Many people abusing opioids experience “nodding,” a symptom of severe drowsiness resembling a person falling into a deep sleep, but really falling into a semiconscious state after taking drugs (commonly opioids like heroin or fentanyl). Nodding off is a dangerous, often involuntary, condition characterized by the head nodding forward while the person drifts between consciousness and sleep. Nodding may indicate a severe lack of oxygen and an excess of carbon dioxide preceding an overdose. New brain imaging data suggest that nodding could be contributing to damage in oxygen-sensitive brain areas. It’s important to know that opioid-overdose-related brain injuries resemble global hypoxic–ischemic brain injury, the same injury class seen after near-drowning, choking/asphyxiation, or cardiac arrest. All are primarily oxygen deprivation injuries.

Drug overdose deaths have dropped significantly, but remain unacceptably high. Interruptions in the drug supply chain and increased availability of naloxone for reversing overdoses have been major factors in progress. But for every fatal drug overdose, there are many more often ignored, non-fatal overdoses, and their immediate as well as cumulative effects are very dangerous. Opioid misuse and addiction, with and without overdoses, damage important memory centers in the brain. “On the nod” often represents subclinical overdose, and repeated episodes may contribute to cognitive impairment, neurocognitive consequences of repeated opioid-related hypoxia, cardiac arrhythmias, and brain injury anoxia, especially with fentanyl.

We know many overdoses aren’t reported, whether the rescued person overdosed at home or elsewhere, and took naloxone. In 2023, U.S. pharmacies dispensed 2.1-plus million naloxone prescriptions, a significant increase from earlier years (1.7 million in 2022).

According to Casillas et al., from 2010 through 2020, there was approximately one fatal overdose per 15 non-fatal overdoses. Thus, if roughly 80,000 people died annually from overdoses, total overdoses (fatal non-fatal) likely exceeded 1 million annually.

The nodding individual appears deeply asleep: The head droops forward, eyes close halfway, speech slows or trails off, and the body becomes slack and heavy. A person may briefly respond to their name or a touch, fading into silence moments later. Someone who arouses briefly but immediately nods off is not “safe.” Emergency medicine providers don’t and........

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