getting treatment. So for me as a doctor, I can't tell if somebody's got a low blood sugar or having an overdose if I'm not working at the hospital. So absolutely call 911 and give naloxone. I consider it like a one-two punch. 911 naloxone, 911 naloxone, 911 naloxone. Because if you're wrong, you will not hurt them because 911 is on the way. Now, when should you not give naloxone? And I'm gonna try to convince you that if someone's really unresponsive, there's no reason to hold back. So the first question is what if someone's allergic to naloxone? Okay, makes sense. Allergic reactions are obviously bad. The first thing is if you were to come up on scene and someone had a medic alert bracelet, sometimes people will put their allergies on a medical alert bracelet. Let's say there's someone on scene that knows the person, you could ask if there's an allergy. Some people do list an allergy to naloxone, but it's because they got withdrawal from it, not because they got anaphylaxis, like their lips were swelling and they got hives. And I actually researched from the National Library of Medicine, apparently it's actually never really been reported. So, first of all, it's exceedingly rare, if even possible. It's really never been reported when I looked. But let's think about this. If someone's not breathing because of an opioid overdose, that's gonna kill them the fastest. If you save their life with naloxone and get them breathing again and they get an allergic reaction, awesome. You just saved their life. The paramedics and the emergency department will treat the allergic reaction. But if they die from an overdose because we're afraid of an allergic reaction, we missed that opportunity and they died. So if you are totally afraid that someone's gonna have an allergic reaction to naloxone and they're not breathing and dying from an overdose in front of you, give the naloxone, tell the paramedics, they will take care of it, and you just saved a life. Now, for people who are on opioids regularly and have opioid dependence, when you give them naloxone, you're blocking the effects of opioids and they will get withdrawal. My dad, when he was dying of cancer, was on morphine as a part of his palliative care regimen. My dad never misused his meds, he never snorted them, he never smoked them, he never took more than prescribed, he did not have an addiction, but he was dependent. So when someone takes opioids regularly and they have dependence, whether from addiction or not, if you give them naloxone, they will go into opioid withdrawal. Now, again, if they are dying from an overdose in front of you, if they are not breathing, don't worry about withdrawal. Give them naloxone, save their life. 911's on the way. When the paramedics get there, they'll start an IV, they'll give them nauseam meds, they'll give them IV fluids, they will treat their withdrawal. So don't hold back because you're worried about withdrawal. Now, that being said, that goes back to if somebody can talk to you, they don't need naloxone. They might be sleepy and nodding off, and someone needs to watch them. But if they can talk to you, they don't need naloxone, we don't need to unnecessarily cause withdrawal. Now, if you give someone naloxone who is not overdosing or does not have opioids in their system, it does absolutely nothing. I usually get somewhere between one and five doses of naloxone a week because I go to schools and community organizations to give naloxone training. I've gotten naloxone too many times to count. It's a little bitter. Sometimes I get a little nauseated afterwards, but it does not do anything. So you can't hurt anyone with naloxone as long as you called 911. Okay. Now, how do you go ahead and give it? I actually have a box here on my desk. We'll go through it just a sec. But the nasal spray is super easy. Many years ago, it was only available as an injection. You had to pull it out of a vial and draw it up into a syringe. The nasal naloxone is very easy. It comes in a box. It's a pre-packaged nasal spray. The most common is each spray contains four milligrams. And here's how you give it. If you suspect an overdose, call 911, open your box, give a spray in one nostril. If you don't get a response in two minutes, give the second dose into the other nostril. It is the same dose if it's a two-day old, a 42-year-old, or a 92-year-old. You don't have to worry about dosing it differently. And it also works on pets like cats and dogs. In terms of how it works, we talked a little bit about this. It works in the body at the site where opioids bind to opioid receptors, and it removes the opioid molecule from the receptor and binds it to the receptor. The way I describe it to people is the way molecules and hormones and medications work in our body is it's based on shape. So we have an opioid receptor in our brain. Morphine is a particular shape, it fits in that receptor, so it binds. Fentanyl has a similar shape, so it sits in that receptor and binds. It's like a lock and a key. Naloxone fits in that opiate receptor, but it doesn't open the receptor. It's like a dummy key. It fits in the lock, blocking other keys, but you can't open the door. Now, this is a question I always get. Gosh, do I need to clean the nose? No, you do not. You literally just need to put the nasal spray into their nose and push the plunger. A couple of tips when you're responding to an overdose outside of a medical setting. So unfortunately, as we all know, people who use substances have to have particular supplies to use them. We call it paraphernalia. There's a lot less injection drug use in the fentanyl era, but somebody could still have needles on their person. So when