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Copyright (c) 2025 Nadia Mohammed Hassan Khormi, Tahani Mari Madine Alsayed, Ruba Ahmed Bakr Najjar, Nouf Abdullah Mohammad Alraee, Amal Mohammed Ali Alsabai, Manal Abdullhadi Abdullah Alshehri, Sameer Ali Ibrahim Zakri, Asma Saud Alanazi, Mai Fhaid Alshammari, Hend Fihaid Alshammari
This work is licensed under a Creative Commons Attribution 4.0 International License.
A Comprehensive Narrative Review of Protocol Development for Acute Opioid Overdose Events in Outpatient Clinic Waiting Rooms: Integrating Emergency Response, Public Health Surveillance, and Institutional Policy
Corresponding Author(s) : Nadia Mohammed Hassan Khormi
Saudi Journal of Medicine and Public Health,
Vol. 2 No. 2 (2025)
Abstract
Background: The opioid overdose crisis represents a significant global public health emergency, with mortality increasingly occurring in non-traditional settings, including healthcare facilities. Clinic waiting rooms, as points of first contact, are high-risk environments where overdoses may occur unexpectedly, presenting complex clinical, ethical, and administrative challenges that intersect clinical medicine, public health surveillance, and legal frameworks.
Aim: This narrative review synthesizes current evidence and best practices to formulate a comprehensive protocol for managing acute opioid overdose in clinic waiting rooms, with specific emphasis on integrated public health reporting systems, standardized incident documentation, and clear guidelines for law enforcement notification, particularly through the role of the medical secretary.
Methods: A systematic search of electronic databases (PubMed, Scopus, CINAHL, PsycINFO) was conducted for literature published between 2010 and 2024.
Results: Effective management requires a tiered response: immediate emergency intervention with intramuscular or intranasal naloxone by trained first responders, followed by structured post-resuscitation care. Notification of law enforcement must be guided by strict protocols balancing legal mandates, patient confidentiality, and harm reduction principles, with the medical secretary playing a pivotal administrative and coordinating role.
Conclusion: A pre-emptive, protocol-driven approach that integrates clinical emergency response with robust administrative procedures for incident documentation and judicious external notification is paramount. This strategy not only improves individual patient outcomes but also strengthens institutional preparedness and contributes to broader public health efforts to mitigate the opioid crisis.
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- Azharuddin, S., Ogbebor, O., Shuster, M., Smith, B., Arshad, H., & Cheema, T. (2023). Toxicological emergencies. Critical Care Nursing Quarterly, 46(1), 82-99. DOI: 10.1097/CNQ.0000000000000439
- Bagley, S. M., Schoenberger, S. F., Waye, K. M., & Walley, A. Y. (2019). A scoping review of post opioid-overdose interventions. Preventive medicine, 128, 105813. https://doi.org/10.1016/j.ypmed.2019.105813
- Beaugard, C. A., Hruschak, V., Lee, C. S., Swab, J., Roth, S., & Rosen, D. (2023). Emergency medical services on the frontlines of the opioid overdose crisis: the role of mental health, substance use, and burnout. International Journal of Emergency Services, 12(1), 91-102. https://doi.org/10.1108/IJES-11-2021-0073
- Beletsky, L., & Davis, C. S. (2017). Today’s fentanyl crisis: Prohibition’s Iron Law, revisited. International Journal of Drug Policy, 46, 156-159. https://doi.org/10.1016/j.drugpo.2017.05.050
- Beletsky, L., Ruthazer, R., Macalino, G. E., Rich, J. D., Tan, L., & Burris, S. (2007). Physicians’ knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities. Journal of Urban Health, 84(1), 126-136. https://doi.org/10.1007/s11524-006-9120-z
- Centers for Disease Control and Prevention. (2023). Drug overdose deaths. National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db522.htm
- Clark, A. K., Wilder, C. M., & Winstanley, E. L. (2014). A systematic review of community opioid overdose prevention and naloxone distribution programs. Journal of addiction medicine, 8(3), 153-163. DOI: 10.1097/ADM.0000000000000034
- Coffin, P. O., & Sullivan, S. D. (2013). Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in Russian cities. Journal of medical economics, 16(8), 1051-1060. https://doi.org/10.3111/13696998.2013.811080
- Collins, A. B., Baird, J., Nimaja, E., Ashenafi, Y., Clark, M. A., & Beaudoin, F. L. (2023). Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department. BMC health services research, 23(1), 370. https://doi.org/10.1186/s12913-023-09387-7
- Daniulaityte, R., Juhascik, M. P., Strayer, K. E., Sizemore, I. E., Zatreh, M., Nahhas, R. W., ... & Carlson, R. G. (2019). Trends in fentanyl and fentanyl analogue-related overdose deaths–Montgomery County, Ohio, 2015–2017. Drug and alcohol dependence, 198, 116-120. https://doi.org/10.1016/j.drugalcdep.2019.01.045
