Journal Review

I need you to write a journal review from 3 to 5 paragraphs using APA format. The summery of the article should not exceed 1/4 of the whole review. The rest should be your opinion and why you think that way. I will attach the journal that need to be reviewed and the grading rubric.
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The Journal of Emergency Medicine, Vol. 52, No. 1, pp. 52–58, 2017
! 2016 Elsevier Inc. All rights reserved.
0736-4679/$ – see front matter
Evidence Based
Medicine
IS A PREHOSPITAL TREAT AND RELEASE PROTOCOL FOR OPIOID
OVERDOSE SAFE?
Daniel Kolinsky, MD,* Samuel M. Keim, MD, MS,† Brian G. Cohn, MD,* Evan S. Schwarz, MD,* and
Donald M. Yealy, MD‡
*Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, †Department of Emergency Medicine,
The University of Arizona College of Medicine, Tucson, Arizona, and ‡Department of Emergency Medicine, University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania
Corresponding Address: Samuel M. Keim, MD, MS, Department of Emergency Medicine, The University of Arizona College of Medicine, PO Box
245057, Tucson, AZ 85724
, Abstract—Background: 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. Objectives: We sought to determine if a ‘‘treat and release’’ clinical pathway is safe in prehospital patients with suspected opioid overdose. Results: 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. Conclusion: 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. ! 2016 Elsevier Inc.
All rights reserved.
CASE PRESENTATION
Paramedics have administered 0.4 mg of naloxone intravenously (IV) to a somnolent patient with a known history of
IV heroin addiction. The patient rapidly is aroused to an
alert state. He admits to using heroin from a new source
and verbalizes that it was clearly more potent than he
initially suspected. After 20 min on the scene, he requests
to sign an Against Medical Advice (AMA) refusal form.
According to protocol, the paramedics have contacted
medical control to report a potential refusal of transport.
The patient’s housemate has agreed to observe him, but
you wonder if this ‘‘treat and release’’ practice is safe.
CONTEXT
Opioid abuse remains an increasing problem in the
United States because of the high prevalence of heroin
abuse and the increasing abuse of prescription opioid
medications. The sale of opioid pain relievers (OPRs)
has steadily increased since 1999, and the rates of
both deaths from overdose and hospital admission for
treatment have increased (1). This includes an increase
in the abuse of longer-acting agents, such as methadone. In the United States, death rates from prescription OPR overdose quadrupled between 1999 and
, Keywords—emergency medical services; naloxone;
opioid overdose; prehospital
Reprints are not available from the authors.
52
Prehospital Treat and Release After Naloxone?
2010, while deaths from heroin increased at a slower
rate (2). With the advent of prescription drug monitoring databases, there has been resurgence in the abuse
of heroin. However, OPRs are still frequently abused.
In 2010, there were 135,971 United States (US) emergency department (ED) visits and 16,651 deaths in the
US caused by OPR overdose (3,4). The estimated total
ED cost for those discharged from the ED was
$234,542,324 (3).
The mainstay of treatment for opioid overdose is the
mu opioid receptor antagonist naloxone. Naloxone is
safe to administer, and severe adverse events are rarely
reported (5). Most emergency medical services (EMS)
systems mandate that all patients suspected of opioid
overdose be transported to the emergency department
(ED). This includes patients who improve after
naloxone administration because of concerns that they
are at risk for rebound toxicity related to the short
half-life of naloxone compared to the longer duration
of action of other opioids. Some have advocated for
up to 6 h of observation after reversal of toxicity (6).
However, the increase in ED overcrowding and lengthy
wait times has led to efforts to develop methods to
disposition these patients more rapidly. One group
created a prediction rule for safe, early discharge of patients with presumed opioid overdose within 1 h of
arrival to the ED (7).
The next step might be to question policies to transfer all
opioid overdoses to the ED for evaluation and observation.
In various European EMS systems, releasing such patients
at the scene after a 15- to 20-min observation period, as
long as they return to their baseline, is standard practice
(8). One study determined risk factors (i.e., age >50 years
and overdose during the weekend) that identify high-risk
patients who are poor candidates for this strategy (9). The
goal of this review is to determine if a ‘‘treat and release’’
policy is supported by the current available evidence.
