Opiate Overdose, Consciousness & Respiratory Depression

[Ektor]

There is a question that i think very important for harm reduction when regarding opioids.

Short question: Is it possible to overdose on opioids to a level that stops breathing and still remain conscious?

This question arises from my opioid (ab)use. I, as maybe many other opioid users, have experienced situations that while on strong doses of some opioid you feel your breathing rate is greatly diminished, breath is shallow and not deep at all, and you have the sensation that if you pass out or fall asleep your breathing will stop, maybe even the feeling that you could stop breathing just if you stop thinking about it.

Is this feeling sensible? Is the required level of mu-receptor activation the same for serious respiratory depression and for passing out?
I wander if there is a difference between tolerant and non tolerant individuals, maybe tolerance to different effects develops at a different rate, and if so which effect is more susceptible to tolerance, respiratory depression or sedation?

Of course if you really stop breathing you WILL pass out, but if you are still conscious passing out after stopping to breathe would require a state where you would HAVE TO think bout breathing to continue breathing and not pass out consequentially. But i have to say this state is pretty uncommon(at least never happened to me) and i would even assume it is also impossible, because even if sometimes you have the feeling of not being able to breathe and breathing rate is crazy down you will continue breathing when you think bout something else.

So other 2 questions arise:

When you reach a level of great breathing inhibition while awake can your breathing stop if you pass out?

How dangerous is having a depressed BUT NOT STOPPED breathing and is there an easily tellable safety margin before respiratory depression becomes dangerous (for example: if i'm ok when i'm awake i'll be ok even sleeping)?

Thanks very much for your attention and sorry for the length of this post!!


peace

Edit: sorry i didnt find initially that there was another post like this in the archive, but after reading that i realize this post is still useful cause it would be interesting to know better if is possible to have serious dangerous respiratory depression without before passing out or even(for a tolerant individual) without feeling too much sedated/high, as its obvious you will pass out AFTER you stop breathing. Sorry for my confusion...

 

[Swimmingdancer]

This is a very good question and something that is relevant to a lot of posts we get from people who are afraid to go to sleep while on opioids.

I have not yet been able to find a definitive answer, but I have never personally seen or heard of anyone actually stop breathing from an opioid overdose before losing consciousness. Although I guess it can be very hard to know for sure because people with opioid ODs are just found unconscious and barely breathing or not breathing at all, so who knows exactly what order things happened in. I know when I've actually OD'd all I remembered was falling asleep, I had no recollection of an awareness of difficulty breathing prior to passing out. And if you go long enough without breathing you are going to pass out regardless.

You are right that tolerance to different effects of opioids can develop at different rates. Tolerance to euphoria can happen before tolerance to respiratory depression for example. I'm not sure about tolerance to sedation. But serious respiratory depression would likely make you pass out before you actually went into respiratory arrest.

It is quite common to, as you said, "feel your breathing rate is greatly diminished, breath is shallow and not deep at all, and you have the sensation that if you pass out or fall asleep your breathing will stop, maybe even the feeling that you could stop breathing just if you stop thinking about it". It is often just a heightened awareness of the fact that you are breathing more shallowly and/or slowly than normal, which causes anxiety. It's especially noticeable if you are lying on your back in bed trying to go to sleep. Then you start getting paranoid about falling asleep, wondering if the respiratory depression will get worse in your sleep or wondering if you stay awake you can somehow force yourself to keep breathing or call for help in time.

I really don't think trying to force oneself to stay awake is going to make a difference, but if respiratory depression is significant it's best to get help or at least get someone to watch over you and check to make sure you stay breathing so they can call emergency if need be.

As to ways to know whether or not you need medical assistance or whether or not it's safe to go to sleep, that really depends on the opioid you've taken, the ROA, and whether or not you've taken any other drugs.

For example, an OD on IV heroin when no other drugs are taken is going to happen very quickly, and you don't see it coming or have time to call 911, you just pass out and stop breathing. That's why it's so important not to inject heroin alone. If it's been over 30 min since you injected the heroin and you are still conscious and breathing and didn't take any other drugs (or didn't miss a huge shot or something) I'd assume you're not at much risk of stopping breathing.

An oral methadone overdose, on the other hand, can take a very long time to come on, the respiratory depression can peak after the "high", and often people seem ok, go to bed and don't wake up. Methadone also builds up in the system so even if a person took the same dose multiple days in a row (aside from someone who is on MMT and already stabilized on that dose), they can OD.

ODs on other long-acting or ER opioids can have later onsets for respiratory arrest as well.

