Wikipedia:Reference desk/Archives/Science/2018 April 28

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April 28

Deaths from opioid withdrawal

How often do people die due to complications of opioid WITHDRAWAL?

I'm hoping for a good reference that says it's rare, as a coworker has claimed that it is a common occurrence in the United States today. Thank you any help you can provide, and have a nice day. :) — Preceding unsigned comment added by 2600:100E:B010:D644:B13E:8816:6408:E067 (talk) 14:50, 28 April 2018 (UTC)

Yes, people can die from opiate withdrawal: "Death is an uncommon, but catastrophic, outcome of opioid withdrawal. The complications of the clinical management of withdrawal are often underestimated..."

Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.

Alansplodge (talk) 16:33, 28 April 2018 (UTC)

Thank you!

From the first link: "How could someone die during opiate withdrawal? The answer lies in the final two clinical signs presented above, vomiting and diarrhoea. Persistent vomiting and diarrhoea may result, if untreated, in dehydration, hypernatraemia (elevated blood sodium level) and resultant heart failure."

That strongly supports my belief that it is almost impossible to be picked up by an ambulance and die on the way to the hospital from opioid WITHDRAWAL. Which is what my coworker claims happens frequently in the US.

The latter link is a study of the mortality of patients on opioid replacement therapy, so there does not seem to be much mention of death from withdrawal, since anyone in the study experiencing withdrawal would presumably be having those symptoms under medical supervision where, again, they are extremely unlikely to die suddenly of dehydration.

2600:100E:B010:D644:1415:E13:2FA1:9E59 (talk) 19:07, 28 April 2018 (UTC)

That scenario is certainly not impossible. Rehydrating someone who is nearly dead of dehydration is not as simple as giving him a glass of water, and people attending might be afraid to call the ambulance until it's too late to save the person. Death by dehydration is also not a very painful way to go nor does it generally have quick onset and sudden symptoms like heroin overdose, so it might appear a less acute problem to untrained people. 78.0.233.56 (talk) 22:31, 28 April 2018 (UTC)

In adults, opiate withdrawal is uncomfortable but not inherently dangerous, which is why there are several trials that have used naltrexone to induce sudden long-lasting withdrawal in people addicted to heroin or methadone. On the other hand, neonatal withdrawal has a high mortality rate. Klbrain (talk) 23:39, 28 April 2018 (UTC)

It sounds to me like your coworker is mixing up some things. Someone calls an ambulance if they fear someone has overdosed on opioids. In an overdose, death is generally from respiratory arrest, as opioids depress breathing. The initial treatment is immediate administration of naloxone. This reverses the effect of opioids. This can be unpleasant for the person, and there have been instances of people brought out of overdose by emergency personnel and then attacking them. However, EMTs would have to be exceedingly incompetent to let someone die from dehydration or hyponatremia on the way to a hospital. EMTs will be familiar with these, as they're reasonably common in emergency settings, and will commence treatment, such as intravenous fluids, if they suspect it. --47.146.63.87 (talk) 07:23, 29 April 2018 (UTC)

According to [1] and [2] [3], other than the aforementioned risk of combativeness from the patient one of the other issues is that after administration of naloxone the patient may simply refuse to go to hospital due to some combination of fear of prosecution and having no desire to try and overcome their addiction.

The second source also mentions that the there is a risk of aspiration of vomit especially if too much naloxone is given or it's given too fast. Paramedics would likely have sufficient training to avoid this, but naloxone may also be given by other first responders like the police or even bystanders who may have less training. I doubt that deaths are common once paramedics are there or if they are taken to hospital, but it would complicate management.

This guidance on prehospital treatment of opioid related emergencies [4] may be of interest. It mentions for example that many cases involve comorbidities such as multiple drugs so need to be handled accordingly. (It does mention the role of lay responders including them administering naloxone. It also mentions that despite common concerns, it is unlikely limited naloxone administration will lead to severe withdrawal symptoms.)

Refusing follow up treatment leads to obvious concerns over whether the patient may overdose perhaps even on what's already in the system (since the effect of the opioids often outlasts naloxone) or by taking more perhaps due to their lost high. An older study found no evidence for this [5].

But a more recent albeit I think unpublished (only presented in a conference) mentioned in this abstract [6] and in this blog found that while 80% of these patients survived a year, over 6.5% died within the day, and 9.3% within the year. Of the 10% of so who died within a year excluding those who died the same day, around 50% died within a month. All these taken together seem to suggest many of those who receive naloxone are at a critical stage were follow up treatment is desirable including both short term to ensure no further problems in a hospital or similar and longer term in whatever environment to help manage the addiction and whatever other problems they face that may be contributing (e.g. mental illness). Somewhat mentioned by the sources, beyond getting them to a hospital which may be a way to try and get them into such long term treatment, it also needs to be available and you need to come up with strategies to maximise chances of convincing them into follow up treatment. E.g. [7] (This source also mentions another issue, even if they get to hospital they may soon leave, so it's helpful if these efforts come as soon as possible.)

BTW, of some limited (since we're talking about people who have received naloxone not people going through normal withdrawal) relevance to the original question: The author of the study on deaths after refusing treatment also did this published study that only identified 2 deaths that occurred near the time of transport out of 105 patients [8]. (If I understand what they are saying correctly, one died in hospital, one died after treatment.) Although it's possible their methodology would have missed deaths in the ambulance, if these people were dead on arrival and never admitted. (And I guess they would have been missed by the other study on those refusing treatment. Still if this really were happening a lot I strongly suspect there would have been enough knowledge of it that it would have been looked at.)

Even more minor relevance to the original question, some of the earlier sources and [9] mention another issue namely mention that some paramedics or other first responders may refuse to perform CPR and take great care to protect themselves due to concern over hazards at the scene especially fentanyl which a potent opiod which can have an effect simply from skin contact. (These are more likely to be an issue before the patient is in the ambulance.)

Some have express concern over the cost or moral hazard or risks to responders from naloxone treatment and are suggesting usage should be reduced or restricted [10] [11] [12] [13] [14]. The cost issue is well recognised even outside such discussions [15] [16]. I'm sure if you'll look you'll also find discussions on how while a lot of money be spent on treating opioid related emergencies, a lot less is spent on treatment for addicts including related issues which may be contributing to their addiction. And it isn't just because people are refusing treatment.

15:05, 29 April 2018 (UTC)

While I don't think deaths in am ambulance are likely, I don't think you can assume people with withdrawal will be doing it under medical supervision. Treatment centres are often very stretched when there is a addiction epidemic. Of course many people are going to quickly fail and so will have limited withdrawal if they attempt to beat it with limited support but if you have a lot of cases it's likely you'll still have a fair few who don't have medical supervision and are trying to overcome their addiction. In addition, withdrawal may not always be entirely by choice if someone with a problem has trouble getting another 'hit'. Note I'm also not saying that this means there is any significant chance of them dying from withdrawal even outside an ambulance. Nil Einne (talk) 15:12, 29 April 2018 (UTC)

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