you go to respond to an overdose, you want to make sure that there's not any uncapped needles that could pose a risk to you. Similarly, most of the pipes are glass. So if there's a broken pipe, that could also be a potential injury to you as well. The last thing we would want to do is put any of our responders to overdoses at risk. We'll talk about if you want to wear protective equipment, what you should wear now that we're in the fentanyl era. The other thing to know is that this naloxone only lasts about maybe 45 minutes. So let's say somebody has an overdose, they stop breathing, one of you calls right away 911 and gets a dose of naloxone in them, they might be awake by the time the paramedics arrive. Now, unfortunately, if we release them, the naloxone will wear off in about 45 minutes, and those opioids in their brain haven't gone anywhere, they will rebind to the opiate receptor and the patient will overdose again. And this is actually what we do at the hospital. So let's say somebody overdoses, 911 gets called, they get a dose of naloxone, they wake up, they come see us in the emergency department. We literally put a pulse oximeter or an oxygen monitor on their finger and we just watch them for about four hours. So if somebody starts getting sleepy again and re-overdoses, we'll redose their naloxone. Or if it's a really bad overdose, like someone took an unusually large amount of opioid or an opioid that lasts a long time, like methadone, which lasts for several days. We sometimes even watch them in the hospital overnight and will give them continuous infusion of naloxone through an IV. We talked about for people who are chronically on opioids, giving them naloxone can cause withdrawal. So we only want to give it if someone is truly overdosing. What I will tell you is when we look at the different ways that naloxone is dosed, it can be given as an IV started by the paramedics or in the hospital, as an intramuscular shot that can be given by a paramedic or in the hospital, or the nasal spray by anyone. And when we give people a dose of IV naloxone, it comes on in seconds. These people sit up bold or upright, they're in withdrawal, it's very unpleasant. The shot, the intramuscular shot, comes on a little bit more slowly, and the nasal spray is much gentler. People usually wake up over maybe about 90 seconds. And we seem to see because of that that people don't have as bad of a withdrawal from the nasal spray. I don't have any scientific data on that, but that's what we've been experiencing locally. I'll tell you a story from the ER to illustrate this. Gosh, probably 2019, I was working in the emergency department, and we get a call. We need a doctor in the parking lot right now. And you all can imagine that's not good. Normally, you know how slow the ER is. You check in, you show your insurance, you talk to the nurse, they confirm your allergies, they check your blood pressure. It's fairly slow. Doctor in the parking lot means someone's dying in the parking lot. So we go running out to the parking lot, and thank goodness one of the nurses saved my bacon that day because she grabbed our box of nasal naloxone that we keep in the front of the emergency department. So we go running out, and there's a sedan with four people in it. The driver is looking straight ahead, the front passenger is looking straight ahead, the back left passenger is looking straight ahead, the back right passenger is clearly not well. He's drooling, his lips are purple, and we can't wake him up. And so I ask the guys in the car, like, what is going on? And they're all worried about getting in trouble, so they don't say a thing. So the nurse acts decisively, she puts the nasal naloxone into the window, into this guy's nose, she squeezes a dose, we rip him out of the car and go running into the emergency department with this poor man on a gurney as fast as we can. Within about two minutes, he has color changed. He went from purple around his lips to the usual pink color, meaning he started to breathe again and his oxygen started to return. By about three minutes, he was starting to open his eyes. And by about five minutes, he was able to fully have a conversation with us and tell us what happened. And so, thank goodness to his friends for driving him to the hospital that day because they saved his life. And yeah, he had overdosed on some sort of pill that day, presumably fentanyl. When does my naloxone expire? So the box on the bottom of it usually has the expiration date. The one I have on my desk expired in August 2025. It actually still works after the expiration date. It only loses about 5% of how well it works for every year after the expiration date. So the naloxone that we're going to train with today is still 95% effective. So absolutely, if all you have is expired naloxone, give it. Where do you store it? It stores best at room temperature. And in Monterey County, we all know it's mostly room temperature here throughout the year. If it's a really hot day, you can expose the naloxone up to about 104 degrees Fahrenheit based on the manufacturer recommendations. You should not freeze it. So maybe if you went up to the mountains and it got really cold, it might be damaged, or you went into the Central Valley, you could damage it. But it still works. Basically, you damage the molecule and it's going to be less effective. But it still does work. So if all you have is an naloxone that got exposed to some heat, call 911 and give it. And yes, I keep one in my glove box, it's convenient. I usually keep it in my glove box and in my work bag. The other thing is the Good Samaritan law, which is that if you are responding to an overdose and you are