Adding other drugs/alcohol into the mix makes things much more complicated of course.

I don't think a state where you HAVE to consciously breathe and if you don't think about breathing you will stop breathing is actually possible, it can just feel that way. If you're going to stop breathing it's going to happen, breathing is an automatic function and if your body can't over-ride the respiratory depression to breathe your mind presumably can't.

I will keep doing more research and asking more doctors about this matter, because it would be really good to know for sure what to tell someone when they are afraid they might stop breathing if they go to sleep - is going to sleep going to make them any more likely to stop breathing? and if they stay awake would they be able to call for help themselves? how can they know when it's time to call help, etc?

Best solution is to always err on the side of caution with doses and not use alone (the other person doesn't have to be using, I just mean that someone is around who would notice if you were unresponsive and/or not breathing).

(sorry my post is so long too, just trying to be thorough)

 

[Mr.Scagnattie]

In my experience, based on my own OD's and being around friends who have overdosed... you are not conscious of the changes happening to your body.. a real overdose, one where you're going to drop and need to be taken out of your unconscious state, isn't something you can control or recognize. It just happens. You're not thinking.."oh shit I'm going to stop breathing soon". You just stop breathing and pass out. If you are that aware of your psychical and mental state, chances are you are not overdosing. Again, that's just going on my own experiences and what I've seen happen. I have seen many overdoses and those it's happening to are in no way aware or responsive, certainly not to the degree of being able to notice a problem before it happens.

This is why OD's are so dangerous if you are not with somebody else.. because you alone can not be relied upon to recognize the signs of an OD before they happen... you just go from being awake and fine to unconscious and waking up in an ambulance or to your friend smacking you in the face.

 

[Pagey]

I agree with mr.scagnattie - you don't realize you're actually overdosing. I actually did sort of experience what you're asking but it was on a benzo + alcohol combination. My breathing was getting really, reaaaally slow and all of a sudden I just stopped. I wasn't really aware of it until I started feeling extremely lightheaded, I took a huge gulp of air and I passed out shortly after that. I think somewhere in the back of my brain I was vaguely conscious that I was overdosing but not enough to do anything about it.
I've only OD'ed once on opiates and I passed out before noticing anything.

 

[blight12]

Great post! This makes we wonder if by staying awake or keeping somebody awake it could help prevent danger or death similar to how they say to keep those with a concussion awake?

As if conscious effort to breath is far more effective then your unconcious taking over after you have fallen asleep.

I would also be interested at how long would it take for you to know you are likely safe after nasal Heroin usage? As per swimmingD's estimates per IV, oral etc.

Interesting.

 

[Mr.Scagnattie]

Great post! This makes we wonder if by staying awake or keeping somebody awake it could help prevent danger or death similar to how they say to keep those with a concussion awake?

As if conscious effort to breath is far more effective then your unconcious taking over after you have fallen asleep.

Interesting.

Yes. Keeping somebody awake can definitely go a long way.. however, if it's really bad.. unfortunately nothing you can do is going to keep them conscious and aware. There are varying levels to overdoses. Some happen where with a good friend nearby, slapping you in the face, talking to you, giving you pain stimuli, etc.. you will come out of it or perhaps never pass out to begin with. However, there are other OD's that happen so fast.. they just go from awake one second to down and out the next where nothing you do will bring them around.

 

[blight12]

I agree with mr.scagnattie - you don't realize you're actually overdosing. I actually did sort of experience what you're asking but it was on a benzo + alcohol combination. My breathing was getting really, reaaaally slow and all of a sudden I just stopped. I wasn't really aware of it until I started feeling extremely lightheaded, I took a huge gulp of air and I passed out shortly after that. I think somewhere in the back of my brain I was vaguely conscious that I was overdosing but not enough to do anything about it.
I've only OD'ed once on opiates and I passed out before noticing anything.

Did the above benzo/alc experience actually turn out to be a real OD and how did you survive it or was this an example of perceiving resp dep but not actually OD'ing? Thanks!

 

[blight12]

Yes. Keeping somebody awake can definitely go a long way.. however, if it's really bad.. unfortunately nothing you can do is going to keep them conscious and aware. There are varying levels to overdoses. Some happen where with a good friend nearby, slapping you in the face, talking to you, giving you pain stimuli, etc.. you will come out of it or perhaps never pass out to begin with. However, there are other OD's that happen so fast.. they just go from awake one second to down and out the next where nothing you do will bring them around.

Cool ok. I read many posts here about how ROA of H via nasal might be more dangerous then IV since it takes longer to know you are safe and thus dose more. An interesting alternative perspective over the usual about how IV is more dangerous due to the usual details.

