Quick Summary
If you are worried that someone you love is misusing opioids, you are not alone. NIDA says about 5.7 million people in the United States had opioid use disorder in 2023. The signs usually show up as a pattern across physical effects, changes in behavior and how the person uses their medication or other opioids. No single sign proves anything. These changes can have many causes, including medication side effects or other health conditions, and only a clinician can diagnose opioid use disorder. This guide covers what to look for, what overdose looks like, how to keep naloxone on hand and how to start a caring conversation.
Key Takeaways
- NIDA lists drowsiness, confusion, nausea, constipation and slowed breathing among the effects of prescription opioids.
- Misuse includes taking a medicine in a way or dose other than prescribed, taking someone else’s prescription or taking it to get high.
- Opioid use disorder is diagnosed when a person shows a pattern of two or more symptoms from a list of 11 in the DSM-5.
- Overdose signs include not waking up, slow or stopped breathing, purplish lips or nails and pinpoint pupils. Call 911 and give naloxone if you have it.
- The FDA approved the first over-the-counter naloxone nasal spray in 2023, so families can keep it at home without a prescription.
Opioid misuse can be hard to spot. A person can keep going to work, show up for family dinners and seem mostly fine while things are getting worse underneath. It may start with a prescription after an injury or surgery. It may involve pills bought from someone else, heroin or fentanyl. Either way, the people closest to them often notice something is off before anyone says it out loud.
This guide is meant to help you make sense of what you are seeing. It is not a way to diagnose someone. The information comes from the National Institute on Drug Abuse (NIDA), the U.S. Food and Drug Administration (FDA) and SAMHSA.
What Opioid Misuse Means
Opioids include prescription pain relievers like oxycodone, hydrocodone, morphine and codeine, along with fentanyl and heroin. NIDA’s Prescription Opioids DrugFacts says prescription opioids “are generally safe when taken for a short time and as prescribed by a doctor, but they can be misused.” It lists three kinds of misuse:
- Taking the medicine “in a way or dose other than prescribed”
- Taking “someone else’s prescription medicine”
- Taking the medicine “for the effect it causes-to get high”
NIDA adds that some people crush pills, open capsules, snort the powder or dissolve it and inject it. Our page on opioid addiction treatment has more background.
Physical Signs Worth Noticing
NIDA says people who use prescription opioids “can feel relaxed and happy, but also experience drowsiness, confusion, nausea, constipation, and slowed breathing.” NIDA describes these effects for prescription opioids. Heroin and illicit fentanyl carry extra risk because they can be stronger than expected or mixed with other drugs. With heavier or ongoing use, you might notice:
- Nodding off or seeming sedated at odd times, like mid-conversation or at the dinner table
- Seeming confused, foggy or slow to respond
- Ongoing constipation or nausea
- Changes in sleep, appetite or weight
- Signs of withdrawal when they go without, which NIDA describes as “muscle aches, abdominal cramps, agitation, anxiety, nausea and vomiting, chills, diarrhea, and more”
Withdrawal is an important clue. NIDA’s opioids research page explains that “people may continue to use opioids to avoid withdrawal symptoms.” Someone who seems sick or irritable in the morning and fine after a trip to the bathroom or the car may be managing withdrawal.
Behavior and Pattern Changes
Behavior changes are often what families notice first. Common ones include:
- Running out of a prescription early, or “losing” pills and needing refills
- Seeing more than one doctor for pain medication
- Pills missing from your medicine cabinet or a relative’s
- Asking to borrow money, unexplained spending or missing valuables
- Secrecy about where they are, who they are with or their phone
- Pulling away from family, friends or activities they used to enjoy
- Falling behind at work or school
- Defensiveness or anger when medication or drug use comes up
Any of these can have other causes. What matters is a pattern that keeps building over weeks or months. If stimulants could also be involved, our post on signs someone is using meth covers those signs.