EVIDENCE SEARCH
A PubMed MEDLINE search was performed with the
keywords ‘‘prehospital AND naloxone’’ and ‘‘emergency
medical services AND naloxone AND opioid overdose’’
with no limits, yielding 118 articles. EMBASE was
searched with the terms ‘‘emergency medical services
AND naloxone AND opioid overdose,’’ resulting in 42 citations. All citations were reviewed to identify original
research evaluating the safety of administering naloxone
to patients with suspected opioid toxicity in the prehospital
setting and not transporting them to the hospital. Five relevant articles were identified. One article was excluded
because its dataset was used in a larger trial that was
included (10). The bibliographies of these articles were reviewed for additional references, but none were identified.
53
EVIDENCE REVIEW
Prehospital Treatment of Opioid Overdose in Copenhagen—Is it Safe to Discharge on Scene?
Population. This study included all patients with suspected opioid overdoses evaluated by the Medical Emergency Care Unit (MECU) in Copenhagen, Denmark,
from 1994 to 2003 (11).
Study design. This was a retrospective chart review of all
patients diagnosed with an opioid overdose in the MECU
database. All overdose cases with a Danish social security
number were checked for survival data with the Central
Personal Registry, and autopsy reports on all subjects
who died within 48 h of MECU contact were collected.
Mandatory toxicologic screening was a part of these autopsy reports and included the substance most likely to
be the cause of death. Patients who died within 48 h of
MECU contact were further classified as ‘‘rebound toxicity
unlikely’’ or ‘‘rebound toxicity likely’’ based on police investigations; patients seen alive >6 h after MECU contact
were classified as ‘‘rebound toxicity unlikely.’’
Primary outcome. The primary outcome was the risk
of dying from rebound toxicity within 48 h of being
released by the MECU.
Exclusion criteria. All patients diagnosed on scene by
the MECU doctor were included. However, patients
without a Danish social security or patients who refused
to provide their social security number could not be followed in the Central Personal Registry.
Main results. There were 2241 cases of opioid overdose
with a positive patient identification that were released at
the scene. Among these, 18 deaths within 48 h were identified for an all-cause mortality rate of 0.80% within 48 h.
Four of these cases were excluded: 2 patients were not
given naloxone, 1 case was admitted to the hospital after
MECU contact for an unrelated reason, and 1 subject
committed suicide by hanging. Therefore, 14 deaths
(0.62%) possibly caused by rebound opioid toxicity were
identified. Opioid rebound toxicity was found to be the
likely cause of death in 3 cases (0.13% [95% confidence
interval {CI} 0.04–0.39%). Another 1427 patients where
positive identification was not obtained were treated for
a presumed opioid overdose and released at the scene.
Follow-up could not be obtained for any of these patients.
Assessment for Deaths in Out-of-Hospital Heroin
Overdose Patients Treated with Naloxone Who Refuse
Transport
Population. This study included all patients with suspected opioid overdoses evaluated by San Diego EMS
or a mobile intensive care nurse (MICN) from 1996
to 2000 (12).
54
Study design. This was a retrospective chart review
conducted using the San Diego County Quality Assurance Network database and the San Diego County Medical Examiner’s (ME) Office database. A list was
compiled of all paramedic responses in San Diego
County in which a patient received naloxone and signed
out AMA before transport. A second list was compiled
of all cases in the ME database in which a metabolite
of morphine was noted as contributing to the cause of
death. The 2 lists were cross-referenced to identify any
patients treated with naloxone by paramedics within
12 h preceding the time of death documented by the
ME’s office.
Primary outcome. The primary outcome was the death
from rebound opioid toxicity within 12 h of being
released by San Diego EMS or MICN.
Exclusion criteria. Patients who received naloxone
and were subsequently released by EMS without transport that were later confirmed dead within 12 h having
morphine listed as a contributory cause of death on the
ME’s report were included in the study. Patients not
meeting these criteria were excluded.
