Fentanyl overdose: What to do when someone overdoses and stops breathing

Jan. 10, 2023
A man resting against a wall that is filled with grafitti.
Fentanyl is a synthetic opioid that can be deadly when used improperly. Photo: Getty Images.

In Colorado and across the United States, the number of people dying from overdoses of illicitly manufactured fentanyl, has risen dramatically.

Pharmaceutical fentanyl, according to the Centers for Disease Control and Prevention, is a synthetic opioid approved for treating severe pain, typically for cancer patients.

Most of the harm and death in the U.S. is linked to illegally made fentanyl that has a heroin-like effect. It’s often mixed with a combination of other drugs, and it is highly addictive – and deadly.

Physicians in hospital emergency departments across the United States are seeing a significant increase in patients seeking treatment for fentanyl – either for an overdose or addiction.

Dr. Robert Lam, an emergency care physician who is concerned about the number of fentanyl overdoses he treats.
Dr. Robert Lam

“This really hit home when I had a patient who was 18 who came to the emergency department seeking treatment for fentanyl. And it was particularly disturbing to me as a physician because she presented with no friends, no family, no one to support her, and I knew that this represented a significant diagnosis that could affect her life,’’ said Dr. Robert Lam, an emergency care physician at UCHealth Memorial Hospital in Colorado Springs.

“She may face a lifetime of addiction, a risk to her health and even a significant risk of death. As a physician, it is a particular tragedy. I don’t think any young person with their whole life ahead of them should face this threat to their well-being, and I think it is important that we address this epidemic.’’

Below, Dr. Lam provides valuable information on fentanyl overdoses, and how to recognize signs and symptoms of addiction.

What is fentanyl?

Fentanyl is a synthetic opioid, approved for treating pain, usually in cancer patients.  It is prescribed in the form of patches or lozenges.

Illicitly manufactured fentanyl is driving the number of overdose deaths in the United States. Fentanyl is often combined with other drugs and the dosage of fentanyl in these drugs in unknown to the user. Fentanyl that is illegally made comes in the form of a powder or liquid. The powder can be pressed into the form of a tablet. One pill can kill.

What happens to someone physically when they overdose on fentanyl?

Fentanyl acts on multiple organ systems in the body. It can act on the brain, so a patient who has overdosed on fentanyl can continue to fall asleep. They may fall unconscious.

Most important is the effect that fentanyl can have on breathing. Fentanyl can cause you to slow or even stop your breathing and that is what can cause a patient to actually pass away from lack of oxygen.

The effect on breathing and lack of oxygen can also be reflected in other organ systems. You may see changes in the color of a patient’s skin, nails or around the lips. You may notice that they may not have a lot of muscular tone, they may feel weak and unable to respond. But most important is the effect that it has on breathing and why patients can die from a fentanyl overdose.

How quickly, from the point of ingesting, can someone begin to show these symptoms of a fentanyl overdose?

Fentanyl is a very powerful medication. Depending on the amount of ingestion or the strength of ingestion, and the potency of the amount that was ingested, it can happen in a matter of minutes. We talked about the effect of fentanyl on breathing so that stopping breathing and lack of oxygen means that a patient can pass away in a matter of minutes. Time is really of the essence when you’re dealing with a patient who has suffered an overdose of fentanyl.

What should someone do when they see signs of a person stopping breathing?

The first thing is to call for help. It is really important to get on the phone and call 911 because that patient needs emergency care right away. If you have naloxone (a drug to rapidly reverse an opioid overdose also known as Narcan) then this is the time to give naloxone because time is of the essence to restore a patient’s breathing.

If a patient stops breathing or their heart stops beating, if you’re trained to do so, you should give rescue breaths or CPR. And if a patient comes around and becomes more responsive, we recommend putting them in the rescue position, laying them on their side, so they don’t choke and opening up the airway.

And you should stay with the patient even if they respond to naloxone. That’s a patient who needs emergency care. Stay with them until emergency help arrives. They need to be assessed by professionals in emergency care related to their overdose.

How do you perform rescue breaths?

If you are trained in CPR, then you should know how to open up a patient’s airway and then deliver a couple of rescue breaths to start with. That’s really important for a patient who has stopped breathing, and you can continue rescue breaths in a cycle if you’re trained to do so when delivering CPR. Rescue breaths and compressions for patients who have stopped breathing and whose heart has stopped beating usually go together.

Why call 911 instead of driving a patient to a hospital?

Fentanyl is an extremely potent medication that can stop or slow breathing, and patients can die in a matter of minutes. This is where time is of the essence. The fastest way to get them help, the fastest way to save their life, is to start with a call to 911.

What is naloxone or Narcan, and how can someone get it?

Naloxone or Narcan is a lifesaving medication, and it can reverse the effects of fentanyl and other opiates when given in time. And in Colorado, naloxone can be obtained without a prescription from a pharmacy. And any patient or family member or friend who has someone in their life who may be suffering from opiate misuse disorder or uses high doses of opiates should have that medication just in case there is an emergency.

How is naloxone or Narcan administered for a fentanyl overdose?

There are two major ways that you can administer naloxone. One is by injection, but even easier, now we have a nasal spray.

The nasal spray doesn’t require any special training. It is very easy to use and can be administered to any patient, and it is very rapid-acting.

What is the risk of addiction to fentanyl?

This is an important point: Anyone can become addicted.

In recent surveys, it showed that one in seven Americans identified as suffering from some substance use disorder. There is not one underlying driver for addiction for patients. Patients can sometimes use drugs of abuse or inappropriately use drugs to treat trauma or stress. Sometimes patients use it to treat when they have an untreated mental health issue. Sometimes patients can become addicted when using legitimately prescribed drugs for conditions. One unifying thing is that the longer a patient uses drugs than the easier it is to become addicted.

