3.3 Opioids: Intoxication, Overdose, and Withdrawal

Opioids and the lethal-overdose pattern

Opioids include heroin, fentanyl and fentanyl analogs, and prescription analgesics (oxycodone, hydrocodone, morphine, methadone). They act on mu-opioid receptors to produce analgesia, euphoria, sedation, and physical dependence. For the CADC exam, the single most important opioid distinction is overdose versus withdrawal, because their priorities differ completely.

Where alcohol and sedatives have lethal withdrawal, opioids have lethal overdose. The classic opioid overdose triad is:

Other overdose signs include cyanosis (blue lips/fingertips), gurgling or "death rattle," and limp body. Fentanyl has driven overdose mortality because it is far more potent than heroin (roughly 50-100 times morphine) and frequently contaminates other drug supplies — counterfeit pills, heroin, cocaine, and methamphetamine — so a user may not know they ingested it. Even more potent analogs such as carfentanil can require multiple naloxone doses and are harder to reverse.

The harm-reduction implication the exam may reference is that fentanyl test strips and naloxone distribution are evidence-based overdose-prevention tools the counselor can educate about and refer to within scope.

Intoxication short of overdose shows drowsiness, nodding, slowed speech, constricted pupils, poor attention, and reduced respiratory effort. The CADC role with people who use opioids includes recognizing immediate and ongoing needs, case management, referral, and collaboration — not giving medication instructions or replacing medical evaluation. One more high-yield contrast: opioids constrict pupils, but in a combined or hypoxic overdose pupils may dilate, so a normal pupil exam never rules out opioid overdose when breathing is compromised.

Naloxone and emergency response

Naloxone (Narcan) is an opioid antagonist that displaces opioids from mu receptors and rapidly reverses respiratory depression. The exam expects you to recognize it as the antidote and to know the overdose response, not to act as a prescriber.

• Intranasal naloxone is supplied as a 2 mg or 4 mg single-dose spray; the 4 mg spray is the common community/take-home form.
• Re-administer every 2-3 minutes (alternating nostrils for the spray) if there is no response, while waiting for EMS.
• Naloxone's duration of action is shorter than many opioids' (especially long-acting agents and potent synthetics), so respiratory depression can return — "re-narcotization." The person must be monitored and transported even if they wake up.
• Naloxone can precipitate acute withdrawal in a dependent person (sudden vomiting, agitation), but reversing a stopped breath always takes priority.

Applied scenario: a client is found in the waiting area barely responsive, with slow breathing and pinpoint pupils after reporting fentanyl use. The best answer is to activate emergency response, administer naloxone if available and trained per agency protocol, support breathing, and call EMS. A weak answer is to begin a treatment-plan discussion, take a detailed family history, or let the client "sleep it off."

Trap: confusing withdrawal discomfort with overdose danger. Opioid withdrawal is dramatic but the breathing-threatening event is overdose. If breathing is compromised, emergency response comes first; if the client is alert but withdrawing, assessment, support, referral, and coordination with withdrawal-management services are the path.

Withdrawal, COWS, and medications for opioid use disorder

Opioid withdrawal is intensely uncomfortable but not typically life-threatening in otherwise healthy adults (dehydration from severe vomiting/diarrhea is the main medical risk). Onset depends on the drug: short-acting opioids (heroin) begin withdrawal in ~8-24 hours and peak around 1-3 days; long-acting opioids (methadone) begin in ~24-48 hours and last longer.

The Clinical Opiate Withdrawal Scale (COWS) is the tool to recognize: an 11-item clinician-rated scale (resting pulse, sweating, restlessness, pupil size, bone/joint aches, runny nose/tearing, GI upset, tremor, yawning, anxiety/irritability, gooseflesh skin) scored 0-48.

COWS guides medical timing for starting buprenorphine (induction usually waits for moderate withdrawal to avoid precipitated withdrawal). The CADC does not dose; the value is recognizing that a structured tool drives the medical decision.

Medications for opioid use disorder (MOUD) are evidence-based recovery pathways: methadone (full agonist, clinic-dispensed), buprenorphine (partial agonist, often combined with naloxone as Suboxone), and naltrexone (antagonist, including extended-release Vivitrol). The scope-aware exam answer treats MOUD as legitimate recovery — never as "not real recovery" — supports informed choice, and coordinates with qualified prescribers when releases allow.

Language and traps: use person-first language (person with opioid use disorder, return to use, medication treatment). Avoid stigmatizing terms. The biggest traps are (1) deciding whether medication is "allowed" — eligibility, prescribing, and dosing are outside CADC scope; and (2) framing abstinence-only as the only valid path. The counselor educates generally, refers, coordinates, and documents.

• Slow or absent breathing with pinpoint pupils is an overdose emergency.
• Naloxone 4 mg intranasal, repeat q2-3 min; expect possible re-narcotization.
• Withdrawal is distressing but rarely lethal; COWS (11 items, 0-48) grades it.
• MOUD (methadone, buprenorphine, naltrexone) is evidence-based recovery.
• Buprenorphine is started only after withdrawal has begun (guided by COWS) to avoid precipitated withdrawal.