Main results. There were 998 patients identified who
received naloxone and were released AMA by the paramedics. The mean age was 37.7 years, and 83.8% were
male. There were 601 deaths reported by the ME database in which morphine was listed as contributing to
the cause of death. The mean age of these patients was
40.1 years, and 83.6% were male. After crossreferencing these lists, no deaths attributable to an opioid
overdose, identified by the presence of a morphine
metabolite on toxicology screening, could be identified
within 12 h of naloxone administration by EMS (0%;
95% CI 0–0.37%).
No Deaths Associated with Patient Refusal of Transport
After Naloxone-Reversed Opioid Overdose
Population. All patients successfully treated with
naloxone by the San Antonio Fire Department (SAFD)
EMS for suspected opioid overdose that were not transported to the hospital were included (13).
Study design. SAFD EMS retrospectively reviewed
electronic medical records of all patients presenting
with opioid toxicity that were not transported after
receiving naloxone. Patients with a normal mental status
and normal vital signs after receiving naloxone were
allowed to refuse hospital transport and were released
at the scene. The authors compiled a report of all patients
who received naloxone and were not transported during a
20-month period from November 2007 to June 2009. The
ME cross-referenced that list for any fatalities in their
system and then made a separate list of all deaths that
occurred within either 48 h or 30 days of the patient being
D. Kolinsky et al.
released by SAFD EMS. The ME also manually searched
their database for any patients matching the description of
a patient that was treated and released by SAFD.
Primary outcome. The primary outcome was 48-h
mortality in patients who were successfully treated with
naloxone and not transported to the hospital.
Exclusion criteria. Patients who could not be resuscitated and died in the field or who were transported to the
hospital were excluded.
Main results. SAFD treated 1700 patients with
naloxone, of which 552 patients refused transport. The
cohort consisted of mostly male patients (72%), with an
average age of 38 years (range 13–91 years). No attempt
was made to identify the opioid that the patient used or
the route of ingestion. Nine deaths were identified by
the ME’s office, with only 2 occurring within 30 days
of treatment by SAFD. The first patient died from a combined ingestion of heroin and cocaine 4 days after being
released. The second patient died from a gunshot wound
7 days after being released.
Recurrent Opioid Toxicity After Prehospital Care of
Presumed Heroin Overdose Patients
Population. All patients with presumed heroin overdoses
who were evaluated by Helsinki EMS from 1995 to 2000
were included (14).
Study design. EMS records from Helsinki were retrospectively reviewed for patients presenting after a presumed opioid overdose. In addition to symptoms,
patients must have been witnessed using heroin or had
circumstantial evidence of drug use. Patients with a suspected opioid overdose with a Glasgow Coma Score
(GCS) #8 were considered as overdoses, even in the
absence of respiratory depression, and were treated
with naloxone. Patients were considered to be naloxone
responders if their GCS improved to >8, their respiratory
rate was >12 breaths/min, and their peripheral oxygen
saturations were >90%. In addition to their name and
date of birth, EMS records included the type of opioid
used and the route of administration. Data from all patients who were treated and released were compared to
both the ME records and cardiac arrest database to determine if any patients died within 12 h of being released. Of
note, Helsinki EMS differs in that it is organized into a
3-tier system, with the first 2 tiers consisting of firemen
or paramedics. The third tier is a mobile intensive care
unit staffed by emergency medical technician/firemen
and an emergency physician.
Primary outcome. The primary outcome was death
within 12 h after evaluation and treatment by Helsinki
EMS.
Exclusion criteria. Patients who suffered from signs
and symptoms of heroin overdose that were witnessed
Prehospital Treat and Release After Naloxone?

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Figure 1. Evidence-based medicine teaching points.
using heroin or showed evidence of drug use evaluated
and treated by Helsinki EMS that were later confirmed
dead within 12 h. Patients who were not meeting these
criteria were excluded. Patients with polysubstance
ingestion, alcohol use, or the use of any opioid other
than heroin were excluded.
56
D. Kolinsky et al.
Main results. Helsinki EMS treated 269 patients for a
presumed opioid overdose from January 1995 to
December 2000. Of these, 124 patients were excluded,
leaving 145 total patients. Four patients were excluded
because of insufficient data; the rest were excluded
because of coingestion of alcohol, other drugs, or op …
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