Thing is i am STILL trying to determine a way to know if my dosage of nasal H is safe or not without any previous opiate experience.
I end up being overly careful or freaking out when nodding which might be me passing out and dying? How do i know.
As a big long time stimulant user its easy to tell to much with stims, but with opiates, when its to much, you wont even realize it.
This is really difficult to work with ffs.

Another relevant question. Could you save somebody from an opiate OD by shooting them up with meth or another stim?

 

[Pagey]

Did the above benzo/alc experience actually turn out to be a real OD and how did you survive it or was this an example of perceiving resp dep but not actually OD'ing? Thanks!

I think it probably was a real OD as I was then passed out for about 35 hours and I woke up having vomitted everywhere (charming I know). Just not a fatal one luckily

As for the meth/stim question I don't know, but I would recommend keeping Naloxone around just in case. It's not too difficult to get hold of and that's what they use in the ER to counter opiate overdoses.

 

[Mr.Scagnattie]

Cool ok. I read many posts here about how ROA of H via nasal might be more dangerous then IV since it takes longer to know you are safe and thus dose more. An interesting alternative perspective over the usual about how IV is more dangerous due to the usual details.

Thing is i am STILL trying to determine a way to know if my dosage of nasal H is safe or not without any previous opiate experience.
I end up being overly careful or freaking out when nodding which might be me passing out and dying? How do i know.
As a big long time stimulant user its easy to tell to much with stims, but with opiates, when its to much, you wont even realize it.
This is really difficult to work with ffs.

Another relevant question. Could you save somebody from an opiate OD by shooting them up with meth or another stim?

The only way to figure out the proper dosage is to start incredibly slow and cautiously increase your dose until you get to where you want to be. For the first few times of using, keep it to as small an amount as you can until your body becomes more used to it.

As far as bringing people out of an OD via stimulants.. yes it is possible though not always guaranteed to work. I've brought friends back to consciousness with IV cocaine multiple times. It all depends on how serious their overdose is and how much dope in their blood you have to contend with. For some OD's, narcan is the only way to bring them out.. but if you don' have that and regular means aren't working.. an injection of a strong stimulant could do the trick. Of course, you need to know what you are doing as far as dosing it out, proper injection technique, etc.. or you could just make it worse.

 

[Jabberwocky]

from my experience with ODing on opiates - yes you can enter this state. in fact i just entered a similar state a few minutes ago from dosing .5mg of xanax while i already had 160mg of oxy inside of me + some clonaz from this morning. luckilly i was taking it sublingually and could spit it out (well most of the rest of it) and now i just feel a little drowsy. i could actively feel my breathing getting slower and slower.

the other time i OD'ed i physically noticed my breathing getting super shallow, to the point where i could hardly even breathe anymore. i then managed to swallow down 20mg of dexedrine and i could feel my heart rate getting faster and it made it easier to breathe. before i took the dexedrine, i could actively realise and notice my breathing getting more and more shallow it was horrifying. i was just sinking into the couch unable to breathe properly - and wasnt really sure to be honest as to what was going on. i was slipping away from consciousness, and life, and swallowed the tabs in desperation - saving my life.

they say normally that by taking a stimulant you'll do yourself worse and end up in a worse position..... but i dunno, maybe i got lucky that time. but it definaely saved my life thats for sure

 

[BurroughsTheCat]

^ good insight to this, and glad you are all right. Lucky you had the stims there. But as a previous poster said, having some Narcan around can be the diiference between life and death. 2 times I overdosed and ended up in hospital the needle was still in my arm, the 3rd time I had taken it out, but I hadn't let go of the tie around my arm, so thats why it took a few seconds to hit me.
I have been off my face a good few times where I was struggling to breathe. Not choking, but like having to make a conscious effort to breathe for a few minutes. I was up all night banging heroin and Fentanyl (extracted from patches...not CONDONING IT!!!) and was at the stage where I was falling asleep and snapping awake with like 30 mins passed...anyway I was doing that and finding it hard to breathe, really had to put my mind to it to take steady deep breathes and shake the constricting feeling from my chest. It wasn't nice.
Overdosing is scary because you just have no clue it is happening 99% of the time. It reminds me of falling asleep,you never know the second it happens...it just happens...then you wake up. Or not if you are not lucky.

