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Best evidence topic reports
Discharge of patients who have taken an overdose of opioids
Free
  1. Simon Clarke, Specialist Registrar,
  2. Paul Dargan, Specialist Registrar
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK;
  1. kevin.mackway-jones{at}man.ac.uk

Abstract

A short cut review was carried out to establish whether patients with no recurrence of symptoms one hour after receiving naloxone for an opioid overdose can safely be discharged. Altogether 195 papers were found using the reported search, of which five presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

http://dx.doi.org/10.1136/emj.19.3.250

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    Report by Simon Clarke,Specialist Registrar 
 Checked by Paul Dargan, Specialist Registrar

    Clinical scenario

    A 30 year old opioid addict is brought to the emergency department having overdosed on heroin. He is successfully treated with a titrated bolus of naloxone. You wonder when it will be safe to discharge the patient.

    Three part question

    In [patients given naloxone for the treatment of opioid overdose] is [a lack of recurrence of symptoms after one hour] a sensitive predictor for [safe discharge from the department]?

    Search strategy

    Medline 1966–09/01 using the OVID interface. [{exp narcotics OR opioid.mp OR opiate.mp OR morphine.mp OR buprenorphine.mp OR codeine.mp OR dextromoramide.mp OR diphenoxylate.mp OR dipipanone.mp OR dextropropoxyphene.mp OR diamorphine.mp OR heroin.mp OR alfentanil.mp OR fentanyl.mp OR remifentanil.mp OR meptazinol.mp OR methadone.mp OR nalbuphine.mp OR oxycodone.mp OR pentazocine.mp OR pethidine.mp OR phenazocine.mp OR tramadol.mp} AND {exp overdose OR overdos$.mp OR exp poisons OR poison$.mp OR “acute intoxic$”.mp OR “acute toxic$”.mp} AND {exp patient admission OR admission.mp OR exp patient discharge OR discharge.mp OR observ$.mp OR monitor$.mp OR predict$.mp}] LIMIT to human AND English.

    Search outcome

    Altogether 194 papers found. Of these only five were relevant to the preoperative setting (table 5).

    View this table:
    Table 5

    Comment(s)

    The evidence consists of observational studies, three of which are retrospective reviews of medical records and thus there are concerns regarding the reliability of the data collected. In addition, only Christenson's study attempts to apply a “rule out” strategy by attempting to identify the clinical variables that predict a low risk of delayed complications from the opioid overdose. Further work is required to validate the rule in different populations by further prospective studies. Also, comparative trials need to be undertaken to assess the validity of the rule for different opioid overdoses.

    ▸ CLINICAL BOTTOM LINE

    The evidence suggests that if a patient remains well one hour after administration of naloxone, then it is safe to discharge them.

    Report by Simon Clarke,Specialist Registrar 
 Checked by Paul Dargan, Specialist Registrar

    References

    1. Smith DA, Leake L, Loflin JR, et al. Is admission after intravenous heroin overdose necessary? Ann Emerg Med1992;21:1326–30.
      OpenUrlCrossRefPubMedWeb of Science
    2. Osterwalder JJ. Patients intoxicated with heroin or heroin mixtures: how long should they be monitored? Eur J Emerg Med1995;2:97–101.
      OpenUrlCrossRefPubMed
    3. Watson WA, Steele MT, Muelleman RL, et al. Opioid toxicity recurrence after an initial response to naloxone. J Toxicol Clin Toxicol1998;36:11–17.
      OpenUrlPubMedWeb of Science
    4. Vilke GM, Buchanan J, Dunford JV, et al. Are heroin overdose deaths related to patient release after prehospital treatment with naloxone? Prehospital Emerg Care1999;3:183–6.
    5. Christenson J, Etherington J, Grafstein E, et al. Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule. Acad Emerg Med2000;7:1110–18.
      OpenUrlPubMedWeb of Science