Opioids are a class of medications used to treat moderate-to-severe pain. But they have the potential to cause dependence, misuse, and overdose. Likewise, drinking alcohol can be dangerous if you drink too much and too often.

We know that both opioids and alcohol can be dangerous individually, but what do we know about the risks of mixing these substances? Is there any amount of alcohol that's safe to drink while taking opioids? Our pharmacists answer these questions and more.

First, what are opioids?

An opioid is any chemical that attaches (binds) to specific areas of your nerve cells called opioid receptors. Prescription opioids are most commonly used for pain relief. Examples include:

• Morphine (MS Contin, Kadian)

• Codeine

• Hydrocodone / acetaminophen

• Oxycodone / acetaminophen (Percocet)

• Oxycodone (Roxicodone, Oxycontin)

• Hydromorphone (Dilaudid)

• Fentanyl patches, buccal tablets (Fentora), and lozenges

• Tramadol (Ultram, Conzip)

• Methadone (Methadose)

• Buprenorphine / naloxone (Suboxone)

Opioids and alcohol: Is this ever a safe combination?

No, the research is clear that using opioids and alcohol together is risky, especially when either substance is used in excess.

Over 25% of adults with opioid use disorder (OUD) also have an alcohol use disorder (AUD). And people who binge drink are twice as likely to misuse prescription medications, including opioids, while drinking. Additionally, one study found that almost 15% of people who died of opioid-related causes in 2017 were also drinking alcohol.

That's why it's never safe to combine alcohol and opioids. While each substance can be harmful on its own - especially if used incorrectly or in excess - combining them increases your chance of side effects, long-term health problems, and even death.

What are the risks of mixing opioids and alcohol?

Mixing opioids and alcohol, even in small amounts, can lead to serious side effects. Both opioids and alcohol slow down brain activity. When taken together, the effects on the brain and body can intensify.

Risks of mixing opioids like oxycodone or hydrocodone and alcohol include:

• Drowsiness

• Dizziness

• Slower reaction time

• Low blood pressure

• Slowed breathing

• Overdose and death

Combining opioids and alcohol can also increase your risk of long-term problems, such as:

• Substance use disorders

• Risky sexual behavior

• Injuries and violence

In 2016, the FDA gave all opioid medications a black box warning for serious side effects when opioids are combined with other medications and substances that affect the brain, including alcohol. A black box warning is the most serious warning the FDA can put on a medication label.

Is having 1 or 2 drinks OK?

In short, no.

It's not safe to drink alcohol while taking opioids like hydrocodone or oxycodone. The more alcohol you drink, and the higher your opioid dose, the greater the risk. However, no matter your opioid dose or how much you drink, this combination is never considered safe.

If you've been prescribed an opioid, let your prescriber know if you drink alcohol. They'll likely recommend avoiding alcohol entirely while you're taking the opioid.

If avoiding alcohol isn't possible for you, it's best to avoid opioids. In this case, talk with your prescriber. They may be able to recommend non-opioid alternatives to manage your pain. They can also provide you with resources to help you cut back or stop drinking completely, if needed.

When can you start drinking alcohol after taking opioids?

It depends on what prescription opioid you've been taking. Some opioids, like hydrocodone / acetaminophen and oxycodone / acetaminophen, are short-acting. They don't last in the body for more than a few hours. But other opioids - including methadone, morphine, and fentanyl patches - are long-acting. Their effects may last for several hours, or even several days.

If you were prescribed a long-acting opioid, your prescriber may want you to wait several days after finishing the medication before you drink any alcohol. This will help make sure there's no opioid left in your body.

No matter which opioid you were taking, talk to your prescriber before drinking any alcohol, even if it's just one drink.

Are there any painkillers that aren't affected by alcohol?

Common painkillers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), don't interact with alcohol in the same way that opioids do. This means your risk of having an overdose isn't increased if you drink alcohol and take NSAIDs like ibuprofen (Advil, Motrin) or naproxen (Aleve, Naprosyn), any more than your risk of drinking alcohol without taking NSAIDs. The same is true of acetaminophen (Tylenol).

However, NSAIDs and acetaminophen can still interact with alcohol in other ways. For example, combining NSAIDs and alcohol raises your risk for stomach bleeding and kidney or liver problems. And combining acetaminophen and alcohol increases your risk of liver damage.

If you drink alcohol, speak to a healthcare professional before taking an NSAID or acetaminophen. In many cases, occasional NSAID or acetaminophen use is likely OK if you drink small amounts of alcohol. But if you have certain health conditions, like a history of a stomach bleed or liver damage, your prescriber may recommend avoiding these painkillers.

What does an overdose look like?

In serious cases, drinking alcohol while taking opioids can lead to an overdose. Opioids or alcohol alone can also cause an overdose. Signs and symptoms of an opioid overdose include:

• Small pupils ("pinpoint" pupils)

• Being unconscious

• Being unable to speak

• Slowed breathing

• Vomiting or gurgling sounds

• Limp body

• Blue skin and lips

• Slowed heart rate

An alcohol overdose may look similar to an opioid overdose. Other symptoms may include low body temperature, confusion, and seizures.

What should you do if you witness an opioid or alcohol overdose?

If you think someone is experiencing an overdose, there are two actions you should take as quickly as possible:

• Administer naloxone (Narcan, Zimhi) or nalmefene (Opvee, Zurnai) if you have it. These medications can save a life by quickly reversing the effects of an opioid overdose. It's recommended to give a dose every 2 to 3 minutes until the person responds. Even if you don't know what substance caused the overdose, administer naloxone or nalmefene. Although these medications only work for overdoses involving opioids, they're not harmful if the person doesn't have opioids in their system.

• Call 911 immediately after administering naloxone or nalmefene. Alcohol and/or opioid overdoses are life-threatening. First responders can help manage this situation before overdose symptoms worsen. Even if you've administered naloxone or nalmefene, the person overdosing will still need emergency care.

Narcan nasal spray is available OTC, and you may be able to get it for free in some cases. Injectable naloxone and nalmefene products are only available with a prescription. It's a good idea to keep one of these products on you at all times if you or a loved one takes opioids.

If you or someone you know struggles with substance use, help is available. Call SAMHSA's National Helpline at 1-800-662-4357 to learn about resources in your area.