What is the best course of action for a patient with a suspected narcotics overdose who refuses medical treatment in the emergency room?

Management of Narcotics Overdose Patient Refusing Emergency Treatment

Patients who have been successfully resuscitated from opioid overdose with naloxone and refuse transport or further treatment must be counseled about the risk of recurrent respiratory depression, but if they demonstrate normal mental status, normal vital signs, and can ambulate normally after a brief observation period, they may be allowed to refuse care following local protocols for determination of capacity. 1

Immediate Risk Assessment

When a patient refuses treatment after naloxone administration for suspected opioid overdose, you must rapidly assess their capacity to refuse care and their immediate risk for recurrent toxicity:

• Check mental status using Glasgow Coma Scale - the patient must have a GCS of 15 to be considered for safe discharge 2
• Verify vital signs are completely normal - including respiratory rate ≥10 breaths/min, normal blood pressure, and normal oxygen saturation 1, 3
• Observe ambulation - the patient must be able to walk normally without assistance 2
• Document time since naloxone administration - naloxone's duration of action is only 45-70 minutes, which is shorter than most opioids 3

Critical Decision Point: Type of Opioid Matters

The safety of discharge depends heavily on which opioid was involved:

• For short-acting opioids (heroin, fentanyl, immediate-release morphine): A 1-hour observation period after naloxone is sufficient if the patient meets all discharge criteria above 2, 1
• For long-acting or sustained-release opioids: The patient requires extended observation (6-8 hours minimum) in a healthcare facility due to high risk of recurrent toxicity 1, 3, 4
• If the specific opioid is unknown: You must assume worst-case scenario and strongly advocate for transport and extended observation 1

Evidence on Refusal of Transport

Research examining over 5,400 patients who refused transport after prehospital naloxone administration found only 4 deaths from recurrent opioid toxicity, yielding a number needed to transport of 1,361 to save one life 2. However, this data predominantly involved heroin overdoses, not long-acting opioids or polysubstance use 2.

Two studies specifically focused on heroin overdoses included 1,069 patients not transported, with zero deaths 2. This suggests that for confirmed short-acting opioid overdoses in patients meeting strict discharge criteria, refusal of transport carries relatively low mortality risk.

Mandatory Actions Before Allowing Refusal

Even if you determine the patient has capacity to refuse:

• Provide explicit warnings about the risk of recurrent respiratory depression occurring hours after apparent recovery 1, 3
• Distribute take-home naloxone with instructions for bystanders or family members 1, 5
• Provide opioid overdose education to the patient and any available contacts 1, 6
• Arrange psychiatric evaluation if this was a suicide attempt or if resources allow 4, 5
• Offer referrals to medication-assisted treatment and harm reduction programs 5, 6
• Document the patient's mental status, vital signs, and your assessment of decision-making capacity thoroughly 1

Follow Local Protocols

Prehospital providers faced with patients refusing transport after life-threatening overdose are specifically advised to follow local protocols and practices for determination of patient capacity to refuse care 1. These protocols typically require:

• Consultation with medical control or online physician oversight
• Documentation that the patient understands the risks of refusal
• Verification that the patient is not under the influence of substances impairing judgment
• Witness signatures when possible

Common Pitfalls to Avoid

• Do not assume brief recovery means safety - recurrent CNS and respiratory depression can occur hours after initial naloxone response, particularly with long-acting formulations 1, 3
• Do not discharge based solely on patient insistence - you must objectively verify normal vital signs, GCS 15, and normal ambulation 2
• Do not fail to consider polysubstance use - co-ingestion of benzodiazepines, alcohol, or other CNS depressants increases risk and may require longer observation 4, 7
• Do not skip naloxone distribution - providing take-home naloxone is a Class IIa recommendation and may prevent death from subsequent overdose 1, 5

When Refusal Should Not Be Accepted

You should strongly advocate against discharge and consider involving security, social work, or legal consultation if:

• The patient has altered mental status (GCS <15) 2
• Vital signs remain abnormal 1, 3
• Long-acting or sustained-release opioid involvement is suspected or confirmed 1, 3
• Less than 1 hour has elapsed since naloxone administration for short-acting opioids 2
• Polysubstance overdose is evident 4, 7
• The patient cannot ambulate normally 2
• There is evidence of ongoing intoxication impairing decision-making capacity 1