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Gupta P, Mayampurath A, Gruenloh T, Oguss M, Afshar AS, Spigner M, Gussick M, Churpek M, Lee T, Afshar M. Prior emergency medical services utilization is a risk factor for in-hospital death among patients with substance misuse: a retrospective cohort study. BMC Emerg Med 2024; 24:110. [PMID: 38982351 PMCID: PMC11234660 DOI: 10.1186/s12873-024-01025-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/18/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Substance misuse poses a significant public health challenge, characterized by premature morbidity and mortality, and heightened healthcare utilization. While studies have demonstrated that previous hospitalizations and emergency department visits are associated with increased mortality in patients with substance misuse, it is unknown whether prior utilization of emergency medical service (EMS) is similarly associated with poor outcomes among this population. The objective of this study is to determine the association between EMS utilization in the 30 days before a hospitalization or emergency department visit and in-hospital outcomes among patients with substance misuse. METHODS We conducted a retrospective analysis of adult emergency department visits and hospitalizations (referred to as a hospital encounter) between 2017 and 2021 within the Substance Misuse Data Commons, which maintains electronic health records from substance misuse patients seen at two University of Wisconsin hospitals, linked with state agency, claims, and socioeconomic datasets. Using regression models, we examined the association between EMS use and the outcomes of in-hospital death, hospital length of stay, intensive care unit (ICU) admission, and critical illness events, defined by invasive mechanical ventilation or vasoactive drug administration. Models were adjusted for age, comorbidities, initial severity of illness, substance misuse type, and socioeconomic status. RESULTS Among 19,402 encounters, individuals with substance misuse who had at least one EMS incident within 30 days of a hospital encounter experienced a higher likelihood of in-hospital mortality (OR 1.52, 95% CI [1.05 - 2.14]) compared to those without prior EMS use, after adjusting for confounders. Using EMS in the 30 days prior to an encounter was associated with a small increase in hospital length of stay but was not associated with ICU admission or critical illness events. CONCLUSIONS Individuals with substance misuse who have used EMS in the month preceding a hospital encounter are at an increased risk of in-hospital mortality. Enhanced monitoring of EMS users in this population could improve overall patient outcomes.
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Affiliation(s)
- Preeti Gupta
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA
| | - Anoop Mayampurath
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA
| | - Tim Gruenloh
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA
| | - Madeline Oguss
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA
| | - Askar Safipour Afshar
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA
| | - Michael Spigner
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Megan Gussick
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Matthew Churpek
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA
| | - Todd Lee
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI, 53792, USA
| | - Majid Afshar
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA.
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, 610 Walnut Street, Madison, WI, 53726, USA.
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2
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Naumann J, Benson J, Lamberson M, Hunt S, Moran W, Stevens MW, Wolfson D. At-risk patient documentation and naloxone dispersal for a rural statewide EMS "Naloxone Leave Behind" program. J Am Coll Emerg Physicians Open 2024; 5:e13186. [PMID: 38766594 PMCID: PMC11099750 DOI: 10.1002/emp2.13186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/21/2024] [Accepted: 04/22/2024] [Indexed: 05/22/2024] Open
Abstract
Objectives For successful Naloxone Leave Behind (NLB) programs, Emergency Medical Services (EMS) must identify patients at-risk for opioid overdose. We describe the first year of Vermont's NLB program and report rates of EMS documentation of at-risk patients with subsequent distribution of NLB kits in the subgroup of those refusing transport to an emergency department (ED). Methods This retrospective cohort review of all EMS encounters over 1 year compared on-scene EMS documented to retrospective chart reviewidentified at-risk patients eligible for NLB kit dispersal. EMS was educated to identify at-risk patients through statewide mandatory training modules. At-risk patients were identified by electronic chart review using the same training criteria. As per protocol, patients identified as at-risk by EMS who refuse ED transport are eligible for NLB. NLB-appropriate patients by retrospective chart review without NLB protocol use documentation by EMS were considered "missed." Results Of 110,701 EMS encounters, 2507 (2.4%) were at-risk by chart review. Among these, 793 refused transport to an ED. In this chart-review at-risk non-transported group, EMS documented 407 (51.3%) patients as at-risk by documenting use of the NLB protocol. Of these 407, EMS provided 141 (34.6%) with NLB kits. Fifteen (3.7%) patients refused kits. There were 386 (48.7%) potentially "missed" opportunities for NLB dispersal. Conclusion EMS documented 51.3% of patients eligible for NLB dispersal, with 34.6% receiving kits. There was no documentation for 48.7% of chart-review at-risk patients, suggesting "missed" distribution opportunities. This study highlights the need for improved EMS identification of at-risk patients, EMS documentation adherence, and NLB kit provision.
