Columns, Patient Care

Mortality Rates for Overdose Patients Who Refuse Transport

Issue 11 and Volume 42.

What’s the mortality rate for patients who receive naloxone and then refuse transport?

The Research

Levine M, Sanko S, Eckstein M. Assessing the risk of prehospital administration of naloxone with subsequent refusal of care. Prehosp Emerg Care. 2016;20(5):566-569.

The Science

The authors of this study reviewed a three-year period (July 1, 2011, to Dec. 31, 2013) for all patients who received naloxone (Narcan) by EMS providers with the Los Angeles Fire Department, and who subsequently refused additional medical care and were released at the scene.

They examined the coroner’s records to determine if any of these patients died within 24 hours, 30 days, or six months of their EMS encounter.

Of the 205 cases identified, the median age was 41 and 13% were female. Only one subject died within 24 hours of EMS care. The cause of death was coronary artery disease and heroin use. Two died within 30 days, one from coronary artery disease and cirrhosis and the other from unknown causes.

The authors conclude, “The practice of receiving prehospital naloxone by paramedics and subsequently refusing care is associated with an extremely low short- and intermediate- term mortality.”

Medic Wesley Comments

This study was published March 28, 2016. The data obtained was from 2011-2013. Oh, how quickly things change in the drug trade. The Centers for Disease Control (CDC) reported the number of opioid-related deaths in 2014 was a 9% increase from the previous year.1 The illegal drug trade changes every day. More potent forms of opioids are being manufactured, and with that, more deaths occur.

Releasing patients after administration of naloxone is a risk. The trend in this country is to blame someone else for our own bad choices and consequences-and to a certain degree, that liability rests with us, the healthcare professionals who had an opportunity to intervene and get these victims the help they need.

Once a patient is brought back to a functional respiratory status, or in some protocols, brought into consciousness, the patient is still at risk of relapse. Because the drug will outlast the antidote, the patient can’t be deemed competent or have the capacity to make a rational judgment.

The “treat and street” method works for some calls; however, there are just too many unknowns to say it’s a safe practice in today’s illicit drug use.

Don’t get me wrong. I understand that there aren’t enough resources to transport every drug overdose or to house those making reckless decisions. However, there are enough groups that think drug users are a vulnerable class, and therefore it’s public safety’s responsibility to rescue those individuals from the edge of death, at any cost. There are many in the legal profession willing to take this issue to court at the expense of your agency.

Rely on medical direction to see you through these cases, and make decisions in the best interest of the patient. The fact that a patient made a dangerous decision doesn’t relieve us from our professional and ethical duty to be a patient advocate.

Doc Wesley Comments

I agree with Medic Wesley that a “treat and street” approach may represent increased liability. Unfortunately, there’s no data to support that claim. I agree that this paper may not address the possible effects of significantly more powerful opiates such as carfentanyl, since it and other opiates didn’t become prevalent until after the study period reviewed by the authors.

It would be interesting to learn what percentage of known carfentanyl overdoses are returned to a clinically sober condition after naloxone administration. My experience has been that their respiratory status is improved, but they’re neither awake nor clear-headed enough to ambulate without assistance and competently refuse care.

Our EDs are sinking under the overwhelming amount of patients with drug, alcohol and mental illness. I understand the pressure that society places on us to protect them from themselves, but we have to stop trying to save everyone and concentrate on those that want help.

Those that want help will take it when offered. We live in a society that places the highest priority on patient autonomy; we’ve accepted standards to test the competency of a person who may be under the influence of drugs or alcohol. If this paper does anything, it should cause you to review your policies and determine if you’re meeting that standard when you release these patients from the scene.

Reference

1. Data overview: Opioid overdose. (n.d.) Centers for Disease Control and Prevention. Retrieved Oct. 3, 2017, from www.cdc.gov/drugoverdose/data/index.html.