Although I was not able to find any newer protocols for the treatment of overdoses in the emergency room, I have a few comments I would like to make about tragedies such as this and the linked guidelines.

First, while the flowchart in the NEJM article mentioned the consideration of discharge after 4-6 hours of observation (post naloxone infusion given the obtainment of normal vitals), the supplementary writing suggests that 12-24 hours of care are needed when a continuous naloxone infusion is administered. It is interesting, that both yourself, and the health professionals treating the deceased patient, both cited/exercised 6 hours of observation. While you noted the apparent inadequacy of this; the treating physicians deemed this acceptable. The treating physicians were most likely familiar with these guidelines which seems to suggest a very real danger of a paint-by-numbers approach to medicine. Instead of recognizing the caveat printed in the NEJM article, most individuals appear to simply focus on the algorithm presented.

Second, a few things about the events leading to the death of the patient. It is odd, that during the 6-hours of observation, the guidelines do not place a specific recommendation for the use of toxicology screening to identify the specific opioid or the presence of polysubstance use. Maybe the physicians who treated the deceased patient performed this screening, but this seems unlikely as people love to report on the atrocities caused by specific opioid agents. Also, I would like to know why this person was arrested and incarcerated. Unless she had some quantity of illicit drugs on her person, there doesn't seem to be cause for arrest. It is disgusting that law enforcement officers view drug users as criminals and circumvent reasonable thought in order to get a pat on the back from extreme teetotalers (unless of course there was a legitimate reason for arrest). Additionally, why was this woman allowed to die in the jail, did nobody check on a compromised inmate who was just released from the emergency room for a drug overdose as few hours ago? While respiratory depression (maybe?) was the means by which the patient/inmate died, the real cause of death appears to be negligence. 

Third, the most reprehensible thing in the passing of the unconscious female motorist, was her opioid overdose was extremely treatable (as evidenced by this person’s temporary recovery). This is the real tragedy of these deaths; they can be easily prevented. At this point, I need to rant on the ramifications of sensationalizing deaths resulting from opioids. Thanks to the superfluous war on drugs, people seem to views occurrences such as this as proof that these substances are a treacherous societal scourge. This is a major component in the push for physicians to avoid the use of opioids/opiates in treating patients. This is foolishness and other analgesics (NSAIDs, acetaminophen, etc.) are similarly dangerous (though possibly less fatal [Solomon et al., 2010]) and, therefore, do not make the choice of pain management any simpler.

Most of this content is somewhat irrelevant, but I just thought I would share my views on the failings of overdose management. I am glad to see that someone (you) recognized the insufficient guidelines in treating these occurrences.  

References: 

Solomon DH, Rassen JA, Glynn RJ, Lee J, Levin R, Schneeweiss S. The comparative sagety of analgesics in older adults with arthritis. Arch Intern Med. 2010;170(22):1968-1978.

I agree with most of your comments.  I read the caveats in the NEJM article, but I wasn't trying to suggest that the ED doc at SIU Hospital was following the article, rather the "one size fits all" (or as you put it, "paint by numbers") algorithm that is part of their rule book.  I was just rather surprised that the "latest" protocol for opioid overdose management, coming at a time when the CDC has just published a report calling on the medical community to combat stunning mortality and morbidity of the addiction epidemic, was a 2012 article in NEJM, which I think of as a "Reader's Digest" of the medical literature.  Where is a well-thought out protocol?  I couldn't find one.

To answer your question regarding arrest, I believe the deceased was found with a friend, both of whom were unconscious, and at least the driver was charged with driving under the influence of alcohol or narcotics under New York State Law.  I am just recounting what I remember.  I don't know what the passenger was charged with, but any amount of unprescribed controlled substance would constitute sufficient grounds for arrest in New York state.  I'm not saying that's how it *should* be, just how it is.

I do think the jail/NYPD should have more screening when incarcerating arrestees.  I think in this case, there may have been a mistaken belief that SIU Hospital had given the pt a "clean bill of health".  We don't know what the cause of death was, but it could have been BOTH respiratory depression AND negligence, no?

We are making some progress in destigmatizing addiction, and gains in pushing for treatment before or instead of punishment.  I think the opioid crisis cuts both ways here. For more on stigmatisation, see the copious work of Sarah Wakeman, MD, at Harvard/MGH and others.  Progress is slowly being made.

I certainly concur that, notwithstanding the correlations between pain management and addiction, coercing prescribers to avoid opioids is not the answer.  Should pain management prescribers adhere to common sense in quantity and frequency of dosage?  Obviously.  Should opioids themselves, which are an indispensable component of the PM pharmacopeia, be vilified in that context?  Obviously not - point well taken.  

The truly sad point here is that a young woman died needlessly, while (apparently) both the docs and the cops followed "the rules".  The rules need to be fixed.  It is really disturbing, as you point out, that a resuscitated patient was allowed to slip back into a coma and die because a rule book somewhere says that 6 hours of "stable vital signs" is sufficient for discharge.  I'm not blaming anyone here but the rule book itself.  

ED's usually test for nine drugs including multiple forms of opiates including methadone. If she had tested positive for this, than the observation period should have been longer 

Which 9, out of curiosity, in your experience?  Thanks. 

1. Amphetamine

2. Barbiturate

3. Benzodiazepine

4. Cannabinoid (Marijuana)

5. Phencyclidine (PCP)

6. Tricyclic (Antidepressants)

7. Cocaine

8. Methadone

9. Opiates

I'm guessing that alcohol could also interact with opioids (including methadone) to increase the lethality (and potentially affect the half-life, etc).  We are developing a protocol for testing a technology-based tox-screen in the ED when pts present with signs of voluntary substance overuse.  We are looking at 5 categories: (1) opioids (methadone, diacetylmorphine (Heroin), oxycodone primarily); (2) GABA-ergic anxiolytics (benzodiazepines and barbiturates primarily); (3) cannabis; (4) stimulants (amphetamines, methylphenidate, and cocaine primarily); and (5) alcohol.  Does anyone think, from a psychopharmacological or neurophysiological perspective, that we are either (a) leaving out critical substances, e.g. phencyclidine, tricyclics, etc or (b) lumping together substances, e.g. benzodiazepines and barbiturates in an improper way?  Any comments most welcome.    [N.B. We based our decision to exclude, for example, PCP on the basis that that background probabilities for presence are low and presentations similarly are rare.  But if there are any ED / A&E docs out there who see these substances more frequently, it would be very helpful to know sooner than later.  Thanks.]