Improving Outcomes, Improving Throughput

How soon to safely discharge the opiate OD?

For those of us wondering how long we need to keep the thrashing, agitated, cursing “narcan’ed” patient in our ED, look no further. This is essentially a review of the literature on whether or not adopting a treat & release policy for opiate overdose in the prehospital realm is safe & feasible.

They review 4 papers, 3 of which contain data points from 1994-2003, of which two were non-US studies. In general, they look at some short time period for bouncebacks, (6-12 hours), and if the patient does not come back to receive chest compressions or repeat narcan dosing, they considered it a win. Ultimately, out of 3875 patients that received narcan in the field and were able to AMA after a 15-20 minute observation period, only 3 had a recurrence that resulted in death.

Digging a bit deeper, part of the problem here is that two of the papers had exclusion criteria that does not necessarily fit what happens in practice. One paper excluded patients brought to the hospital, while another excluded those with polysubstance abuse. I’m not sure about your patient population, but the heroin abusers I’ve like to chase with China White with a stick of xanax. Fortunately, the two US studies were more likely applicable, with almost no exclusion criteria – and of which zero patients out of 1550 prehospital treat & release patients died within 12 hours.

So how does this apply to the ED? It is important to note that there are clinical decision rules to help guide who can go home relatively quickly.  If patients can ambulate, has normal vitals and a GCS of 15, then your miss rate is likely well below 1% for them to return in the next few hours from this particular overdose. So, by the time a patient is reversed with narcan, you write the chart and get discharge papers ready, if they remain alert, oriented, competent and reasonable, they can likely go. However, it should be noted that there were a small number of patients who returned within a few weeks with various other issues – one patient hung themselves within 48 hours. Another overdosed 4 days later. All in all, still <1% dying within 30 days, but this is potentially a teachable moment. Patients do have the right to make bad decisions, but that shouldn’t necessarily allow us to stigmatize them and not at least offer them the help they likely need.

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2 thoughts on “How soon to safely discharge the opiate OD?

  1. Patrick – great question to ask and a nice review of the article. The real issue here is that the studies are older and without the best of methodologies. Currently, we are all seeing patients who think they’re getting heroin, but who knows what they’re actually getting. This is probably the biggest danger now. As you note, polysubstance is a huge issue that is tough to account for. Despite this evidence, I’m still watching patients for a couple of hours (2-3) and releasing them after this if they’re still stable.

    Thanks for the review!

    • Thanks for the Read Swami!

      You bring up great points. I had thought of the “is this really heroin” issue… and well, the San Diego Study was from 2007-2009 and only looked at “morphine equivalents” on post-mortems.

      I think there are two arguments here, and it looks like we might fall on different sides: One, keep them for awhile because “who knows if its heroin” (which, by the way, why do we think they knew what they were shooting before?) or secondly, “whats the utility of narcan in non-specific opioid overdoses?” if they reverse and stay that way for 30 minutes, these studies suggest they could likely do ok, though I freely admit, they probably undersell the risk a good bit.

      This also brings up another can of worms – can patients have the right to make poor decisions? I realize there have been few lost cases when youre looking out for the best interest of the patient, but in theory, once reversed, they are potentially of sound mind (perhaps slightly agitated, perhaps withdrawing, but lets imagine they are now of sound mind)… They are now alert, oriented, able to make decisions, if they are competent and reasonable – do they have the ability to AMA?

      Food for thought & future discussion in either direction… I posted this in part because we’re doing a journal club for our department and anticipate this same discussion…

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