- Fortune, S., Pavlova, A., Hetrick, S. E., Scarth, B., Hawton, K., & Witt, K. G. (2021). First Responder, clinician, and non‐clinical support staff knowledge, attitudes, and behaviours towards people presenting for emergency care following self‐harm: a mixed evidence synthesis. The Cochrane Database of Systematic Reviews, 2021(12), CD014939. https://doi.org/10.1002/14651858.CD014939
- Gatewood, A. K., Van Wert, M. J., Andrada, A. P., & Surkan, P. J. (2016). Academic physicians' and medical students' perceived barriers toward bystander administered naloxone as an overdose prevention strategy. Addictive behaviors, 61, 40-46. https://doi.org/10.1016/j.addbeh.2016.05.013
- Green, T. C., Case, P., Fiske, H., Baird, J., Cabral, S., Burstein, D., ... & Bratberg, J. (2017). Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states. Journal of the American Pharmacists Association, 57(2), S19-S27. https://doi.org/10.1016/j.japh.2017.01.013
- Hamilton, L., Davis, C. S., Kravitz-Wirtz, N., Ponicki, W., & Cerdá, M. (2021). Good Samaritan laws and overdose mortality in the United States in the fentanyl era. International Journal of Drug Policy, 97, 103294. https://doi.org/10.1016/j.drugpo.2021.103294
- Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936.
- Kennedy, L. C., Binswanger, I. A., Mueller, S. R., Levy, C., Matlock, D. D., Calcaterra, S. L., ... & Frank, J. W. (2018). “Those conversations in my experience don’t go well”: A qualitative study of primary care provider experiences tapering long-term opioid medications. Pain medicine, 19(11), 2201-2211. https://doi.org/10.1093/pm/pnx276
- Kerr, D., Kelly, A. M., Dietze, P., Jolley, D., & Barger, B. (2009). Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction, 104(12), 2067-2074. https://doi.org/10.1111/j.1360-0443.2009.02724.x
- Martin, R. A., Alexander-Scott, N., Berk, J., Carpenter, R. W., Kang, A., Hoadley, A., ... & Clarke, J. G. (2023). Post-incarceration outcomes of a comprehensive statewide correctional MOUD program: a retrospective cohort study. The Lancet Regional Health–Americas, 18. https://doi.org/10.1016/j.lana.2022.100419
- Natale, I., Harvey, C., Wood, P., & Anderson, K. (2023). “It can save your life, that's all I know,” barriers and facilitators for engagement in take-home naloxone for people receiving opioid substitution treatment in regional Australia: An explorative study. Qualitative Research in Medicine & Healthcare, 7(2), 10868. https://doi.org/10.4081/qrmh.2023.10868
- Neale, J., Farrugia, A., Campbell, A. N., Dietze, P., Dwyer, R., Fomiatti, R., ... & Strang, J. (2022). Understanding preferences for type of take-home naloxone device: international qualitative analysis of the views of people who use opioids. Drugs: Education, Prevention and Policy, 29(2), 109-120. https://doi.org/10.1080/09687637.2021.1872499
- Nelson, L. S., & Goldfrank, L. R. (2019). Goldfrank's toxicologic emergencies. (No Title).
- O’Donovan, R., & McAuliffe, E. (2020). A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour. BMC health services research, 20(1), 101. https://doi.org/10.1186/s12913-020-4931-2
- Romero, R. B., Sánchez-Lira, J. A., Pasaran, S. S., Rivera, A. C., Corral, L. A., Salimian, A., ... & Goodman-Meza, D. (2023). Implementing a decentralized opioid overdose prevention strategy in Mexico, a pending public policy issue. The Lancet Regional Health–Americas, 23. https://doi.org/10.1016/j.lana.2023.100535
- Rzasa Lynn, R., & Galinkin, J. L. (2018). Naloxone dosage for opioid reversal: current evidence and clinical implications. Therapeutic advances in drug safety, 9(1), 63-88. https://doi.org/10.1177/2042098617744161
- Samuels, E. A., Dwyer, K., Mello, M. J., Baird, J., Kellogg, A. R., & Bernstein, E. (2016). Emergency department‐based opioid harm reduction: moving physicians from willing to doing. Academic Emergency Medicine, 23(4), 455-465. https://doi.org/10.1111/acem.12910
- Strang, J., McDonald, R., Campbell, G., Degenhardt, L., Nielsen, S., Ritter, A., & Dale, O. (2019). Take-home naloxone for the emergency interim management of opioid overdose: the public health application of an emergency medicine. Drugs, 79(13), 1395-1418. https://doi.org/10.1007/s40265-019-01154-5
- Weiner, S. G., Baker, O., Bernson, D., & Schuur, J. D. (2020). One-year mortality of patients after emergency department treatment for nonfatal opioid overdose. Annals of emergency medicine, 75(1), 13-17. https://doi.org/10.1016/j.annemergmed.2019.04.020
- Wermeling, D. P. (2015). Review of naloxone safety for opioid overdose: practical considerations for new technology and expanded public access. Therapeutic advances in drug safety, 6(1), 20-31. https://doi.org/10.1177/2042098614564776
- Wolff, J., Gitukui, S., O'Brien, M., Mital, S., & Noonan, R. K. (2022). The overdose response strategy: reducing drug overdose deaths through strategic partnership between public health and public safety. Journal of public health management and practice, 28(Supplement 6), S359-S366. DOI: 10.1097/PHH.0000000000001580
- World Health Organization. (2014). Community management of opioid overdose. World Health Organization.
- Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: a team effectiveness framework and evidence-based guidance. Frontiers in Communication, 6, 606445. https://doi.org/10.3389/fcomm.2021.606445
References
Azharuddin, S., Ogbebor, O., Shuster, M., Smith, B., Arshad, H., & Cheema, T. (2023). Toxicological emergencies. Critical Care Nursing Quarterly, 46(1), 82-99. DOI: 10.1097/CNQ.0000000000000439
Bagley, S. M., Schoenberger, S. F., Waye, K. M., & Walley, A. Y. (2019). A scoping review of post opioid-overdose interventions. Preventive medicine, 128, 105813. https://doi.org/10.1016/j.ypmed.2019.105813
Beaugard, C. A., Hruschak, V., Lee, C. S., Swab, J., Roth, S., & Rosen, D. (2023). Emergency medical services on the frontlines of the opioid overdose crisis: the role of mental health, substance use, and burnout. International Journal of Emergency Services, 12(1), 91-102. https://doi.org/10.1108/IJES-11-2021-0073
Beletsky, L., & Davis, C. S. (2017). Today’s fentanyl crisis: Prohibition’s Iron Law, revisited. International Journal of Drug Policy, 46, 156-159. https://doi.org/10.1016/j.drugpo.2017.05.050
Beletsky, L., Ruthazer, R., Macalino, G. E., Rich, J. D., Tan, L., & Burris, S. (2007). Physicians’ knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities. Journal of Urban Health, 84(1), 126-136. https://doi.org/10.1007/s11524-006-9120-z
Centers for Disease Control and Prevention. (2023). Drug overdose deaths. National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db522.htm
Clark, A. K., Wilder, C. M., & Winstanley, E. L. (2014). A systematic review of community opioid overdose prevention and naloxone distribution programs. Journal of addiction medicine, 8(3), 153-163. DOI: 10.1097/ADM.0000000000000034
Coffin, P. O., & Sullivan, S. D. (2013). Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in Russian cities. Journal of medical economics, 16(8), 1051-1060. https://doi.org/10.3111/13696998.2013.811080
Collins, A. B., Baird, J., Nimaja, E., Ashenafi, Y., Clark, M. A., & Beaudoin, F. L. (2023). Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department. BMC health services research, 23(1), 370. https://doi.org/10.1186/s12913-023-09387-7
Daniulaityte, R., Juhascik, M. P., Strayer, K. E., Sizemore, I. E., Zatreh, M., Nahhas, R. W., ... & Carlson, R. G. (2019). Trends in fentanyl and fentanyl analogue-related overdose deaths–Montgomery County, Ohio, 2015–2017. Drug and alcohol dependence, 198, 116-120. https://doi.org/10.1016/j.drugalcdep.2019.01.045
Fortune, S., Pavlova, A., Hetrick, S. E., Scarth, B., Hawton, K., & Witt, K. G. (2021). First Responder, clinician, and non‐clinical support staff knowledge, attitudes, and behaviours towards people presenting for emergency care following self‐harm: a mixed evidence synthesis. The Cochrane Database of Systematic Reviews, 2021(12), CD014939. https://doi.org/10.1002/14651858.CD014939
Gatewood, A. K., Van Wert, M. J., Andrada, A. P., & Surkan, P. J. (2016). Academic physicians' and medical students' perceived barriers toward bystander administered naloxone as an overdose prevention strategy. Addictive behaviors, 61, 40-46. https://doi.org/10.1016/j.addbeh.2016.05.013
Green, T. C., Case, P., Fiske, H., Baird, J., Cabral, S., Burstein, D., ... & Bratberg, J. (2017). Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states. Journal of the American Pharmacists Association, 57(2), S19-S27. https://doi.org/10.1016/j.japh.2017.01.013
Hamilton, L., Davis, C. S., Kravitz-Wirtz, N., Ponicki, W., & Cerdá, M. (2021). Good Samaritan laws and overdose mortality in the United States in the fentanyl era. International Journal of Drug Policy, 97, 103294. https://doi.org/10.1016/j.drugpo.2021.103294
Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936.
