Heroin overdoses and naloxone reversal: ok for discharge or mandatory observation?

In this podcast Dr. Rita McKeever and I review the recent article entitled Do heroin overdose patients require observation after receiving naloxone? from our toxicology friends at Washington University – Michael W. Willman, David B. Liss, Evan S. Schwarz & Michael E. Mullin.  They reviewed the literature to try and answer the following 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 observed prior to discharge?

(3) How effective in heroin users is naloxone administered by first responders and bystanders? Are there risks associated with naloxone distribution programs?

We also take a look at Ed Boyer’s article Management of Opioid Analgesic Overdose and an important but older article entitled Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule.

The clinical prediction rule that may predict safe discharge is as follows:

1) can mobilize as usual; 2) have oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and <20 breaths/min; 4) have a temperature of >35.0 degrees C and <37.5 degrees C; 5) have a heart rate >50 beats/min and <100 beats/min; and 6) have a Glasgow Coma Scale score of 15

We conclude that if the patient demonstrates all six features carefully applied WITH the caveat that there be no verbal or tactile stimulation prior to the evaluation, then the patient  is likely to be safe to discharge after reversal with naloxone. This concept has not been strictly tested in the literature, but the article in Clinical Toxicology supports this practice. And now on to the podcast … let us know what you think!