January 21, 2019

The HOUR Trial: Clinical Decision Rule for Opioid Overdose Patients in the Emergency Department

Background Information: In 2017, more than two-thirds of the 70,000 drug overdose deaths in the United States involved an opioid.¹ Many emergency departments are affected as opioid overdoses increased 30% from July 2016 through September 2017 in 52 areas in 45 states.² With the half-life of naloxone being between 60-90 minutes the appropriate disposition and observation time of these patients following naloxone reversal continues to be debated in the literature.^3,4, A study on heroin overdose patients treated and released by pre-hospital providers showed no deaths in the one-year period studied.⁵ While this only applies to isolated heroin use, other studies have shown no increased incidence of death within 48 hours of patients treated with naloxone for non-fentanyl opioid overdoses.^6,7 Many of these studies, however, suffer from poor follow up which is unsurprising given the difficulty in tracking patients with opiate use disorders. It is important to note that the increased presence of synthetic and long-acting opioids further complicates this topic. A systematic review of a clinical prediction rule known as the St. Paul’s Early Discharge Rule, concluded that ambulatory patients with normal vital signs, and a Glasgow Coma Scale (GCS) of 15 only needed 1 hour of observation prior to discharge.^8,9 The authors of this study sought to validate this single center derived rule and its six criteria.