September 3, 2016

I Hate Transporting (Some) Narcan Patients

I am not your boss, supervisor, manager, or medical director. I have nothing to do with your protocols, policies, QA reviews, or your ability to continue to receive a regular paycheck. I also do not fill an official role in Denver Health, so the thoughts below are my own opinions. You know about opinions, right? Adopt the concepts below at your own risk.

You are assigned to the report of an unconscious party in a nearby apartment and arrive to find a patient as advertised. The patient is a mid-twenties male with pale skin and miosis. He has a heart rate of 100 beats per minute and his respiratory rate is so slow that you get bored counting it and estimate it to be about four per minute. A heroin rig is on the end table next to him. You administer 0.5mg intranasal Narcan and add a few breaths via a bag-valve mask while you are waiting for him to wake up. After a few minutes, the patient wakes and begins to breathe normally. There is no indication of co-ingestion, alcohol use, or other medical concerns. The patient’s heart rate slows to 70 beats per minute and his oxygen saturation is 99% on room air.
The patient seems to be a pretty nice dude. He is rather ashamed you had to wake him up. He explains that he had been clean for about nine months, but had just experienced personal stress and fell off the wagon. “I guess I don’t have the tolerance I used to. I guess I took too much,” he tells you.

He also tells you that he doesn’t want to go to the hospital.

So here is the thing. He is completely awake now. He is answering all questions appropriately. He can tell you how many quarters are in a buck-fifty and who is president. Hell, he can even tell you who governor and mayor are. You explain to him that the smack he overdosed on may have a longer action than the Narcan you reversed it with. His overdose could return. He absorbs that information and still doesn’t want to go to the hospital.

Is he allowed to refuse transport to the hospital?

Some paramedics take all patients who received naloxone to the hospital. Some EMS protocols even require it.

Should he be allowed to refuse transport? I’m asking about what should be done, not what is mandated, or what your common habit is. What should the answer be? To me, the answer depends on patient safety and patient autonomy. Is it safe for him to refuse transport? Does he have the required decision making capacity to refuse transport?

What does published research say about the safety of non-transport after prehospital naloxone administration?
  • Sporer’s group published an article in 1996 that looked at the rate of patient admission after Narcan administration (1). They report admission is rare – only 2.7% of patients transported after naloxone were admitted to the hospital. The most common reason for admission was noncardiogenic pulmonary edema, which they described as “clinically obvious.” Other causes included pneumonia, infections, and persistent respiratory and mental status depression.
  • Vilke, et al., compared records from the San Diego medical examiner’s office with positive opioid test results to prehospital records (2). None of the 117 opioid-involving deaths in the ME’s records and the 317 prehospital refusal after naloxone matched within a 12-hour window. Another San Diego study (3) four years later looked at almost one thousand patients who received prehospital naloxone and refused transport. None appeared in ME records within 12 hours.
  • A study from Helsinki, Finland, headed by Boyd (4) attempted to describe the incidence of recurrent toxicity and the time interval in which it occurs. One hundred forty-five uncomplicated heroin overdose patients were included. Eighty-four refused transport. Seventy-one had no life-threatening events in a 12-hour follow-up period; the others were lost to follow up. Of the sixty-one who were transported, 12 (19.6%) needed more naloxone, but all occurred within an hour. The authors specifically state: “Allowing presumed heroin overdose patients to sign out after prehospital care with naloxone is safe.”
  • Wampler, et al., published a study (5) from San Antonio that was similar in design to the Vilke studies discussed above. They compared refusals after Narcan to the county medical examiner’s database within 48 hours of the refusal. Of 552 patients, none presented to the medical examiner within 2 days. A 30-day comparison of records found 9 patients who received Narcan and died, but the shortest interval was 4 days post event.
  • A huge study from Rudolph’s group (6) included 4,762 cases of acute opioid overdose over a ten-year period. Only 14 patients who were released on-scene after having been treated with naloxone died within 48 hours. Only three presented with possible rebound opioid toxicity as the reported cause of death (0.13% of the patients released on scene).
  • Finally, a recent study published by Levine, Sanko, and Eckstein (7) presented a multi-year retrospective review of LAFD’s records. Two hundred five refusal-post-Narcan patients were identified. One subject died within 24 hours of refusing care due to “coronary artery disease and heroin use.” Two others died within 30 days. A fourth subject died 16 months after refusing transport. “The practice of receiving prehospital naloxone by paramedics and subsequently refusing care is associated with an extremely low short- and intermediate-term mortality.”

As a final example of the safety of non-transport after naloxone administration, I give you the fact that people can buy Narcan in a grocery store pharmacy, administer it to their friends or family, and not go to the hospital. They can do all of that without involving the EMS system at all. In the imaginary case that began this post, if the patient’s girlfriend had given Narcan he could have avoided a hospital bill pretty easily.

I think there is some evidence to indicate that non-transport after opioid overdose reversal is a generally safe practice. The published research has holes, as does research on most topics, but seems to lean toward a feeling of safety. So we can consider the second point: Does the patient have decision-making capacity?

I have published my thoughts on decision-making capacity previously. In short, I don’t necessarily care if the patient is sober (although you could make the argument that I have used pharmacology to make him so) or competent. I care that the patient, at that moment,
  • can make and communicate a medical choice [check],
  • can appreciate the concepts of diagnosis, prognosis, suggested care, alternatives, and risks/benefits [check],
  • can make decisions without delusions or coercion [check], and
  • can use logical reasoning [check].

Seems to me that the patient described here has decision-making capacity.

So why must he go to the hospital? Well, I don’t think he does.

This is an example with a simple, uncomplicated heroin overdose that doesn’t present additional complications. There are no other ingestions. He isn’t rolling on an eight ball, or alcohol, or anything else. His overdose wasn’t related to a suicide attempt. He actually has the obvious ability to make decisions, and there isn’t residual confusion or mental slowness. All of those points wouldn’t exist in every case of Narcan administration. It is the subtleties of each case that make disposition decisions a giant grey area.

I am not saying the patient’s decision doesn’t constitute an Against Medical Advice refusal. My medical advice is that he be transported. People refuse against my advice all the time. We are taught that people are allowed to make decisions that we disagree with. Sometimes we disagree strongly. But the principle of informed patient autonomy is a bedrock, foundational principle of medical care.
This doesn't override your rights to self-determination. Source
But I disagree with the black and white outlook that requires transporting a patient who possesses intact decision-making capacity. People with decision-making capacity are allowed to decline transport in my world. In an ideal world, I would even add another milligram or two of Narcan IM to help make sure the overdose is less likely to return. But transport? This guy? Nah…

1. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med 1996;3(7):660-667.
2. Vilke GM, Buchanan J, Dunford JV, Chan TC. Are heroin overdose deaths related to patient release after prehospital treatment with naloxone? Prehosp Emerg Care 1999;3(3):__.
3. Vilke GM, Sloane C, Smith AM, Chan TC. Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Acad Emerg Med 2003;10(8):893-896.
4. Boyd JJ, Kuisma MJ, Alaspää AO, Vuori E, Repo JV, Randell TT. Recurrent opioid toxicity after prehospital care of presumed heroin overdose patients. Acta Anaesthesiologica Scandinavica 2006;50(10):1266-1270.
5. Wampler DA, Molina DK, McManus J, Laws P, Manifold CA. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care 2011;15(3):320-324.
6. Rudolph SS, Jehu G, Louman Nielsen S, Nielsen K, Siersma V, Rasmussen LS. Prehospital treatment of opioid overdose in Copenhagen – Is it safe to discharge on scene? Resuscitation 2011;82(11):1414-1418.

7. 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):__.

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