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Affiliation(s)
- Jesse Naumann
- Department of Emergency MedicineLarner College of Medicine, University of VermontBurlingtonVermontUSA
| | - Jamie Benson
- Department of RadiologyUniversity of VermontBurlingtonVermontUSA
- Division of Acute Care SurgeryDepartment of SurgeryUniversity of VermontBurlingtonVermontUSA
| | - Miles Lamberson
- Department of Emergency MedicineLarner College of Medicine, University of VermontBurlingtonVermontUSA
| | - Samantha Hunt
- Department of Emergency MedicineLarner College of Medicine, University of VermontBurlingtonVermontUSA
- Department of Emergency MedicineDartmouth HealthBurlingtonVermontUSA
| | - William Moran
- Division of Emergency PreparednessResponse, and Injury PreventionVermont Department of HealthBurlingtonVermontUSA
| | - Martha W. Stevens
- Department of Emergency MedicineLarner College of Medicine, University of VermontBurlingtonVermontUSA
| | - Daniel Wolfson
- Department of Emergency MedicineLarner College of Medicine, University of VermontBurlingtonVermontUSA
- Division of Emergency PreparednessResponse, and Injury PreventionVermont Department of HealthBurlingtonVermontUSA
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3
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Taylor JL, Gott J, Weisenthal K, Colicchio P, Dyer S, Komaromy MS. Post-Overdose Extended-Release Buprenorphine Initiation Facilitated by a Partnership Between Emergency Medical Services and an Outpatient Substance Use Disorder Observation Unit. SUBSTANCE USE & ADDICTION JOURNAL 2024:29767342241249386. [PMID: 38736211 DOI: 10.1177/29767342241249386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
BACKGROUND People who experience a nonfatal opioid overdose and receive naloxone are at high risk of subsequent overdose death but experience gaps in access to medications for opioid use disorder. The immediate post-naloxone period offers an opportunity for buprenorphine initiation. Limited data indicate that buprenorphine administration by emergency medical services (EMS) after naloxone overdose reversal is safe and feasible. We describe a case in which a partnership between a low-barrier substance use disorder (SUD) observation unit and EMS allowed for buprenorphine initiation with extended-release injectable buprenorphine after naloxone overdose reversal. CASE A man in his 40's with severe opioid use disorder and numerous prior opioid overdoses experienced overdose in the community. EMS was activated and he was successfully resuscitated with intranasal naloxone, administered by bystanders and EMS. He declined emergency department (ED) transport and consented to transport to a 24/7 SUD observation unit. The patient elected to start buprenorphine due to barriers attending opioid treatment programs daily. His largest barrier was unsheltered homelessness. His severe opioid withdrawal symptoms were successfully treated with 16/4 mg sublingual buprenorphine/naloxone and 300 mg extended-release injectable buprenorphine (XR-buprenorphine), without precipitated withdrawal. Two weeks later, he reported no interval fentanyl use. DISCUSSION We describe the case of a patient successfully initiated onto XR-buprenorphine in the immediate post-naloxone period via a partnership between an outpatient low-barrier addiction programs and EMS. Such partnerships offer promise in expanding buprenorphine access and medication choice, particularly for the high-risk population of patients who decline ED transport.
