Written by Elizabeth Cairns, Mobilize Recovery Special Projects and Michael Masiowski, MD, reviewed by Code Recover Clinician Advisors, August 2026

Peer recovery support specialist Rob Banghart talks about the importance of connection when a patient is in crisis

When a patient comes in who has received naloxone pre-hospital or in the ED, they are typically sedated when they arrive. Clinical staff will explain the need to keep them under observation for a period of time to be sure the half life of the naloxone is long enough to continue to counteract the substance on which they overdosed. But frequently, after about 45-60 minutes, we see the patient’s behavior change. Their attitude may shift from “thank you for saving my life,” to, “I need to get out of here.” They become combative and confrontational. They might even rip out their IV and leave against medical advice. 

Why does this happen and how should the ED team respond?

Understanding the reasons for the patient’s behavior is the first step to managing it effectively. During an opioid overdose, the drug saturates mu-opioid receptors throughout the brain and brainstem, suppressing the drive to breathe. Naloxone reverses this by knocking opioids off those receptors and briefly blocking them, which is why it restores breathing within minutes.

For a person whose brain has physically adapted to opioids, that same abrupt clearing can also set off precipitated withdrawal. Unlike the withdrawal that comes on gradually over hours or days, precipitated withdrawal arrives suddenly and can be more severe. It doesn't happen to every patient — how likely and how intense it is depends on the person's degree of opioid dependence and how much naloxone reached their system — but it's common enough in the post-overdose population that the ED team should anticipate it. (source)

When it sets in, the brain's stress and alarm circuitry, no longer suppressed by opioids, floods the body with the signals of a physiological crisis: surging heart rate, sweating, nausea, muscle pain, and an overwhelming sense of dread. This is not a psychological overreaction or a behavioral choice — it is a neurobiological alarm state. (source) As the initial sedation wears off and this distress takes over, often around the 45-to-60-minute mark the team is already monitoring, the patient's demeanor can flip from grateful to desperate to leave.

The patient is likely not aware of any of this, but they do know they are afraid — of what is happening in their body, and of what it will mean for their job, their family, and what comes next. A peer navigator who has experienced withdrawal firsthand can name that fear in terms the patient will accept from someone who has been there, in a way that a clinician often cannot.

It's important for clinicians to understand this agitated behavior as a symptom. Some clinicians may feel relieved to be rid of an agitated OUD patient who leaves against medical advice, but they have missed an opportunity to reach and provide care to that person, who is in acute distress and now at elevated risk of a fatal overdose — among patients who left AMA after an overdose-related ED visit, 9% experienced another overdose within one week. (source) Stabilizing the patient with MOUD and providing empathy and advocacy via a peer navigator not only soothes the patient's agitation; more importantly, it keeps them engaged and provides them with care that can save their life.