A study addressing a few questions regarding naloxone and opioid overdose…
Willman MW, Liss DB, Schwartz ES, Mullins ME. Do heroin overdose patients require observation after receiving naloxone? Clin Toxicol (Phil). 2017 Feb;55(2):81-87.
The study aimed to answer 4 questions: 1.) What are the medical risks to a heroin user who refuses ambulance transport after naloxone? 2.) If the heroin user is treated in the emergency department with naloxone, how long must they be observe prior to discharge? 3.) How effective in heroin users is naloxone administered by first responders and bystanders? 4.) Are there risks associated with naloxone distribution programs?
The researchers performed a literature review using Pubmed and GoogleScholar to answer these questions. The researchers found 8 articles pertinent to the first 2 questions, and 15 relevant to the 3rd and 4th questions.
Question 1: 8 observational prospective and retrospective studies were found that addressed this question. Most of the studies were performed in Scandinavian countries. Most studies related to out of hospital naloxone administration. Many of the studies utilized a similar format: they queried death records after heroin overdose patients who received naloxone refused hospital transport to see if any deaths resulted. Out of 5443 patients in the included studies, there were 4 deaths from rebound opioid toxicity. The number needed to transport to save 1 life is 1361. Because most of the studies in this group were performed in Scandinavian countries where there is a national health system and death record, the authors reported that missed deaths from geographical misses was highly unlikely. Rates of adverse events reported were low to moderate based on what the included study authors deemed an adverse event (some considered nausea and vomiting adverse events.). There were no serious or life threatening adverse events reported in these studies.
Question 2: 5 articles were found addressing this question. This section focused on an article from Vancouver published in the year 2000 that created a decision rule for safety of discharge after opioid overdose treated with naloxone. This study reported that patients should be safe for discharge if they have a GCS of 15, normal vital signs, and mobilized as usual after 1 hour of observation. The authors concluded that this decision rule can be applied broadly to opioid overdoses observed in the ED after receiving naloxone.
Question 3 and 4: 15 articles were found addressing these topics. The authors found articles that supported that naloxone administered by bystanders is effective. They described a systematic review that reported a 100% survival rate and described other studies that had very high survival rates with bystander naloxone administration. They reported few if any risks related to naloxone distribution programs.
This was a literature search that aimed to answer several questions. It serves as a good review on this topic, but few major conclusions can be made from this article alone. EMS and treat-and-release naloxone administration is likely pretty safe if the patient has no concerning features related to their overdose. The author’s conclusion regarding the second question, that patients can be safely discharged after 1 hour of ED observation if they meet certain criteria, is bold. They base this conclusion on a study published in the year 2000 that created a decision rule that was never validated. Drugs of abuse are ever evolving and it is difficult for me to completely agree with this conclusion based on older, non-validated data. Lastly, naloxone distribution programs are effective and pretty safe!