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Affiliation(s)
- Jessica L Taylor
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Jacqueline Gott
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
- Department of Nursing, Boston Medical Center, Boston, MA, USA
| | - Karrin Weisenthal
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
- Department of Emergency Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Paige Colicchio
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Sophia Dyer
- Department of Emergency Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
- Boston Emergency Medical Services, Boston, MA, USA
| | - Miriam S Komaromy
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
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4
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Friedman NMG, Bivens MJ. Expanding access to substance misuse services through emergency medical services: envisioning a novel partnership for addiction medicine clinicians. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2024; 50:8-11. [PMID: 38212992 DOI: 10.1080/00952990.2023.2286585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/18/2023] [Indexed: 01/13/2024]
Abstract
Emergency medical services (EMS) can be an invaluable ally of addiction medicine clinicians, but the potential role of EMS in combating the opioid epidemic has been under-realized. EMS has historically focused on emergency response and resuscitation in cases of overdose; however, EMS is also well-positioned to build rapport with persons who use drugs (PWUD), provide harm reduction services, and connect PWUD with additional treatment services and resources. A select number of EMS organizations have begun to offer substance-related programming that extends beyond resuscitation, but these offerings remain limited in scope and impact. This perspective argues that addiction medicine clinicians can bolster the ability of EMS to provide high quality substance-related services by engaging in prehospital care education, program development and research, and clinical care. This perspective shares practical strategies for addiction medicine clinicians to partner with EMS and considers several potential barriers that must be overcome, including bureaucratic challenges, variability in the scope of practice of EMS providers across different locations, and limited funding.
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Affiliation(s)
| | - Matthew J Bivens
- Department of Emergency Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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5
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Hossain S, Jackson A, Burkom H, Boyd C. Effects of the First Year of the COVID-19 Pandemic on Utilization of Emergency Medical Services in Maryland. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2024; 30:E5-E13. [PMID: 37966957 DOI: 10.1097/phh.0000000000001843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
BACKGROUND The opioid epidemic in the United States has devastated the lives of individuals and imposed decades-long opportunity costs on the community. METHODS We analyzed Emergency Medical Services (EMS) data from the Maryland Department of Health installation of the Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE) to assess the impact of COVID-19 on EMS call volume and how COVID-19 impacted patients' decisions whether to accept transport to a hospital following an EMS call. RESULTS The rate of patients accepting transportation via EMS to a hospital emergency department (ED) declined for both opioid-related and non-opioid-related calls from prepandemic (before April 2020) to mid-pandemic (mid-March 2020 to mid-April 2020). The opioid-related call volume increased more from pre- to mid-pandemic for male patients than for female patients, and this "gender gap" had not returned to prepandemic levels by April 2021. CONCLUSION Consistent with reports from other states, the pandemic worsened the opioid crisis in Maryland, impacting some populations more than others while also decreasing the likelihood that individuals experiencing an opioid-related overdose would seek further medical care following an EMS call.
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Affiliation(s)
- Sharmin Hossain
- Maryland Department of Human Services, Baltimore, Maryland (Dr Hossain); Johns Hopkins Applied Physics Laboratory, Laurel, Maryland (Ms Jackson and Mr Burkom); and Independent Researcher (Ms Boyd)
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6
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Friedman NMG, Molina CA, Glenn MJ. Harm reduction and emergency medical services: Opportunities for evidence-based programming. Am J Emerg Med 2023; 72:85-87. [PMID: 37499554 DOI: 10.1016/j.ajem.2023.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/12/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
Overdose fatalities are increasingly attributed to synthetic opioids, including fentanyl, which may be added to samples of illicit substances unknowingly to the user. As recently as April 2023, the Centers for Disease Control and Prevention has also raised awareness of the risks of xylazine, an animal tranquilizer that has been found in adulterated samples of illicit substance. A growing body of evidence supports the use of drug testing services, including fentanyl and xylazine test strips, to reduce the risks associated with substance use and prevent fatal overdoses. Emergency medical services clinicians serve on the frontline of the opioid epidemic and are uniquely positioned to distribute harm reduction materials. In this article, we advocate for emergency medical services to distribute fentanyl and xylazine test strips. We also critically evaluate legal and other barriers to implementation.