Kennedy, L. C., Binswanger, I. A., Mueller, S. R., Levy, C., Matlock, D. D., Calcaterra, S. L., ... & Frank, J. W. (2018). “Those conversations in my experience don’t go well”: A qualitative study of primary care provider experiences tapering long-term opioid medications. Pain medicine, 19(11), 2201-2211. https://doi.org/10.1093/pm/pnx276
Kerr, D., Kelly, A. M., Dietze, P., Jolley, D., & Barger, B. (2009). Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction, 104(12), 2067-2074. https://doi.org/10.1111/j.1360-0443.2009.02724.x
Martin, R. A., Alexander-Scott, N., Berk, J., Carpenter, R. W., Kang, A., Hoadley, A., ... & Clarke, J. G. (2023). Post-incarceration outcomes of a comprehensive statewide correctional MOUD program: a retrospective cohort study. The Lancet Regional Health–Americas, 18. https://doi.org/10.1016/j.lana.2022.100419
Natale, I., Harvey, C., Wood, P., & Anderson, K. (2023). “It can save your life, that's all I know,” barriers and facilitators for engagement in take-home naloxone for people receiving opioid substitution treatment in regional Australia: An explorative study. Qualitative Research in Medicine & Healthcare, 7(2), 10868. https://doi.org/10.4081/qrmh.2023.10868
Neale, J., Farrugia, A., Campbell, A. N., Dietze, P., Dwyer, R., Fomiatti, R., ... & Strang, J. (2022). Understanding preferences for type of take-home naloxone device: international qualitative analysis of the views of people who use opioids. Drugs: Education, Prevention and Policy, 29(2), 109-120. https://doi.org/10.1080/09687637.2021.1872499
Nelson, L. S., & Goldfrank, L. R. (2019). Goldfrank's toxicologic emergencies. (No Title).
O’Donovan, R., & McAuliffe, E. (2020). A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour. BMC health services research, 20(1), 101. https://doi.org/10.1186/s12913-020-4931-2
Romero, R. B., Sánchez-Lira, J. A., Pasaran, S. S., Rivera, A. C., Corral, L. A., Salimian, A., ... & Goodman-Meza, D. (2023). Implementing a decentralized opioid overdose prevention strategy in Mexico, a pending public policy issue. The Lancet Regional Health–Americas, 23. https://doi.org/10.1016/j.lana.2023.100535
Rzasa Lynn, R., & Galinkin, J. L. (2018). Naloxone dosage for opioid reversal: current evidence and clinical implications. Therapeutic advances in drug safety, 9(1), 63-88. https://doi.org/10.1177/2042098617744161
Samuels, E. A., Dwyer, K., Mello, M. J., Baird, J., Kellogg, A. R., & Bernstein, E. (2016). Emergency department‐based opioid harm reduction: moving physicians from willing to doing. Academic Emergency Medicine, 23(4), 455-465. https://doi.org/10.1111/acem.12910
Strang, J., McDonald, R., Campbell, G., Degenhardt, L., Nielsen, S., Ritter, A., & Dale, O. (2019). Take-home naloxone for the emergency interim management of opioid overdose: the public health application of an emergency medicine. Drugs, 79(13), 1395-1418. https://doi.org/10.1007/s40265-019-01154-5
Weiner, S. G., Baker, O., Bernson, D., & Schuur, J. D. (2020). One-year mortality of patients after emergency department treatment for nonfatal opioid overdose. Annals of emergency medicine, 75(1), 13-17. https://doi.org/10.1016/j.annemergmed.2019.04.020
Wermeling, D. P. (2015). Review of naloxone safety for opioid overdose: practical considerations for new technology and expanded public access. Therapeutic advances in drug safety, 6(1), 20-31. https://doi.org/10.1177/2042098614564776
Wolff, J., Gitukui, S., O'Brien, M., Mital, S., & Noonan, R. K. (2022). The overdose response strategy: reducing drug overdose deaths through strategic partnership between public health and public safety. Journal of public health management and practice, 28(Supplement 6), S359-S366. DOI: 10.1097/PHH.0000000000001580
World Health Organization. (2014). Community management of opioid overdose. World Health Organization.
Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: a team effectiveness framework and evidence-based guidance. Frontiers in Communication, 6, 606445. https://doi.org/10.3389/fcomm.2021.606445