How is fentanyl addiction treated?

I think it is fair to think of addiction as a disease. And as such, there are different modalities that we have and different tools that we have to treat that addiction. The most promising tools that we have are medications for opiate use disorder. The most common we can prescribe are methadone, buprenorphine and naltrexone. And those medications have been shown sometimes to help patients overcome addiction and help them stay sober longer, and reduce addiction-related cravings. So those medicines have a lot of promise in treating this particular addiction and other opiate use disorders.

There are other modalities that we can use too. Twelve-step programs, which many people are familiar with, have been a long-time treatment we use to treat addiction. And they help a patient to identify addiction as a chronic, long-term condition. It helps them identify a community of people trying to stay sober together.

I think there are a lot of benefits to those 12-step programs. Therapy can be helpful, counseling can be helpful and can help patients identify the triggers, some of the underlying things that are triggering them to use substances or fueling their addiction.

Inpatient treatment is also an intensive way for patients to become sober and to help with addiction, to give them specific tools to help them stay sober.

What happens if you drink alcohol or ingest marijuana with fentanyl?

What you are describing is a polysubstance use, or a mixing of drugs, and that is a particularly dangerous practice. Some studies have shown that up to half of all deaths by overdose included the mixed use of drugs.

The problem that occurs when you mix the usage of drugs, you can amplify some of the side effects. You can make some of the side effects unpredictable. So, for example, what happens if you mix alcohol and fentanyl? Alcohol acts in the body as a depressant. It can depress your respiratory status; it can depress and make you sleepy. That only is amplified when you add fentanyl to that mix.

Using those two together can make the otherwise sometimes predictable side effects become unpredictable and amplify how severe those side effects can happen, so that is a particularly dangerous practice.

What are the side effects of using fentanyl? 

Fentanyl has multiple effects on the body. It can affect the brain and cause a patient to fall asleep or become difficult to awaken. Some have observed that a patient’s pupils can become very small, and most importantly, it can affect breathing, a slowing or cessation of breathing that can cause a patient to pass away from lack of oxygen.

Patients with fentanyl may not be able to walk, or they can become very weak and not be able to hold their heads up. It can affect their color too. It relates to the effect on breathing and oxygen delivery, so you might see a patient and their skin feels clammy, or they have discoloration in their nails.

Have you seen a first-time user overdose from the use of fentanyl?

Currently, with the epidemic of fentanyl, it is particularly dangerous to experiment with medications, especially since one pill can kill. Any pill that does not come from a legitimate pharmacy could contain a lethal dose of fentanyl, and we are seeing more and more patients that are younger in age that are sometimes first-time users of medication, and they’re experiencing a tragic overdose.

What does fentanyl look like?

Fentanyl, if you are talking about illicitly-produced fentanyl, usually takes the form of two different forms – one is powder, and the other is a liquid. And that powder is unidentifiable from other powders. There is no special look, smell or taste to that powder. Oftentimes, that powder is mixed with other drugs of abuse like methamphetamine or cocaine. Because fentanyl is very cheap to produce, an illicit drug manufacturer may mix it with other drugs hoping to prolong some of the euphoria. But the danger is we don’t know the dosage, which may be so potent that it can cause those side effects – a lack of breathing, and a patient can pass away from that.

Unfortunately, there’s no way to identify either by look, taste, color or smell that fentanyl has been put into another drug. Sometimes people can press that powder into a tablet form, which can look just like other tablets we use. So it might look like Oxycontin or oxycodone. They can even use those same markings on those tablets when really what they’re dealing with is fentanyl, and it can act on the body in a completely different way and, because of the potency, can cause a patient to die.

The liquid form can also be masked in a lot of different substances as well. They can put in eye drops or sprinkle it on candy or put it on paper. The take-home message here is that any medication not obtained from a legitimate pharmacy could be a lethal dose of fentanyl.

What are some of the street names for fentanyl? 

Some of the things that I’ve heard are names like apache, tango and cash, but the biggest thing right now is that they are mixing fentanyl with other drugs of abuse, and that can be unpredictable in the way that it affects people, and very dangerous to a patient.

Have you seen fentanyl that looks like candy?

In the emergency department, we see the effect that it has on patients, but we very rarely see the actual drug. Though I have not encountered fentanyl in a candy form, I am not surprised because this takes many different forms and shapes out in the community.

If I use opiates, specifically fentanyl, what questions should I ask myself about whether I am addicted and how I can get help?

Addiction is complex. The first questions are: Are you using the medication for the right purposes? Do you understand why your doctor prescribed those medications, and are you using them appropriately?

Are you starting to see some of the red flags or warning signs of a patient with addiction? A craving or need to have that medication? A change to your behavior? Are your friends or family noticing a change in you or your behavior? If those things are coming to fruition, the best thing to do is to start by talking to your doctor about some of the things you are noticing. And your doctor can link you to resources for treating addiction, understanding addiction better and getting treatment.

How do you know what kind of drug you are getting on the street?

There are two major ways that we see fentanyl that is illicitly manufactured. And it can come in the form of a powder or a liquid. That powder form can be pressed into a tablet that looks like other drugs that a patient may want to obtain. It may look like oxycontin or oxycodone but actually, be fentanyl. It is a good practice that any drug that is not obtained from a legitimate pharmacy could contain a lethal dose of fentanyl.

About the author

Erin Emery is editor of UCHealth Today, a hub for medical news, inspiring patient stories and tips for healthy living. Erin spent years as a reporter for The Denver Post, Colorado Springs Gazette and Colorado Springs Sun. She was part of a team of Denver Post reporters who won the 2000 Pulitzer Prize for breaking news reporting.

Erin joined UCHealth in 2008, and she is awed by the strength of patients and their stories.