What the Diagnostic Criteria Say
NIDA explains that a person diagnosed with opioid use disorder “has a pattern of two or more symptoms and behaviors related to their substance use.” The DSM-5, which clinicians use to diagnose substance use disorders, lists these 11:
- Consuming the drug in larger amounts or for longer than intended
- Persistently wanting to cut down or regulate drug use
- Spending a great deal of time obtaining, using or recovering from the effects of the drug
- Experiencing a strong desire to use the drug (craving)
- Failing to fulfill major obligations at work, school or home because of drug use
- Continuing drug use even if it causes significant social or interpersonal problems
- Reducing or stopping other activities because of drug use
- Repeatedly using the drug in situations when it is unsafe
- Continuing drug use even when knowing that it causes physical or psychological problems
- Developing tolerance
- Experiencing withdrawal symptoms when stopping drug use
One note: NIDA says tolerance “can also occur with prescription opioids, even when taken as prescribed by a health care provider.” Tolerance by itself does not mean someone has opioid use disorder. Health professionals look at withdrawal, tolerance and other factors together, so a clinician has to see the whole picture. You cannot make this call from the outside, and you do not need to. Your job is to notice and to help them get assessed.
If opioids are in the house, keep naloxone there too and learn how to use it. That isn’t giving up on someone or approving of their use. It’s like keeping a fire extinguisher in the kitchen.
Donnita Smart, LCDC
We’re here to make treatment as accessible and affordable as possible — and are in network with many insurance providers. Not sure about your coverage? We can help.
Signs of an Opioid Overdose
An overdose is a medical emergency. NIDA lists these signs:
- Unconsciousness or inability to wake up
- Slow or shallow breathing or difficulty breathing
- Discolored, purplish skin, especially the nails or lips
- Small, constricted “pinpoint” pupils that do not react to light
If you see these signs, call 911 right away and follow the dispatcher’s instructions. Give naloxone if you have it, try to keep the person awake and breathing, and stay with them until help arrives. These signs can have other medical causes, but if opioids could be involved, treat it as an emergency. Our post on overdose signs goes into more detail, and our post on the Texas Good Samaritan law explains what to know about calling 911 for an overdose.
Overdose risk is not only about how much someone takes. NIDA warns that “people can overdose without knowing that they have taken dangerously high opioid doses,” because fentanyl can be mixed into or sold as other drugs, including counterfeit pills. Mixing opioids with alcohol, sedatives or other drugs also raises the risk. Our post on the risks of mixing drugs covers that.
Keep Naloxone on Hand
Naloxone is a medicine that can reverse an opioid overdose. NIDA says it “can treat an opioid overdose when given right away” and that friends, family and others in the community can use the nasal spray versions. On March 29, 2023, the FDA approved the first over-the-counter naloxone nasal spray, Narcan 4 mg, for use without a prescription. NIDA’s opioids page now notes that “naloxone is available over the counter, without a prescription.”
If you are worried about someone, keep naloxone where people can find it, tell other family members where it is and read the instructions before you ever need them. Our post on fentanyl test strips covers another tool some families learn about.
How to Start the Conversation
Talking to someone about their opioid use is hard, and it may take more than one conversation. SAMHSA’s guide on how to talk to someone about help recommends that you “listen without judgment and speak with kindness,” and notes that “it may take many conversations before they get help.” Some tips from SAMHSA and from experience:
- Pick a calm time when they are not high, in withdrawal or in the middle of an argument.
- Start with care and with specific things you have noticed, not labels.
- Ask open-ended questions. SAMHSA gives examples like “How would you like things to be different?”
- Repeat back what you hear so they feel understood.
- If they do not want to talk, let them know you will be there when they are ready.
Here is one example of how to open: “I’ve noticed you’ve been really tired lately and your prescription seems to be running out early. I love you and I’m worried. Can we talk about what’s going on?”
Start with what you’ve actually seen, like missed work or pills running out early, instead of labels. “I’ve noticed” lands a lot better than “you’re an addict.” The point of the first talk is just to keep the door open.
Donnita Smart, LCDC
It is also important to take care of yourself. Worrying about someone you love is exhausting, and it is not your fault. Our posts on why it’s not your fault and Al-Anon vs. Nar-Anon can help.
Opioid Use Disorder Is Treatable
NIDA calls opioid use disorder “a treatable chronic medical condition,” and says treatment options include medications and behavioral therapy. The FDA-approved medications are methadone, buprenorphine and naltrexone, and NIDA’s page on medications for opioid use disorder explains how each works. NIDA says these medications “can reduce the risk of return to drug use and of overdose death.” Our post on Suboxone vs. methadone compares two of them.
Care can also include medical support during withdrawal, followed by levels of care like residential treatment or an intensive outpatient program. Our page on opioid detox explains what that first step can involve. Withdrawal care is a starting point, not the whole treatment. NIDA’s Principles of Drug Addiction Treatment says medically assisted detoxification “is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.” The right fit depends on the person, and a clinician can help sort that out.