 

[Swimmingdancer]

In my experience, based on my own OD's and being around friends who have overdosed... you are not conscious of the changes happening to your body.. a real overdose, one where you're going to drop and need to be taken out of your unconscious state, isn't something you can control or recognize. It just happens. You're not thinking.."oh shit I'm going to stop breathing soon". You just stop breathing and pass out. If you are that aware of your psychical and mental state, chances are you are not overdosing. Again, that's just going on my own experiences and what I've seen happen. I have seen many overdoses and those it's happening to are in no way aware or responsive, certainly not to the degree of being able to notice a problem before it happens.

This is why OD's are so dangerous if you are not with somebody else.. because you alone can not be relied upon to recognize the signs of an OD before they happen... you just go from being awake and fine to unconscious and waking up in an ambulance or to your friend smacking you in the face.

^This. Especially if it's something like IV heroin, you're not going to be able to save yourself.

Great post! This makes we wonder if by staying awake or keeping somebody awake it could help prevent danger or death similar to how they say to keep those with a concussion awake?

Actually it's a myth that you need to keep someone awake when they've had a concussion. Someone with a concussion should be monitored for the first few hours, so as to determine the severity and whether or not they have more serious injuries. If it is so bad that they are unconscious and unresponsive (unable to wake up) they need medical attention of course. But beyond that, it is not necessary to prevent them from going to sleep. In fact, many doctors now suggest that rest/sleep is very important for someone who has had a concussion. It has nothing to do with a risk of stopping breathing if they go to sleep. [here's a source]

As if conscious effort to breath is far more effective then your unconcious taking over after you have fallen asleep.

This is a good question and the crux of the topic of this thread. I will ask more doctors if they know if conscious breathing is any more effective than unconscious breathing.

I would also be interested at how long would it take for you to know you are likely safe after nasal Heroin usage?

For intranasal use, it looks like it can take up to 90 min for all the active metabolites (6-MAM, morphine) to peak in the blood, but I'm not quite sure after how long one would be able to assume that respiratory depression likely can't get any worse and one would be safe if they were still conscious and breathing.

Yes. Keeping somebody awake can definitely go a long way.. however, if it's really bad.. unfortunately nothing you can do is going to keep them conscious and aware. There are varying levels to overdoses. Some happen where with a good friend nearby, slapping you in the face, talking to you, giving you pain stimuli, etc.. you will come out of it or perhaps never pass out to begin with. However, there are other OD's that happen so fast.. they just go from awake one second to down and out the next where nothing you do will bring them around.

Yeah, we are talking more about ODs severe enough to cause respiratory arrest. Slapping or talking to someone is not likely to prevent that. Also we are talking about what to do when you are alone and awake and have a heightened awareness of your breathing being shallow.

Could you save somebody from an opiate OD by shooting them up with meth or another stim?

This is not a good idea for a number of reasons that have been discussed elsewhere on Bluelight. Always call emergency. The first-line treatment for an opioid overdose is actually administering oxygen. In fact many people are able to respond to oxygen alone and don't end up requiring Narcan. It's really best to leave it up to the professionals (assuming they can get there in time, I realize response time can vary from place to place), but having some oxygen and Narcan (naloxone) on hand is a much better idea than injecting someone with amphetamines. In some places you can actually go take a brief class to learn how to administer Narcan in an OD and get a supply of Narcan. I know there was a program like this in NY, for example.

 

[BurroughsTheCat]

I saw on the news that they are bringing out a nasally administered dose of Narcan for people that wouldn't be able to use a needle in emergency situations. That was a story a month ago or so on a program in America so I'm sure you guys know more than me about it. it would be great if it was de-regulated in some way that more people had access to one of them. It would save so many lives. I've heard that Narcan isn't hard to get over there anyway (I got mine from a friend-of-a-friend that is a nurse)
A friend injected his girlfriend that was Oding with an Epipen...one he has for allergic reactions to bee stings...just in the fleshy part of her upper leg with an auto injector. By the time the ambulance got there he said she was wide awake and there wasn't a bother on her. That could be just luck, but he said it worked. So the stimulants are probably better than nothing.
I often wondered if injecting a dose of Buprenorphine would bring someone around. Forget the Naloxone in Suboxone, the Buprenorphine has a higher binding affinity, and obviously a much higher one than morphine, so theoretically if IVed the bupe would strip plenty of the morphine off the receptor sites and replace it...bringing the person out of it.

 

[Swimmingdancer]

There are many threads on the topics of possible drugs to administer in an opioid overdose:

Thread: Using Suboxone like Narcan?
Suboxone/buprenorphine might work, since it is a lot harder to overdose from buprenorphine than other opioids, so theoretically the bupe might knock the other opioid off the receptors yet hopefully still not cause an OD itself (might be worth checking if bupe has a higher binding affinity that all other opioids or just the most widely-used ones).

