Is admission after intravenous heroin overdose necessary?

doi:10.1016/S0196-0644(05)81896-7

Annals of Emergency Medicine

Volume 21, Issue 11, November 1992, Pages 1326-1330

https://doi.org/10.1016/S0196-0644(05)81896-7 Get rights and content

Study objectives:

To investigate the time of onset and incidence of complications in patients presenting to the emergency department with an IV heroin overdose and the need for routine admission of such patients.

Methods:

A retrospective chart review of hospital and emergency medical service records of 124 patient visits involving IV heroin overdose over a five-month period. We also reviewed the death certificates of 115 persons having succumbed to a narcotic overdose over a 44-month period and compared these with our hospital records.

Setting:

Urban county hospital.

Type of participants:

Patients presenting to the ED with an IV heroin overdose.

Results:

There were five deaths in the ED, 12 hospital admissions, and 107 patients who were discharged home. Neither delayed onset of pulmonary edema nor recurrence of respiratory depression was observed. Of the 115 persons having succumbed to a narcotic overdose, eight had been seen previously at our hospital for a heroin overdose. There is no evidence that any of these eight deaths would have been prevented by a 24-hour hospital observation period.

Conclusion:

Complications arising from an IV overdose of heroin are usually evident on arrival in the ED or shortly thereafter. On retrospective review we have found no evidence that admission to the hospital and 24 hours of observation are of benefit to patients who are awake, alert, and lacking evidence of pulmonary complications after an IV heroin overdose.

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Cited by (50)

