Severe pain is the most common reason for being prescribed an opioid as part of treatment. The pain may be due to acute pain, for example after injuries or surgical procedures. Such pain therefore occurs acutely and is expected to be of short duration, meaning days or weeks. It is very important that the general practitioner (GP) is involved quickly in pain management after discharge from hospital.

Opioid medicines are very effective for pain in the final phase of life, especially pain related to cancer. This may also apply to other diseases in this phase, but regardless, the goal of treatment is to relieve pain during the last period of life.

Some people are also prescribed opioid medicines for chronic pain, meaning long-lasting and persistent pain over months and sometimes for several years. For this type of pain, the use of opioid medicines is not recommended, because over time one develops tolerance and must gradually increase the dose to achieve pain relief. One may also develop an unfortunate dependence on the opioid. For such pain, one should speak with one’s doctor about finding other ways to treat the pain.

The most common opioid medicines for severe pain are morphine and oxycodone. Both can also be sold under other names. It is therefore important to read the package leaflet to know what you are receiving. Other opioid medicines include hydromorphone, pethidine, fentanyl and buprenorphine.

In Norway, some less potent opioid medicines are also used, such as tramadol, tapentadol and codeine. These are also available under different brand names. Even though these are less potent, they can also lead to opioid overdose.

In pain treatment, it is common to combine opioids and non-opioid medicines. Examples include that the doctor, in addition to the opioid medicine, also prescribes paracetamol and ibuprofen to be taken at the same time.

Regardless of which medicine a doctor prescribes, it is important to read the package leaflet. This way you know what you are taking and, not least, what risks the treatment entails.

Opioid medicines provide very effective pain relief by acting on receptors in the brain.

However, in addition to affecting pain receptors, they also have an inhibitory effect on the respiratory center in the brain. At high doses and/or with increased sensitivity to opioids, in the worst case one may stop breathing.

It is important to be aware that it can take some time before respiratory depression occurs. If you yourself experience, or you see that someone else becomes more drowsy and that breathing becomes slower, this may be a sign that an overdose is developing. There is a risk that this may be mistaken for normal sleep, and that an overdose with decreasing respiratory rate is therefore overlooked. A breathing rate of less than 8 per minute is highly suspicious. There may also be other signs of such poisoning/overdose, for example very small pupils. It is important to become well informed about these dangers when using opioid medicines.

Over time, the body will develop tolerance (meaning that a higher dose of opioids is needed to relieve the pain). The dose must therefore be increased to achieve satisfactory pain relief. Dependence may also develop, meaning that it can become difficult to stop using the medication as time goes on. Opioids can also cause troublesome side effects in those receiving treatment, particularly nausea and constipation.

Chronic pain affects up to 30% of the population and is defined as pain lasting for a certain duration (3–6 months) and with a certain intensity (moderate or stronger), most often in the musculoskeletal system (muscles, bones/connective tissue, and joints). Unlike cancer-related pain, people often live with this type of pain for a long time.

The use of opioids for chronic pain that is not caused by cancer, or for pain in patients with a short life expectancy, is challenging and subject to strict restrictions in order to prevent the development of misuse.

In recent years, it has unfortunately been observed that the number of deaths involving prescribed opioids is increasing, a development that is causing serious concern among health authorities.

If someone experiences this type of chronic pain, they should therefore, in consultation with their general practitioner (GP), try to find alternative forms of treatment to relieve the pain rather than relying on opioids.

The Norwegian Directorate of Health describes an overdose as a condition triggered by the use of intoxicating substances or addictive medicines. The condition leads to severe impairment of the patient’s respiration, circulation and/or level of consciousness. An overdose may be caused by intake of alcohol, medicines or illegal drugs.

Typical signs and symptoms of opioid overdose are reduced consciousness/unconsciousness, a breathing rate of less than 8 per minute, and very small pupils.

It is important to point out that the risk of a harmful overdose increases when different medicines, drugs and alcohol are combined.

In practice, this means that the brain becomes so affected that it is difficult to stay awake, and the respiratory center may stop functioning. In the worst case, one may suffer brain damage or die.

In Norway, more people die from overdoses than in traffic accidents, and in recent years more people have died from overdoses involving prescription opioid medicines than from illegal drugs, such as heroin.

Fatal overdoses fortunately occur quite rarely, and they can often be prevented.

If one is being treated with opioids for severe pain, it is important to be aware of factors that can increase the risk that an overdose may develop.

When starting to use an opioid medicine, one must take this into account and adapt daily routines accordingly. Injury and illness that occur during opioid treatment can change sensitivity to the opioid; the required dose may be affected.

Even more important is that the use of other medicines that affect the brain, and alcohol, can enhance the effect of opioids—for example on the respiratory center—making a dangerous overdose more likely.

Many people enjoy a glass of wine or beer from time to time and have this as a natural part of their habits. However, it is important to be aware that continued use of alcohol when starting new medicines may carry a risk of triggering an overdose which, in the worst case, may lead to death.

Therefore, it is important to read the package leaflets for the medicines you use carefully, especially the section called “Precautions.” If one is still unsure what the precautions mean, one should contact one’s GP or, alternatively, a pharmacist at the pharmacy.

Alcohol has a sedating effect on the brain, making one drowsy, and together with opioids and possibly other medicines this can, in the worst case, lead to unconsciousness and respiratory arrest.

In most cases where overdoses/poisonings lead to death, studies show that it is rare for patients to have only opioids in their blood. Most often, several medicines are found, and sometimes alcohol as well. This has likely contributed to the person ending up with an overdose.

Therefore, the package leaflet for opioid medicines states that one should be cautious with concurrent use of CNS depressants/sedatives such as benzodiazepines or similar medicines, including alcohol.

