Do Overdoses Look Different Now?

The symptoms are the same, but the entire context has changed over the past few decades.

image of narcan near a hand
Illustration by Paul Spella / The Atlantic. Sources: Getty; Shutterstock.

Most likely, the person’s skin color will change. An ashy tone might creep in, or they could turn a shade of blue. If too much fluid pools in their mouth or lungs and mixes with air, foam will appear at their lips. There might be a sound, too—that of light snoring. These are some of the main symptoms of an overdose. Although the drug causing the reaction might be different, the symptoms look the same. “An overdose is an overdose,” Soma Snakeoil, a co-founder of the Sidewalk Project, a harm-reduction organization, told me.

But although overdose symptoms have not shifted, the ability to treat it has, most notably because of the availability of naloxone, the medication that can quickly reverse an overdose and that was approved in late March to be sold over the counter, as Narcan. This move happened at least in part because in the past few decades, the entire context of an overdose in the United States has changed. The U.S. has entered its fourth wave of the opioid crisis, and the death toll is different now: Overdoses have been steadily increasing for many years, but this wave, also known as the “era of overdoses,” has seen the highest number of fatal overdoses yet. “I think what makes this current crisis so unique is the volume” of overdoses, John Pamplin II, an epidemiologist at Columbia’s school of public health, told me. And that is happening because the drugs have changed too. “It’s not necessarily that more people are using drugs,” Emilie Bruzelius, an epidemiology researcher at Columbia’s school of public health, told me. “The opioids that people are using now are incredibly strong, and they’re more likely to cause an overdose.”

The result is that any person using drugs has a higher chance of overdosing than ever before. “There’s no population segment that is insulated,” Bruzelius said. “It’s really affecting everybody now.”

The origins of the opioid crisis can be traced back to 1999. As doctors prescribed opioids more and more—OxyContin prescriptions for non-cancer-related pain alone increased from about 670,000 in 1997 to 6.2 million in 2002—related deaths rose swiftly. In that same period, the number of deaths increased almost 30 percent, to nearly 9,000. This first wave largely affected white people: By 2010, the opioid mortality rate was more than two times higher for white people than Black people.

That year, a second wave began, in which overdose deaths involving heroin grew most dramatically. By 2015, heroin overdose deaths surpassed the number of deaths attributable to opioid pills. This time, the total opioid mortality rate grew for both Black and white populations; death rates increased by an average of at least 30 percent a year beginning in 2010, and accelerated even faster after 2013. In this same period, illicitly manufactured fentanyl—a synthetic opioid approved for pain relief—was being slipped into heroin, counterfeit pills, cocaine, and other drugs. Many of the people taking these drugs did not realize that they were taking fentanyl at all, leading to a third wave of overdoses. Mortality skyrocketed. In 2017, synthetic opioids were responsible for more than 28,000 deaths, while opioid-pill and heroin overdose deaths had leveled off at about 15,000. The demographics of the crisis continued to shift too, and in 2020, the fastest increases in death rates was experienced by Black and Indigenous Americans, surpassing the death rate of white Americans, Pamplin told me.

The new, fourth wave is characterized by more mixing of different drugs. “People are overdosing from cocaine and fentanyl or methamphetamines and fentanyl or methamphetamines and fentanyl and heroin,” Bruzelius told me. Recently, xylazine—a non-opiate sedative also known as “tranq”—has infiltrated the fentanyl supply, resulting in what the DEA has deemed the deadliest threat yet.

This is the context in which the FDA approved Narcan to be sold over the counter. Narcan packages naloxone as a nasal spray, and the FDA argued that its approval could “help improve access to naloxone, increase the number of locations where it’s available, and help reduce overdose deaths throughout the country.” By binding to opioid receptors, naloxone blocks the effects of opiates in the system. This reverses the impact of an overdose, restoring normal breathing.

But drug policies in America tend to swing, pendulum-like, from one extreme to the other, David Courtwright, a historian at the University of North Florida, told me: A response focused on care for drug users might give way to a more punitive policy. Already, some critics of Narcan’s availability have pushed to restrict its use on the grounds that an effective overdose treatment could encourage drug use—even though there’s “just no kind of scientific or empirical backing” for those arguments, Bruzelius said. Here, the simplest logic holds: If overdoses are affecting every community in America, better to have an accessible treatment everywhere.