Is early discharge safe after naloxone reversal of presumed opioid overdose?

Abstract

Introduction: Patients with suspected opioid overdose frequently require naloxone treatment. Despite recommendations to observe such patients for 4 to 24 hours after naloxone, earlier discharge is becoming more common. This prospective, observational study of patients with presumed opioid overdose examines the safety of early disposition decisions and the accuracy of outcome prediction by physicians 1 hour after the administration of naloxone. Methods: The study was carried out at St. Paul’s Hospital, an inner city teaching centre that cares for most of the injection drug users in Vancouver, BC. Patients were formally assessed 1 hour after receiving naloxone for presumed opioid overdose. Demographics, medical history and physical examination were documented on specific data forms, and physicians recorded their comfort with early discharge. Patients were followed up, and those who required a critical intervention or suffered a pre-defined adverse event (AE) within 24 hours of their 1-hour assessment were identified. Results: Of 573 patients, 48% were discharged in less than 2 hours, 23% in 2–4 hours and 29% in >4 hours. 94 patients who were held in the emergency department (ED) or admitted required a critical intervention, including supplemental oxygen for hypoxia (74), repeat naloxone (52), antibiotics administered intravenously (IV) (14), assisted ventilations (13), fluid bolus for hypotension (12), charcoal for associated life-threatening overdose (6), IV inotropic agents (2), antiarrhythmics for sustained tachycardia >130 beats/min (1), and administration of bicarbonate for arterial [HCO3] <5 or venous CO2 <5 (1). Physicians predicted adverse events with 94% sensitivity and 59% specificity. No discharged patients suffered a serious AE within 24 hours of ED discharge. Conclusions: Emergency physicians can clinically identify patients at risk of deterioration after naloxone reversal of suspected opioid overdose. Prolonged observation or hospital admission is not usually required. Selective early discharge of patients with presumed opioid overdose is feasible and appears safe. A clinical prediction rule may be useful in identifying patients eligible for early discharge.

Part 12: Cardiac Arrest in Special Situations

“…Although a brief period of observation may be appropriate for patients with morphine or heroin overdose, 245 a longer period of observation may be required to safely discharge a patient with life-threatening overdose of a longacting or sustained-release opioid. 239,246 …”

Part 10: Special Circumstances of Resuscitation

“…Although abbreviated observation periods may be adequate for patients with fentanyl, morphine, or heroin overdose, 102,109,[120][121][122][123] longer periods of observation may be required to safely discharge a patient with life-threatening overdose of a long-acting or sustained-release opioid. 93,124,125 Naloxone administration in post-cardiac arrest care may be considered in order to achieve the specific therapeutic goals of reversing the effects of long-acting opioids (Class IIb, LOE C-EO). The use of ILE therapy was first developed as a treatment for cardiac arrest resulting from the local anesthetic bupivacaine.…”

Naloxone Administration in US Emergency Departments, 2000–2011

“…Naloxone has long been used in ED settings to diagnose and manage respiratory depression related to opioid overdose. Prior studies of ED-based naloxone use have examined clinical management following naloxone administration, provider knowledge, and facility-level availability of naloxone [18][19][20][21]. However, few studies have examined the use of naloxone in ED settings in the USA [22,23], and none have examined nationally representative data during the decade preceding this recent support of expanded naloxone access.…”