Opioid antidote induced pulmonary edema and lung injury
2020, Respiratory Medicine Case Reports
Citation Excerpt :
Heroin overdose is clinically diagnosed with a combination of altered level of consciousness and one of the following clinical signs: respiratory rate <12 breaths/min, mitotic pupils, or circumstantial evidence of drug use [4]. Admission diagnosis of heroin overdose has been noted to be non-cardiogenic pulmonary edema (1%–2.4% of patients), pneumonia (0.5%), possible endocarditis (0.25%), and a persistent altered mental status or respiratory depression (0.7%–4%) [5]. Pulmonary complications, of which the most widely reported is edema, are the most common adverse events after an opioid overdose [6,7].
Opioid overdose emergencies are increasing every year, naloxone is the antidote for the treatment of opioid overdose. Naloxone is being dispensed to even lay persons through some programs to prevent opioid overdose deaths.
23 year old patient presented with naloxone treated opioid overdose complained of chest pain, pink frothy sputum production and shortness of breath. Physical exam showed tachycardia, tachypnea and coarse breath sounds. Imaging of the lungs showed diffuse pulmonary edema. Within an hour after the administration of naloxone patient developed pulmonary edema and lung injury. Patient was managed with non-invasive positive pressure ventilation which improved patient's symptoms in less than 6 hours confirmed by radiological improvement in 24–36 hrs.
There are no specific observation guidelines post naloxone treatment in opiate overdose patients. We recommend early treatment of naloxone induced pulmonary complications during the observation period with non-invasive positive pressure ventilation to reduce the morbidity.
Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal
2019, Journal of Emergency Medicine
Citation Excerpt :
The presence of these more potent adulterants further complicates the evaluation and management of the current heroin overdose patient. In addition, we observed both a higher mean initial naloxone dose and broader range of naloxone dosages than previous studies (8–10). This variability in initial naloxone dosing was observed among prehospital providers (EMS) as well as emergency physicians.
Emergency departments (EDs) are experiencing an increasing number of heroin overdose visits. Currently, there is no generally agreed upon ED observation period for heroin overdose patients who receive naloxone.
We aimed to determine the safety of a 2-h observation period for heroin overdose patients who receive naloxone.
We performed a chart review of all patients who presented with any opioid-related complaint between 2009 and 2014 to our urban academic trauma center. Subset analysis of patients with isolated heroin overdose who received naloxone was performed, with the intent of excluding patients intoxicated with long-acting/enteral opioids. The primary outcome was the number of patients who required delayed intervention—specifically, additional naloxone or supplemental oxygen.
Between 2009 and 2014, we recorded 806 visits to our ED for heroin use after receiving naloxone. Twenty-nine patients (3.6%) received a repeat dose of naloxone, and 17 patients (2%) received oxygen ≥2 h after initial naloxone administration. Our 2-h intervention rate was 4.6% (N = 37). This decreased to 1.9% (N = 15) after 3 h and 0.9% (N = 7) after 4 h. Patients with polysubstance use were more likely to receive repeat naloxone (p < 0.01), but not oxygen (p = 0.10). Preexisting cardiopulmonary conditions did not correlate with a need for supplemental oxygen (p = 0.24) or repeat naloxone (p = 0.30).
A 2-h ED observation period for heroin overdose patients reversed with naloxone resulted in a delayed intervention rate of 5%. Clinicians may consider a 3-h observation period, with extra scrutiny in polysubstance abuse.
Controversies and carfentanil: We have much to learn about the present state of opioid poisoning
2017, American Journal of Emergency Medicine
Is a Prehospital Treat and Release Protocol for Opioid Overdose Safe?
2017, Journal of Emergency Medicine
The current standards for domestic emergency medical services suggest that all patients suspected of opioid overdose be transported to the emergency department for evaluation and treatment. This includes patients who improve after naloxone administration in the field because of concerns for rebound toxicity. However, various emergency medical services systems release such patients at the scene after a 15- to 20-min observation period as long as they return to their baseline.
We sought to determine if a “treat and release” clinical pathway is safe in prehospital patients with suspected opioid overdose.
Five studies were identified and critically appraised. From a pooled total of 3875 patients who refused transport to the emergency department after an opioid overdose, three patient deaths were attributed to rebound toxicity. These results imply that a “treat and release” policy might be safe with rare complications. A close review of these studies reveals several confounding factors that make extrapolation to our population limited.
The existing literature suggests a “treat and release” policy for suspected prehospital opioid overdose might be safe, but additional research should be conducted in a prospective design.
Is discharge-on-scene policy really safe after naloxone reversal of acute long-acting opioid toxicity?
2013, Resuscitation
Prehospital treatment of opioid overdose in Copenhagen-Is it safe to discharge on-scene?
2011, Resuscitation
Citation Excerpt :
Observational studies have found that prehospital administration of naloxone by paramedics is safe in regard to serious complications.16,17 Furthermore in one retrospective review the authors found no evidence that admission to the hospital and 24 h of observation are of benefit to patients who are awake, alert, and lacking evidence of pulmonary complications after an IV heroin overdose.9 Our study supports these findings although we did not evaluate adverse events.
In the prehospital setting opioid overdose is often treated with naloxone. In our physician-based medical emergency care unit (MECU) we have adopted a discharge-on-scene policy, where patients are released on scene if no residual signs of opioid intoxication are found after treatment. The aim of this study was to describe our experience with the discharge-on-scene policy used during a 10-year-period with focus on the frequency of rebound opioid toxicity.
Data were prospectively recorded in our MECU database and we reviewed all cases of opioid overdose between 1994 and 2003. The MECU database was cross-referenced with the Central Personal Registry. For patients who died within 48 h of MECU contact we reviewed the forensic autopsy reports to establish whether rebound opioid toxicity was likely.
We found 4762 cases of acute opioid overdose. In 3245 cases positive identification was obtained. Over this ten year period fourteen patients who were released on-scene after having been treated with naloxone died within 48 h, but only in 3 of these we found a rebound opioid toxicity to be the likely cause of death, corresponding to 0.13% of those 2241 released on scene who were identified.
Prehospital discharge-on-scene after naloxone treatment is associated with a low risk of death due to rebound toxicity.

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: Presented at the Society for Academic Emergency Medicine Annual Meeting in Washington, DC, May 1991.

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Original contributionIs admission after intravenous heroin overdose necessary?

Study objectives:

Methods:

Setting:

Type of participants:

Results:

Conclusion:

Am J Med

Ann Emerg Med

Br J Anesth

Narcotics

Hospital morbidity and mortality of acute opiate intoxication

Presse Med

The acute pulmonary edema of heroin intoxication

Radiology

The clinical spectrum of heroin pulmonary edema

Arch Intern Med

Original contribution
Is admission after intravenous heroin overdose necessary?