Heroin Overdose: Signs, Symptoms & Treatment

What is a Heroin Overdose?

One of the most dangerous risks of using opioid drugs, including heroin, is overdose. If someone consumes high enough doses of heroin, the effects of the drug can overwhelm a person’s system, resulting in opioid toxicity.²

Because heroin and other opioids impact areas of the brain important in regulating respiratory rate, at high enough doses, such substances can result in dangerously slowed breathing. Opioid-induced respiratory depression can in turn progress to full respiratory arrest and death in overdose situations.²

This risk of toxicity and overdose may increase when someone consumes heroin or other opioids in conjunction with certain other substances, including alcohol and benzodiazepines.

Additionally, as an illicitly manufactured drug, the purity of a heroin is always unreliable. Manufacturers may cut or lace heroin with other substances, including fentanyl, which is an even more potent, respiratory-depressing opioid.^2,3 As this type of illicit opioid combination can be unpredictably strong, consuming it can pose significant risk to any person thinking they are merely using heroin.

Fentanyl’s Role in Heroin Overdose

Fentanyl is a profoundly powerful synthetic opioid that is 30-40 times more potent than heroin. Unfortunately, overdose deaths involving illicit fentanyl have risen since 2014.⁴ Because fentanyl is relative cheap to produce and easy to source, many dealers sell fentanyl-laced heroin or fentanyl alone under the guise of highly potent heroin.^2,3

It may be impossible for someone to distinguish between pure heroin and heroin that is laced with fentanyl, making it easy to unknowingly ingest enough fentanyl to experience a fatal overdose.^2,3 Additionally, because of its potent effects, fentanyl-related overdoses can be much more difficult to manage than many other types of opioid overdoses and may require more involved care.²

Heroin Overdose Statistics

Although the rate of fatal overdoses involving heroin decreased by almost 7% between 2019 and 2020, the total amount of overdoses is still concerning.^4,5 Statistics from 2020 show that:^1,4

• Heroin was involved in almost 20% of fatal opioid overdoses.
• There were more than 13,000 fatal overdoses involving heroin.

Symptoms of Heroin Overdose

Some of the more pronounced signs of heroin overdose are collectively referred to by medical professionals as the opioid overdose triad.² These three signs include:²

• Respiratory depression.
• Markedly decreased level of consciousness.
• Extremely constricted (pinpoint-sized) pupils.

However, these aren’t the only signs and symptoms that can result from a heroin overdose. Other symptoms of a heroin overdose might also include:^2,5,6

• Uncontrolled vomiting.
• Drowsiness and lethargy.
• Body going limp.
• Loss of consciousness.
• Inability to wake the person up, even if applying a painful stimulus, such as knuckles rubbed along the sternum.
• Making choking or gurgling noises.
• Shallow or labored breathing.
• Slowed pulse.
• Low blood pressure.
• Skin that is pale, blue, clammy, and/or cold.
• Complete respiratory arrest.

Heroin Overdose Risk Factors

A heroin overdose can happen to anyone, including first-time heroin users. However, heroin and other opioid overdoses may be more likely to occur amongst certain people in particular situations, including:^2,3,5

• People of relatively younger age (i.e., between the ages of 20 and 40).
• Male gender.
• People who have experienced prior overdoses.
• People who have severe medical and/or mental health conditions, including depression, HIV, breathing issues, and kidney or liver problems.
• People who use heroin intravenously.
• People who escalate their doses of heroin.
• Using after a period of abstinence when opioid tolerance has declined significantly.
• Using heroin with one or more other substances.

The majority of people who use heroin also use other substances, with many such substance combos increasing overdose risks.¹ This risk becomes even more prominent when someone combines heroin with other CNS depressant substances, such as alcohol or benzodiazepines, as these substances can worsen respiratory slowing.²

What to Do if You Suspect an Overdose

Any type of drug overdose is a medical emergency, so if you know or suspect that someone is currently overdosing, it is critical to call 911 immediately to get medical attention right away.⁵ Nearly all states in the United States have something called Good Samaritan laws, which offer varying degrees of protection from criminal backlash if you call for medical help in the event of an overdose.⁶

Additionally, most allow you to legally obtain and administer naloxone—a medication that can quickly and safely reverse opioid overdose—even without a prescription.⁷ Several doses of naloxone treatment may need to be given in a single heroin overdose situation, particularly if fentanyl is involved, since fentanyl can result in more pronounced and persistent opioid-induced respiratory depression.^5,8

If someone is or might be overdosing on heroin or another opioid, following these steps can save their life:^4,8

1. Call 911 right away and let them know what is happening.
2. Give the person naloxone, if you have it on hand. Sometimes more than one dose of naloxone will be needed, especially if someone is overdosing on fentanyl in conjunction with heroin.
3. If the person is awake and breathing, talk to them and try to keep them awake.
4. If they aren’t awake, lay them in the recovery position on their side so that they don’t choke.
5. Remain with the person until emergency responders arrive.

