3.2 Intoxication and Overdose

Why intoxication and overdose are counselor competencies

Task I.D.2 asks ADC candidates to recognize signs and symptoms of intoxication and overdose. Domain I remains 25% of the ADC Examination (ADC Candidate Guide, effective November 2022, checked 2026-09-20). This section is independent ADC study material by OpenExamPrep. It teaches class toxidromes—patterned clusters of vital signs, pupils, skin, and behavior—so a counselor can activate emergency care, give naloxone when trained and equipped, and speak accurately with nurses and emergency clinicians. OpenExamPrep does not claim IC&RC approval, partnership, or exact equivalence with IC&RC training.

Counselors are not the hospital code team. They are often the first trained person in a residence, group room, or lobby when breathing slows. Wrong pattern recognition kills: treating an opioid overdose as someone who just needs to sleep it off, treating stimulant hyperthermia as anxiety that will walk off, or demanding flumazenil for every suspected benzodiazepine pill.

Northbridge Recovery Center's Dana Ellis is covering evening groups when staff find Marcus slumped in a bathroom stall. She needs a toxidrome map, not a guess based on which substance he admitted at 9 a.m.

Toxidromes by class

A toxidrome is a recognizable syndrome produced by a drug class. Pupils and respiratory rate are the two fastest counselor observations; skin (wet versus dry), temperature, and mental status complete the picture.

Trap: deciding opioid from pinpoint pupils alone. Bright light, cholinergic agents, pontine injury, and some mixed overdoses also shrink pupils. The triad that should move Dana's feet is decreased consciousness plus respiratory depression plus miosis, especially with a known opioid history. Meperidine and some mixed ingestions can present without classic pinpoint pupils. Absence of miosis does not forbid naloxone when breathing is failing and opioids are plausible.

Opioid overdose: the triad, naloxone, and the clock

Opioid overdose kills by stopping ventilation. Carbon dioxide rises, oxygen falls, and the heart follows. Fentanyl and fentanyl analogs can collapse breathing within minutes; a client may still have a pulse while not moving air.

Immediate counselor actions, in order of survival:

1. Stimulate and shout; if there is no response and breathing is slow or absent, call emergency services.
2. Open the airway; provide rescue breathing or a bag-valve mask if trained; use the recovery position if vomiting is likely and the person is breathing.
3. Give naloxone if available (intranasal or injectable per the kit). Naloxone is a competitive mu antagonist. It can restore breathing within minutes.
4. Stay. Naloxone's clinical effect often lasts about 30–90 minutes. Many opioids, especially fentanyl and long-acting methadone or extended-release oxycodone, outlast that window. Recurrence of respiratory depression is expected; repeat doses are common.
5. Do not use cold showers, salt water, or walk it off. Do not leave the person to sleep.

After naloxone, some people wake angry or in precipitated withdrawal. That discomfort is not a reason to withhold a second dose if breathing slows again. Dana documents time of doses, response, and substances reported. She does not argue about wasting a kit.

Methadone and extended-release products need a longer observation plan than a single heroin injection. Polysubstance overdose (opioid plus alcohol or benzodiazepines) may only partly reverse with naloxone; the remaining sedative-hypnotic still depresses ventilation. Naloxone will not reverse alcohol.

Worked stall example: Marcus is unresponsive, pupils pinpoint, respirations about six per minute, lips dusky. Dana calls 911, gives intranasal naloxone, and starts rescue breaths. He stirs at two minutes, then nods again at forty minutes. That second drop is the 30–90 minute clock, not proof the first dose was fake.

Stimulant overdose: heat, heart, and seizures

Stimulant (sympathomimetic) overdose is a different emergency. Cocaine and methamphetamine flood catecholamines. The dangerous cluster is hyperthermia, tachyarrhythmia, severe hypertension, chest pain (ischemia or infarction), stroke, rhabdomyolysis, and seizures.

A client who smoked methamphetamine for 36 hours and now has a temperature of 104°F is not having a panic attack. Heat plus agitation plus muscle activity can cook muscle (rhabdomyolysis), wreck kidneys, and precipitate clotting disasters. Physical restraint in a hot, struggling person can worsen hyperthermia. Dana's job is emergency medical activation, a cooler quiet space if it does not delay EMS, and no amateur benzodiazepine from a pocket.

Medical teams often use benzodiazepines for stimulant agitation and seizures—that is a hospital decision. Counselors should not interpret that practice as permission to share a client's alprazolam in the lobby. Another trap: folklore beta blockers for cocaine chest pain. Unopposed alpha stimulation is a medical controversy counselors should leave to emergency clinicians rather than invent.

Stimulant intoxication that is not yet overdose still shows mydriasis, pressured speech, bruxism, delayed sleep, and risk-taking. Overdose is when temperature, rhythm, blood pressure, or seizures announce organ failure. Do not wait for a confession of how much was used if the body is already in that zone.

Alcohol poisoning

Alcohol poisoning is sedative-hypnotic overdose from ethanol. Signs include vomiting, stupor, cold clammy skin, slow or irregular breathing, hypothermia, and inability to wake. Aspiration of vomit is a classic killer. Hypoglycemia, especially in people with low glycogen stores, can mimic or worsen coma.

Dana does not let him sleep it off in a locked bedroom. She does not treat coffee, a cold shower, or walking as antidotes. She protects the airway by positioning, calls EMS when the person cannot be roused or is breathing poorly, and reports how much was consumed and over what time if known. Mixing alcohol with benzodiazepines or opioids converts a bad night into the synergistic depression taught in section 3.1.

A Northbridge family once asked whether a high blood alcohol concentration (BAC) number from a prior lab meant Marcus was safe at the same number tonight. Tolerance changes how drunk he looks, not whether aspiration and respiratory arrest can still happen. Appearance of sobriety is not a clearance for unmonitored sleep.

Benzodiazepine overdose and why flumazenil is not routine

Pure benzodiazepine overdose in an otherwise healthy adult is less often fatal than barbiturate or mixed overdose, because benzodiazepines have a flatter respiratory-depression curve when used alone. Combined with alcohol or opioids, that safety margin collapses.

Flumazenil is a competitive antagonist at the benzodiazepine site on GABA-A. In selected, closely monitored settings it can reverse iatrogenic benzodiazepine sedation. It is not routine in undifferentiated or mixed overdose for reasons ADC candidates should be able to state:

1. In people with benzodiazepine tolerance or dependence, sudden antagonism can precipitate seizures and acute withdrawal.
2. Co-ingestants that lower seizure threshold (for example, some antidepressants) can convulse once the benzodiazepine lid is removed.
3. Flumazenil does not reverse alcohol or opioids. In Marcus's vodka-plus-alprazolam-plus-oxycodone picture it would miss two of three depressants.
4. Its duration can be shorter than the benzodiazepine, so resedation occurs.

Standard care is airway, breathing, circulation, naloxone if opioids are possible, glucose if indicated, and supportive observation. Dana should not coach families to ask the emergency department for the benzo reversal shot as if it were naloxone for pills.

Scope: counselors recognize, activate EMS, use naloxone under program protocol, and document. They do not push flumazenil, physostigmine, or other antidotes.

Overdose traps

1. Leaving a snoring, unarousable person to sleep off opioids or alcohol.
2. Withholding naloxone because pupils are not pinpoint.
3. Treating stimulant hyperthermia as anxiety that will walk off.
4. Expecting flumazenil to fix mixed alcohol–benzodiazepine–opioid overdose.
5. Assuming one naloxone dose always lasts as long as fentanyl.
6. Counselors administering flumazenil or other antidotes outside license and protocol.