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Affiliation(s)
- Nicholas M G Friedman
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, United States of America.
| | - Caitlin A Molina
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, 1100 Glendon Ave., Suite 850, Los Angeles, CA 90024, United States of America.
| | - Melody J Glenn
- Departments of Emergency Medicine and Psychiatry, University of Arizona College of Medicine, 1501 N. Campbell Ave. AHSL 4161 E, Tucson, AZ 85724, United States of America.
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7
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Carroll G, Solomon KT, Heil J, Saloner B, Stuart EA, Patel EY, Greifer N, Salzman M, Murphy E, Baston K, Haroz R. Impact of Administering Buprenorphine to Overdose Survivors Using Emergency Medical Services. Ann Emerg Med 2023; 81:165-175. [PMID: 36192278 DOI: 10.1016/j.annemergmed.2022.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/28/2022] [Accepted: 07/07/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE To evaluate the efficacy and safety of utilizing emergency medical services units to administer high dose buprenorphine after an overdose to treat withdrawal symptoms, reduce repeat overdose, and provide a next-day substances use disorder clinic appointment to initiate long-term treatment. METHODS This was a retrospective matched cohort study of patients who experienced an overdose and either received emergency medical services care from a buprenorphine-equipped ambulance or a nonbuprenorphine-equipped ambulance in Camden, New Jersey, an urban community with high overdose rates. There were 117 cases and 123 control patients in the final sample. RESULTS Compared with a nonbuprenorphine-equipped ambulance, exposure to a buprenorphine-equipped ambulance was associated with greater odds of engaging in opioid use disorder treatment within 30 days of an emergency medical services encounter (unadjusted odds ratio: 5.62, 95% confidence interval, 2.36 to 13.39). Buprenorphine-equipped ambulance engagement did not decrease repeat overdose compared to the comparison group. Patients who received buprenorphine experienced a decrease in withdrawal symptoms. Their clinical opiate withdrawal scale score decreased from an average of 9.27 to 3.16. buprenorphine-equipped ambulances increased on-scene time by 6.12 minutes. CONCLUSION Patients who encountered paramedics trained to administer buprenorphine and able to arrange prompt substance use disorder treatment after an acute opioid overdose demonstrated a decrease in opioid withdrawal symptoms, an increase in outpatient addiction follow-up care, and showed no difference in repeat overdose. Patients receiving buprenorphine in the out-of-hospital setting did not experience precipitated withdrawal. Expanded out-of-hospital treatment of opiate use disorder is a promising model for rapid access to buprenorphine after an overdose in a patient population that often has limited contact with the health care system.
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Affiliation(s)
- Gerard Carroll
- Department of Emergency Medicine, Cooper University Health Care, Camden, NJ.
| | | | - Jessica Heil
- Division of Addiction, Cooper University Health Care, Camden, NJ
| | - Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Esita Y Patel
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Noah Greifer
- Harvard University Institute for Quantitative Social Science, Cambridge, MA
| | - Matthew Salzman
- Department of Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Emily Murphy
- Department of Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Kaitlan Baston
- Division of Addiction, Cooper University Health Care, Camden, NJ
| | - Rachel Haroz
- Department of Emergency Medicine, Cooper University Health Care, Camden, NJ
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8
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Vo AT, Patton T, Peacock A, Larney S, Borquez A. Illicit Substance Use and the COVID-19 Pandemic in the United States: A Scoping Review and Characterization of Research Evidence in Unprecedented Times. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148883. [PMID: 35886734 PMCID: PMC9317093 DOI: 10.3390/ijerph19148883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/15/2022] [Accepted: 07/19/2022] [Indexed: 02/01/2023]
Abstract
We carried out a scoping review to characterize the primary quantitative evidence addressing changes in key individual/structural determinants of substance use risks and health outcomes over the first two waves of the COVID-19 pandemic in the United States (US). We systematically queried the LitCovid database for US-only studies without date restrictions (up to 6 August 2021). We extracted quantitative data from articles addressing changes in: (a) illicit substance use frequency/contexts/behaviors, (b) illicit drug market dynamics, (c) access to treatment and harm reduction services, and (d) illicit substance use-related health outcomes/harms. The majority of 37 selected articles were conducted within metropolitan locations and leveraged historical timeseries medical records data. Limited available evidence supported changes in frequency/behaviors/contexts of substance use. Few studies point to increases in fentanyl and reductions in heroin availability. Policy-driven interventions to lower drug use treatment thresholds conferred increased access within localized settings but did not seem to significantly prevent broader disruptions nationwide. Substance use-related emergency medical services’ presentations and fatal overdose data showed a worsening situation. Improved study designs/data sources, backed by enhanced routine monitoring of illicit substance use trends, are needed to characterize substance use-related risks and inform effective responses during public health emergencies.