Heroin Overdose Treatment

If someone comes into the ER suffering from a heroin overdose, the priority of medical personnel is to stabilize their condition with supportive care. Ensuring proper breathing is the first step of stabilizing someone who is overdosing, so in people who aren’t breathing, diligent airway management and assisted ventilation may be necessary to make sure they are getting enough air. The emergency room may also take bloodwork to determine what other substances are in someone’s system, as well as to identify any other issues that may be present and contributing to someone’s current condition.

Administering Naloxone

Naloxone is a life-saving opioid overdose reversal drug that can be obtained in most localities without a prescription. Narcan, Kloxxado, and Rivive are naloxone nasal spray devices that are easy to administer: Simply:⁹ 

1. Remove the device from the package.
2. Hold the nasal spray so that your index and middle finger are on opposite sides of the nozzle and your thumb is against the plunger on the bottom of the device.
3. Tilt the patient’s head back while supporting the back of their neck with your other hand.
4. Insert the nozzle into the patient’s nostril so that your fingers on either side of the nozzle touch the bottom of their nose. 
5. Press the plunger firmly to administer the dose.
6. Administer additional doses every 2-3 minutes if the patient does not become responsive.

Opioid overdose symptoms can return when naloxone wears off, so it is crucial that emergency services provide additional support, even if the patient fully regains consciousness.¹⁰

When naloxone is administered to someone who is physically dependent on opioids, withdrawal symptoms may begin immediately.² In some individuals, the markedly unpleasant nature of acute opioid withdrawal can prompt combativeness and agitation. In addition, someone may experience a wide range of emotions related to having just overdosed, including anger, embarrassment, guilt, shame, and gratitude, which can be a lot to deal with at once—in such instances, the support of family and friends can be helpful.⁵

This could be an ideal time for medical providers to discuss the benefits of heroin addiction treatment, which can help address the various behavioral and social aspects of heroin use and opioid use disorder.⁵

Heroin Addiction Treatment

As is the case with all opioids, heroin use can lead to addiction or, in diagnostic terms, the development of an opioid use disorder.1 Heroin is a highly addictive substance, and since OUD is commonly associated with dependence and therefore uncomfortable withdrawal symptoms, treatment often begins with a period of medically managed detox. Medically managed detox allows a patient to withdraw from heroin under the supervision of medical professionals, ensuring their detox is as safe and comfortable as possible.^11,12 Typically, this is accomplished through the use of medications, such as buprenorphine or methadone, which reduce or eliminate withdrawal symptoms and cravings, and can be tapered down as you complete detox.^11,12

However, detox alone won’t create long-term change, and should be followed up with additional treatment to achieve long-term recovery.^11,12 After completing detox, various types of treatments are available to help you on the path to recovery. These can include:

• Inpatient rehab: In an inpatient or residential rehab setting, patients often receive treatment for several weeks to months, as needed for recovery. Throughout treatment, patients undergo daily behavioral therapy in both group and individual sessions. Inpatient treatment entails minimal contact with the outside world as patients heal their minds and bodies. Inpatient rehab helps patients readjust to living without heroin or other substances while receiving around-the-clock support from medical and counseling staff.¹¹
• Outpatient rehab: When appropriate for recovery needs, various levels of outpatient care provide a relatively more flexible treatment setting where patients may live at home or in a structured sober setting while receiving treatment. In outpatient treatment, patients generally attend scheduled, clinic-based group and individual counseling sessions, allowing them to practice what they learn in sessions in the outside world and process experiences in therapy appointments.12
• Behavioral therapy: Individual, group, and family therapy sessions can help patients learn how to communicate more effectively, address underlying issues that have contributed to their addiction, learn how to cope with stressors and triggers, prevent relapse, and strengthen their sobriety.¹¹
• Medication-assisted treatment (MAT): Beyond the period of medical withdrawal management, the use of medications such as methadone, buprenorphine, and naltrexone can continue to help patients manage cravings and reduce their likelihood of relapse. These medications can safely be used for long periods or indefinitely, in some cases, for to help individuals maintain their hard-earned recovery.^11,13

If you or a loved one struggle with opioid addiction, recovery is possible. Call to speak to a compassionate admissions navigator at American Addiction Centers (AAC) or verify your insurance coverage online.