Treating “heroin” overdose: the past is no guide
November 22, 2016, 12:06 am
Do heroin overdose patients require observation after receiving naloxone? Tillman MW et al. Clin Toxicol 2016 Nov 16:1-7 [Epub ahead of print]
The stated goal of this study was to search the medical literature in an attempt to answer 3 main questions:
- “What are the medical risks to a heroin user who refuses ambulance transfer after naloxone?
- “If the heroin user is treated in the emergency department after naloxone, how long must the be observed prior to discharge?
- “How effective in heroin users is naloxone administered by first responders and bystanders?”
The authors searched Pubmed and Google Scholar for articles relevant to these questions, identifying literature going back to the 1990s. The paper does not report any stringent methods as to how relevant literature was selected, or how chosen papers were analyzed. Nevertheless, the authors concluded . . .
Screw it. By the time I was halfway through the paper, I really didn’t care what the conclusions were. It was clear to me that there was no way that this type of literature review — even if it had much better methods — could provide clinically useful answers to the questions asked. The fact is, first responders and emergency practitioners never deal with “heroin overdose patients.” They treat patients who may have taken an opioid that could be heroin, to some substance they thought was heroin, or something that was given or sold to them purported to be heroin. And “heroin” now may not be anything like the “heroin” on the street when much of the research reviewed by the authors was carried out. Today “heroin” may be some god-awful combination of U-47700, fentanyl, carfentanil, and who knows what else — maybe with some heroin thrown in.
We really don’t know the pharmacokinetics of many of these drugs, and there is no reason to believe that they will be the same as those of heroin. I would suggest that data from a decade or two ago have no certain relevance to what we’re seeing clinically today. Over the last several years we’ve entered a whole new world of street drugs, and unfortunately we can not rely on past experience to guide us.