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

Typical signs and symptoms of an opioid overdose are reduced consciousness or unconsciousness, a breathing rate of fewer than 8 breaths per minute, and very small pupils.

It is important to note that the risk of a harmful overdose increases when different medications, 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, this can result in brain damage or death.

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

Fortunately, overdoses occur relatively rarely and can often be prevented. There are several well-known factors that increase the risk of a serious overdose.

A common risk factor is the development of lower tolerance to the substance one usually uses. This may occur, for example, if a person becomes acutely or chronically ill, or if they have not used drugs for a period of time, such as after being released from prison.

If several different drugs and possibly alcohol are used at the same time, the risk of overdose increases significantly because the dangerous effects of opioids on the brain are amplified.

The risk of a serious overdose may be reduced if drugs are smoked rather than injected intravenously. The reason is that absorption into the body occurs more slowly when smoking, and it therefore takes longer before a dangerous situation develops after intake. This may be particularly important if one unknowingly consumes a stronger opioid than expected, for example if fentanyl has been mixed into what one believes is heroin. However, if a person still chooses to inject, it is better to divide the dose rather than take it all at once.

If other medications such as benzodiazepines, sleeping medications, and/or alcohol are used together with opioids, the risk of a dangerous overdose increases.

The opioid being taken may also be mixed with strong sedative substances, for example xylazine (a sedative used in veterinary medicine).

In recent years, new groups of synthetic opioids have appeared in Europe. One reason may be that the Taliban have cracked down on opium cultivation in Afghanistan, which has reduced the availability of heroin. This increases the risk that synthetic opioids will take over the market.

The use of synthetic opioids carries a greater risk of serious overdose than established opioids. Many of these substances are significantly stronger (more potent) than heroin and are therefore more difficult to dose safely.

Nitazenes are a group of opioids that were developed in the 1950s with the intention of using them as pain-relieving medications. Clinical testing showed that they had no advantages over morphine, and they were therefore never put into use. The first reports of nitazenes being used in drug contexts appeared as recently as 2019, and more than 20 different nitazene compounds have now been described.

Nitazenes act in the same way as other opioids. They produce the effects of pain relief, reduced consciousness, respiratory depression, potential for dependence, and small pupils. Nitazenes vary in strength, but some may be more than 100 times stronger than morphine.

Fentanyl is a potent opioid that was developed in the 1960s. It was used in operating rooms and later also as patches for cancer pain. Fentanyl is considered to be 50–100 times stronger than morphine.
Fentanyl was first seized as an illegal drug in Norway in 2016, and according to Kripos it has resulted in several dozen fatal overdoses, including among teenagers as young as 15.

It is easier to miscalculate a dose and ingest a larger amount than intended when highly potent opioids are mixed into the substance being taken. Sometimes strong opioids may be consumed without the user knowing it.

With large doses of fentanyl and certain very potent nitazenes, the effects and overdose symptoms may appear very quickly. It is therefore critical that treatment begins immediately.

Naloxone is a medication that was developed in the 1960s and introduced in hospitals during the 1970s and 1980s. Naloxone counteracts the effects of opioids and only works if opioids are present in the body.

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, they lose their effect. The most important effect in an overdose situation is that the patient begins to breathe again.

Naloxone has traditionally been administered by injection. In recent years, naloxone has also become 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 begin before the ambulance arrives. However, 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. One must always call 113 immediately.

Naloxone has a shorter duration of action than many opioids, and its effect begins to decrease after approximately 30 minutes. This is an important reason to contact 113 immediately.

Naloxone itself has few side effects, but it will remove pain relief and the intoxicating effects. As a result, pain may return and people who use drugs may experience withdrawal symptoms.

The medication buprenorphine, which is also sometimes used as a drug, binds very strongly to opioid receptors in the brain. Naloxone is therefore not able to effectively displace buprenorphine, which weakens its ability to restore breathing.

If an overdose is suspected to be caused by buprenorphine, even two doses of naloxone nasal spray may not be sufficient. It is therefore especially important to begin cardiopulmonary resuscitation (CPR) early and not wait until the ambulance arrives.

In Norway there is a national website with training materials for this, and all medications used as antidotes also have their own training pages.

In summary, the most important steps are:

• Always call 113 immediately for help. If synthetic opioids are involved, time may be extremely limited.
• Ensure that the airway is clear.
• Administer naloxone.
• If there is no pulse or breathing, start cardiopulmonary resuscitation (CPR) and continue until medical personnel arrive.
• If your friend improves, monitor them closely while waiting for help.
• If your friend worsens again, give more naloxone and start CPR again if necessary.

Links to training resources: Forside – Nalokson

If you do not wish to speak with your general practitioner, you can find more information at the following link: Forside – Nalokson

You can also find a list of naloxone distribution sites, and the staff there can help answer questions you may have: nalokson.uio.no/hvordan-finne/