The problem is that even if some of these things might help it is very important to still call emergency.

While conceivably meth, cocaine, or epinephrine could be used to treat some opioid overdoses, each of these drugs has a significant chance of doing more harm than good. In addition, about 2/3 of opioid overdoses involve a mixture of drugs, can you be sure of what someone has taken? Unlike stimulants, however, naloxone (Narcan) isn't going to do harm and is going to be far more effective.

Stimulants such as cocaine, meth, amphetamines - I don't think are a good idea, for a number of reasons. One reason is that you could give someone a stimulant overdose. Respiratory depression can actually be an effect of a cocaine overdose for example, so it could potentially worsen the OD. Or there could be other complications from the mixing of stims/opioids. Another reason, they can last a shorter amount of time, so someone would still need medical attention in case when the stimulant worse off they slipped back into OD, and I worry that if someone was giving a stimulant and then seemed ok they would not get that medical attention.

Epinephrine (aka adrenaline), the ingredient in an Epi-Pen is NOT going to treat a serious OD. If someone is just really sedated it could wake them up, that's probably what happened with your friend. Epinephrine is used in a medical setting for cardiac arrest to get the heart beating again, but the risk of an opioid overdose is respiratory depression, which leads to respiratory arrest, which if untreated finally leads to cardiac arrest. A real life-threatening OD needs to be treated with something that strips the opioid from the receptors, that scene from Pulp Fiction where John Travolta shoots epinephrine into Uma Thurman's heart and she wakes up and is then fine, while dramatic, is false.

The best solution is really to just call 911 (or whatever one's local emergency number is), unless you have oxygen and/or naloxone on hand and know how to administer them, and even then you should still definitely call 911.

 

[Ektor]

Wow!! what a beautiful discussion has emerged from this thread! Swimmingdancer you have been so exhaustive, i'm totally proud of the powers of the net!
i guess we should rather ask a doctor, even better an anesthesiologist or someone like that to know for sure if shallow breath can stop when passing out and what is the tolerance rate to respiratory depression.
So, THANK YOU INFINITY GUYS!!!!!!!
YOU HEVE BEEN GRAET!

 

[Captain.Heroin]

Another relevant question. Could you save somebody from an opiate OD by shooting them up with meth or another stim?

No; it's easy to overdose fatally by combining stimulants and heroin/opiates.

PLEASE only inject people overdosing on opiates with Naloxone also known as Narcan.

I have several vials of the stuff that I got for free, just in case me or anyone else is overdosing on an opiate. I don't even use full agonist opiates anymore; but if I was going to, I would only do it if I was at home with my naloxone (prescribed). You won't have a long time to administer it to yourself if you do overdose, so you don't have spare time to go looking for it.

You can administer air to them if you think it will help as the moderator said above, but I wouldn't - if they are seizing or are black/blue in the face, or 100% unresponsive and are not responding to you shoving them back and forth... it's clear that they'll need the naloxone. I actually personally know someone who went into seizures and 100% unresponsiveness following a single shot of tar heroin.

 

[ryohazuki]

Just two nights ago I had my first nodding dose, IVd 10mg of oxymorphone with zero tolerance, plus I'm like 140lb. I felt my breath getting shallow, and as I was nodding I tried to stay awake. I was afraid of completely nodding out because a long time ago my brother told me falling asleep could kill me, so I fought the nod a bit and manually tried to breathe. After I puked the 2nd time, the next 8 hours I had a horrible headache (opiate hangover?), at first it might've been dehydration but now I think it eventually became intracranial pressure due to respiratory depression, because no matter how much water I drank the headache wouldn't go away.

The hypoventilation associated with administration of opiate agonists, particularly by the intravenous route, can induce cerebral hypoxia and vasodilatation with resultant increase in intracranial pressure

So now I found this thread wondering if I had nearly scathed death or just killed my trip by being paranoid... lol. Next time I try to nod out into eternal internal bliss I'll have someone working an ambu bag over me. heh heh

Did anybody find out if it is reasonable to try to stay awake when noticing your breathing is shallow?

 

[Psychedelic Jay]

You were just more fucked up than normal...

It seems scary at first, but I think you were just too thoughtful of the whole thing. That's what scared you.

 

[Wackyzeb]

Falling asleep further depresses your breathing..
Even while not on any drugs and one falls asleep, their breathing slows...
So if you're experiencing shortness of breath already, falling asleep is only going to make it worse.