When to Reach Out for Help
Reach out to a doctor, counselor or treatment provider soon if:
- Your loved one is running out of prescriptions early or getting opioids from other sources
- They seem sedated, confused or “nodding off” often
- They show signs of withdrawal when they go without
- They have overdosed before, even once
- Opioids are being mixed with alcohol, sedatives or other drugs
If you or someone you know is in emotional crisis, call or text 988. If anyone is in immediate danger or cannot stay safe, call 911 or go to an emergency department. If someone has stopped breathing, cannot be woken or may have overdosed, call 911, give naloxone if available, and stay with the person until help arrives. Alcohol and sedative withdrawal can be dangerous, so anyone who has been drinking heavily or using sedatives regularly should not stop suddenly without medical advice. Medical support can ease opioid withdrawal, but withdrawal care alone does not treat opioid use disorder. Tolerance drops after time without opioids, so going back to a previous amount can raise the risk of overdose.
Talking With a Professional
If the signs are adding up, an assessment is the clearest next step. A clinician can look at the whole picture, including pain conditions, other medications and mental health, and recommend a level of care. It helps to write down what you have noticed and when, any medications involved and any past overdoses. The admissions team at Discovery Point Retreat can explain what an assessment involves. Ask which services are currently available and which level of care might fit where your loved one is now.
Frequently Asked Questions
What are the first signs of opioid misuse?
Early signs often include drowsiness, seeming foggy, constipation, running out of prescriptions early and pulling away from family or activities. No single sign proves misuse, so look for a pattern over time.
Can someone be addicted to opioids if they have a prescription?
Yes. A prescription does not rule out opioid use disorder, especially if the person takes more than prescribed or for reasons other than pain. Tolerance can happen even with prescribed use and does not by itself mean opioid use disorder, so a clinician needs to assess the whole picture.
Do pinpoint pupils always mean opioid use?
No. Pupils can change for other reasons, including some medications and lighting. NIDA lists pinpoint pupils that do not react to light as one sign of overdose when they appear along with other signs like slow breathing and not waking up.
Where can I get naloxone?
Naloxone nasal spray is available over the counter, without a prescription, at many pharmacies. Some local health departments and community programs also offer it.
What if they deny there is a problem?
That is common. SAMHSA notes that it may take many conversations before someone gets help. Stay calm, keep sharing what you have noticed and let them know you will be there when they are ready.
How is opioid use disorder treated?
Treatment can include medications like methadone, buprenorphine or naltrexone, along with behavioral therapy and different levels of care. A clinician can recommend what fits.
References
- National Institute on Drug Abuse (NIDA). Opioids. Accessed October 2026. nida.nih.gov
- NIDA. Prescription Opioids DrugFacts. Accessed October 2026. nida.nih.gov
- NIDA. Medications for Opioid Use Disorder. Accessed October 2026. nida.nih.gov
- NIDA. Principles of Drug Addiction Treatment: A Research-Based Guide, Third Edition. Accessed October 2026. nida.nih.gov
- U.S. Food and Drug Administration (FDA). FDA Approves First Over-the-Counter Naloxone Nasal Spray. Accessed October 2026. fda.gov
- Substance Abuse and Mental Health Services Administration (SAMHSA). How to Talk to Someone About Help. Accessed October 2026. samhsa.gov
- SAMHSA. National Helpline. Accessed October 2026. samhsa.gov
Related Reading
- Opioid Addiction Treatment
- Knowing These Overdose Signs Could Help You Save a Life
- How to Support Someone After They Leave Rehab
- It’s Not Your Fault If Someone You Love Struggles With Addiction
- Texas Good Samaritan Law and Calling 911 for an Overdose
Resources
- 988 Lifeline. Call or text 988, or chat at 988lifeline.org. Free, confidential support 24/7.
- SAMHSA National Helpline. Call 1-800-662-HELP (4357) or visit the SAMHSA National Helpline page for free, confidential referrals to local treatment.
- 911. For any medical emergency, including a suspected overdose, call 911 immediately. If naloxone is available for a suspected opioid overdose, give it and stay with the person until help arrives.
This article is general education and is not medical advice.
If you or someone you love is ready to talk, call Discovery Point Retreat at (855) 245-7133 to speak with our admissions team.
