AMA after Narcan – Is it safe?

In comes a 34-year-old male who is obtunded with pinpoint pupils and breathing at five times a minute; likely due to heroin abuse.  He wakes up after Narcan is appropriately administered, but now he wants to leave.  What is the risk of death if he leaves?  Do we restrain him against his will to monitor him for possible recurrent respiratory depression?

We have some pre-hospital literature that looked into this issue.  The studies looked at patients who refused care after pre-hospital providers administered Narcan for a suspected opiate overdose.  They then searched the death registry to see if those patients later died after refusing care (transport to the hospital).

Wampler et al. looked at 552 patients and found that no one died until at least 4 days later (1).  These deaths four days later were unlikely to be from the initial overdose.  A second study recently published in March of 2016 had 205 patients and showed only one death in 24 hours (2).  Two others died in the 30-day follow up period which again were not likely due to the initial overdose.  Combining the numbers from these two studies equates to 1/757 (0.13%) deaths.

There are limitations with all studies, but death seems unlikely after refusal of care post-narcan administration.  However, our practice should not change as it relates to monitoring patients for about 4 hours to those willing.  Recurrent respiratory depression is a real concern particularly seen in those patients who abuse long acting opiates.  Despite this, some patients who have the capacity to make decisions may not choose the wisest care plan and may leave AMA.  We must still make considerable attempts at providing substance abuse referrals and other appropriate resources as these patients are in great need of help.

Post by: Joe Bove  (@jjbove08)

  1. Wampler D, Molina D, McManus J, Laws P, Manifold C. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care. 2011;15(3):320-324.
  2. Levine M, Sanko S, Eckstein M. Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care. Prehosp Emerg Care. March 2016:1-4.

ALTO at it again

The ALTO program (Alternatives to Opioids) at St. Joe’s has already received national recognition for its work here.  In March we held a legislative summit that was attended by U.S. Senators Bob Menendez, Cory Booker, US Congressman Bill Pascrell, Jr and multiple other members of the local and state government to discuss the opioid epidemic and the ALTO initiative.  Then we were lucky enough to have the New York Times write a story recent story in June on the ALTO program as well.  Not to be outdone, EM Resident recently published a piece to introduce the EMRA readers to the wonders of ALTO and the success we have had thus far with the program, check it out here.

St. Joe’s ALTO Program in the News

On March 28, 2016 St. Joe’s announced the ALTO (Alternatives to Opiates) program in front of a Legislative Summit held here at St. Joe’s. This event was attended by U.S. Senators Bob Menendez, Cory Booker, US Congressman Bill Pascrell, Jr and multiple other members of the local and state government. A former graduate of our EM residency and current Medical Director of Pain Management in the Emergency Department, Dr. Alexis LaPietra has led the development of this program with the support of our Emergency Department Chairman and faculty member, Dr. Mark Rosenberg (@drmrosen). If you want to find out more about the ALTO program please check out the recent Webinar below.