Opioid Overdose Recognition and Naloxone Use in Pharmacy
How to recognise an opioid overdose in or near the pharmacy, when and how to use naloxone, and the pharmacist's role in take-home naloxone supply and harm reduction.
Why this matters
Drug poisoning deaths in England and Wales have risen significantly over recent years, with opioids involved in the majority of cases. Community pharmacies are on the front line: they supply methadone and buprenorphine for supervised consumption, dispense prescribed opioids, and are often located in areas where people who use drugs may be present. A patient or bystander presenting at the counter with a collapsed or unresponsive individual nearby is a scenario that any pharmacist may face.
Naloxone is a fast-acting opioid antagonist that can reverse opioid-induced respiratory depression within minutes. Many community pharmacies in England can supply naloxone without a prescription through commissioned local services operating under Patient Group Directions or other approved supply mechanisms. Knowing how to recognise an overdose, when to act, and how to use naloxone correctly can save a life.
Red flags vs more likely benign
| Feature | More likely benign | Red flag ⚠ |
|---|---|---|
| Consciousness | Alert and responsive to voice | Drowsy, difficult to rouse, unconscious, or unresponsive |
| Breathing | Normal rate and effort | Markedly slow, shallow, irregular, or absent breathing |
| Pupils | Normal size and reactive to light | Pinpoint pupils that are poorly reactive to light |
| Skin and lips | Normal colour and temperature | Pale, cold, clammy, or blue-tinged lips and fingertips |
| Muscle tone | Normal | Limp or floppy |
| Airway sounds | Quiet, normal breathing | Gurgling, snoring, or other signs of airway obstruction |
| Response to stimuli | Responds to voice or gentle touch | No response to voice or gentle physical stimulation |
What to do in pharmacy
While waiting for the ambulance, open and maintain the airway. If the patient is breathing, place them in the recovery position. If naloxone is available and you are trained to use it, administer it according to the product instructions and local protocols.
For intranasal naloxone products such as Nyxoid, administer one spray into one nostril and repeat according to the product instructions if there is no response or if symptoms return.
Even if the patient appears to recover after naloxone, they must still be assessed by emergency medical services. The effects of naloxone may wear off before the effects of the opioid, and recurrent respiratory depression can occur.
Patients taking prescribed opioids who become unexpectedly sedated, particularly following a dose increase or the addition of another sedating medicine, require urgent assessment. Patients receiving supervised methadone who appear unusually sedated should not be allowed to leave until appropriately assessed.
Particular consideration should be given to patients at increased risk of overdose, including those receiving opioid substitution therapy, those recently released from prison, those who have recently completed detoxification or experienced a period of abstinence, and those taking opioids alongside benzodiazepines or other sedating medicines.
Naloxone supply is one of the most effective harm-reduction interventions available in community pharmacy.
Key takeaways
- Call 999 first. Naloxone buys critical time but does not replace emergency medical care, and recurrent overdose can occur after initial recovery.
- The classic opioid overdose triad is pinpoint pupils, reduced consciousness, and slow or absent breathing. Any combination of these features should prompt immediate action.
- Many community pharmacies can supply take-home naloxone. Proactively offering it to people at risk of opioid overdose is an important harm-reduction opportunity.