doing something that you're not supposed to be doing around drugs and alcohol, the Good Samaritan law protects you. Meaning that if the police come on scene and there's paraphernalia or someone's underage and drinking, if you call 911, they will not prosecute you for that sort of possession. And this comes from the fact that people are afraid to go to the hospital or call 911 when someone's overdosed because they're afraid of getting in trouble. And we occasionally have people overdose in the field away from medical settings and they're not able to be saved because their friends are so worried about getting in trouble that they don't call 911. So when clients are in residential or an outpatient, make sure that they know that if they're in a bad situation and someone's overdosed, please call 911 to save someone's life. All right. And then I'll open up the box and we'll go through how to give a dose of the naloxone. Again, I know you all know this, but just to level set, fentanyl is a synthetic opioid. It's a hundred times stronger than morphine. And previously was only used in the medical setting around severe pain. Unfortunately, if you're a drug dealer, fentanyl is a dream come true because it's so potent that it's can be smuggled in small quantities, making it harder to detect by law enforcement. And we've been seeing fentanyl here in the drug supply in Monterey County since about 2019. And the amount of fentanyl that's in this county is absolutely insane. I don't know if you all heard about this, but in November 2025, Salinas Police Department seized 23 pounds of fentanyl. Let me say that again. Salinas Police Department seized 23 pounds of fentanyl. That is enough to kill everyone in Monterey County, 450,000 people, 12 times. The amount of fentanyl that's coming into communities all across this nation is absolutely just insane. Now, when a person has an overdose on any opioid, they will have the same presentation. But because fentanyl is so much more potent, overdose can occur after just a small amount of consumption or exposure. So if you take a four-gram sugar packet, that's a standard sugar packet, the amount of fentanyl that would fit into that packet is enough for a dealer to sell 40,000 doses for use and enough to kill 2,000 people. So unfortunately, what we're seeing is even just a few grains of fentanyl is enough to cause an overdose. Also, because fentanyl is so potent, a lot of times people are just taken so much further down into their overdose by the sheer amount of activation of the opiate receptor by fentanyl that we often need more naloxone. If someone overdoses on their prescription meds after surgery, you might just need one naloxone, four milligram nasal spray, and they're gonna wake up. But on fentanyl, you might need to give them two, three, four, five, six doses of naloxone to wake them up. And the good news is the box has two doses, you're gonna give those, and then because you've called 911, 911 is gonna come and they have more naloxone. Now, there's a lot of mythology around what touching fentanyl will do to you. So, if you think about it, how do people use illegal substances? They smoke them, they snort them, they eat them, and they inject them. That's how we use regular medicine, right? Intravenous, intramuscular, nasal, oral, or inhaled like an inhaler. It's the same routes of administration. People do not rub fentanyl into their skin because it doesn't absorb and it doesn't work. Fentanyl patches require a special gel to allow the fentanyl to be absorbed into the skin. It's made by a pharmaceutical company and it takes about 12 hours to get absorbed. So if you touch fentanyl, you are not going to have to worry about overdose. But if you're outdoors and there's powder and it gets blown into the air and you inhale it, that could result in an overdose. Or if you get a fentanyl on your hand and you rub your eye or rub your nose, that could actually result in you as the responder overdosing. So what I would say is if you're worried about being exposed, rescuing someone with an naloxone, make a little kit like in a Ziploc bag, put your naloxone in it and put the personal protective equipment in it. You need a COVID mask, that'll prevent you from breathing it in or getting it in your nose. Get eye protection, like at Home Depot, that'll keep it out of your eyes. And then go ahead and put your put yourself in some nitrile gloves. That way, if you have any cuts on your hand, it couldn't go in to that cut and be absorbed. And if you're suspecting a fentanyl overdose, you're just gonna give as much naloxone as you have until the person wakes up or the 911 staff arrive. Okay, so let's go through and actually unbox the the naloxone. So here is the naloxone box. It comes in a box of two, and you're gonna open it up here. Okay, again, a little packet here. You're gonna hold it between your fingers, and you're gonna spray it just like that. And here's what it looks like it just sprays. What it does is it coats the inside of the nose. There's tons of veins in the nose. And so those veins absorb the naloxone and bring that back into the circulation. A person does not have to be breathing for this to work. And then again, in terms of how it looks, you just put it into the nose, just like that. And essentially you put it between your index and middle finger and you push it in until those fingers are against the nose. Thank you so much for listening to Addiction Medicine Made Easy. If you found this helpful, please leave a review. It really helps others find the show. And a huge thank you to Central Coast Overdose Prevention for supporting this podcast. And always remember treating addiction saves lives.