Sedatives are medicines that have a calming effect, and when used together with opioids they can contribute to extreme drowsiness, reduced breathing rate, coma, and death.

If these medicines must be used at the same time, this must be done in consultation with the GP. Usually, such medicines should only be used for a limited period of time. With concurrent use, one must monitor closely for signs and symptoms of overdose, and not least inform those closest to you about these signs and what they mean.

If you find it difficult to understand whether the medicines you are using may increase risk, it is sensible to have a discussion with your GP about this. Pharmacists at the pharmacy also have strong expertise in correct medicine use and can provide good information.

Use of other medicines, especially sedatives, together with opioids will increase the risk of overdose because the medicines act on the same areas of the brain.

In addition, intake of alcohol—even just a glass of wine or a beer—may increase the risk, because alcohol also acts in the same way in the brain.

The first thing you should do is gain an overview and seek information about the medicine and which precautions you should follow. If you receive a prescription from your GP, the doctor will usually have an overview of which other medicines you are using. Nevertheless, it is important that you also ask how you should otherwise proceed, for example regarding alcohol use, and what information those closest to you should receive about your medicine use and the dangers associated with it.

If you are prescribed a medicine by someone other than your GP—for example a dentist or the treating doctor in an emergency department or hospital—they may not have a full overview of which other medicines you already use. In that case, it is especially important that you yourself inform the doctor/dentist about this, and that you together agree on which precautions are important during the treatment period. Also remember to inform the doctor or dentist if you drink alcohol.

When you are home again, you should take time to read the package leaflets for the medicines you are taking. Often there is very good information in the section called “Precautions.”

In addition, you should read up on symptoms and signs of an overdose and how to respond if you suspect that an overdose is developing.

It is also very important that you inform those closest to you that you have started using an opioid medicine, which precautions you must follow, what the signs of an overdose are, and what to do if an overdose should occur. If you are overdosed, you are completely dependent on someone else saving you. It is therefore very important that they know what an overdose is and what to do to prevent harm and death.

In consultation with your doctor, you should also consider whether you should have naloxone available. From January 2025, doctors can prescribe naloxone nasal spray without you having to pay a co-payment. Having naloxone nasal spray available near you while you are being treated with an opioid medicine can be lifesaving.

There are several symptoms that indicate an opioid overdose, but not all of them need to occur at the same time. The most important thing to remember is that this is an emergency situation, and you must immediately call 113 if an overdose is suspected.

Common signs and symptoms:

1. Unconsciousness – no response to touch or sound
   Unconsciousness can sometimes be confused with the person simply sleeping. But in an overdose, the respiratory center in the brain is blocked, and breathing may eventually stop completely. The person will not be possible to wake with talking, touch, or painful stimuli.
2. No response to pain
   Try rubbing the breastbone so that it hurts. Press the cuticle, or pinch the ear, under the arm, or the thigh.
3. Snoring, gasping, or gurgling
   When a person falls asleep/becomes unconscious due to opioids, they may make sounds that are easy to confuse with normal sleep.
4. Slow and irregular breathing or no breathing
   If breathing seems slower than normal, this can indicate acute danger. Lack of oxygen can damage the brain, so it is important to start CPR and administer naloxone immediately, if available.
5. Blue earlobes, lips, or nails
   When the body experiences a lack of oxygen, a bluish color can often appear in the skin, especially visible on the lips, earlobes, and nails.
6. Small pupils
   When opioid medicines are used, the pupils become as small as pinheads, a fairly reliable sign of opioid overdose.

If the person is unconscious—that is, they are not breathing or do not respond to shouting or painful stimuli—opioid overdose must be suspected.

Then do the following:

• Call 113 for help.
• Ensure that the airway is clear.
• If you have naloxone nasal spray available, give one dose in the nose. Each spray contains only one dose, so spray directly into the nose without testing the spray first.
• Insert the tip of the spray into the nostril and press until you hear a click. The dose has then been delivered.
• Start CPR if breathing and pulse do not immediately improve.
• If the person does not wake after 2–3 minutes, you can give another dose of nasal spray.
• If you do not have naloxone available, it is crucial to start and continue CPR as quickly as possible until the person either wakes up or the ambulance arrives.

Naloxone works by binding to the same receptors in the brain as opioids and displacing the opioids from these receptors. When the opioids are displaced from the receptors, they lose their effect. Put another way: naloxone reverses the effects of opioids. The most important effect in an overdose situation is that the patient begins to breathe again.

Previously, naloxone was only given as injections. In recent years, naloxone has also been available as a nasal spray. It is safe and easy to use such a nasal spray, and it is recommended to have naloxone available when using opioids.

The nasal spray can be used as first aid by people who witness an overdose. This allows treatment to start before the ambulance arrives. But it is very important that life-saving first aid is also provided, that attempts are made to wake the person, and that breathing support is given if necessary. And one must always call 113 immediately.

Naloxone has a shorter duration of action than many opioids, and the effect will begin to wear off after about 30 minutes. This is also a very important reason to call 113 to get help immediately.

Naloxone itself has few side effects. However, in patients who are treated for pain with opioids, too much naloxone may cause the pain to return.

If you have been prescribed an opioid medicine, the simplest thing is to ask your doctor for more information. The doctor will be able to tell you what risk is associated with the medicine alone and in combination with other medicines and alcohol, and give you advice on which considerations you should take.

All pharmacies have pharmacists who are trained in correct medicine use, and they will be able to provide advice when dispensing prescriptions.

In addition, there are several websites with information about overdoses, and below is a link to more of these:

Home – Naloxone