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Affiliation(s)
- Anh Truc Vo
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Correspondence:
| | - Thomas Patton
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, San Diego, CA 92093, USA; (T.P.); (A.B.)
| | - Amy Peacock
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia;
| | - Sarah Larney
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, QC H3C 3J7, Canada;
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, San Diego, CA 92093, USA; (T.P.); (A.B.)
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Ventura CAI, Denton EE, David JA, Schoenfelder BJ, Mela L, Lumia RP, Rudi RB, Haldar B. Emergency Medical Services Prehospital Response to the COVID-19 Pandemic in the US: A Brief Literature Review. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:249-272. [PMID: 35669176 PMCID: PMC9165654 DOI: 10.2147/oaem.s366006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/23/2022] [Indexed: 11/23/2022] Open
Abstract
This study aimed to analyze prehospital Emergency Medical Services (EMS) response to the COVID-19 pandemic in the US through a brief systematic review of available literature in context with international prehospital counterparts. An exploration of the NCBI repository was performed using a search string of relevant keywords which returned n=5128 results; articles that met the inclusion criteria (n=77) were reviewed and analyzed in accordance with PRISMA and PROSPERO recommendations. Methodical quality was assessed using critical appraisal tools, and the Egger’s test was used for risk of bias reduction upon linear regression analysis of a funnel plot. Sources of heterogeneity as defined by P < 0.10 or I^2 > 50% were interrogated. Findings were considered within ten domains: structural/systemic; clinical outcomes; clinical assessment; treatment; special populations; dispatch/activation; education; mental health; perspectives/experiences; and transport. Findings suggest, EMS clinicians have likely made significant and unmeasured contributions to care during the pandemic via nontraditional roles, ie, COVID-19 testing and vaccine deployment. EMS plays a critical role in counteracting the COVID-19 pandemic in addition to the worsening opioid epidemic, both of which disproportionately impact patients of color. As such, being uniquely influential on clinical outcomes, these providers may benefit from standardized education on care and access disparities such as racial identity. Access to distance learning continuing education opportunities may increase rates of provider recertification. Additionally, there is a high prevalence of vaccine hesitancy among surveyed nationally registered EMS providers. Continued rigorous investigation on the impact of COVID-19 on EMS systems and personnel is warranted to ensure informed preparation for future pandemic and infectious disease responses.
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Affiliation(s)
- Christian Angelo I Ventura
- Department of Graduate Medical Sciences, Boston University School of Medicine Boston, Boston, MA, USA
- Department of Health, Behavior and Society (Incoming), Johns Hopkins Bloomberg School of Public Health Baltimore, Baltimore, MD, USA
- EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA
- Correspondence: Christian Angelo I Ventura, Tel +1 (732) 372-2141, Email ;
| | - Edward E Denton
- EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA
- Department of Emergency Medicine, University of Arkansas for Medical Sciences Little Rock, Little Rock, AR, USA
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences Little Rock, Little Rock, AR, USA
| | - Jessica Anastacia David
- Department of Biochemistry and Microbiology, Rutgers University New Brunswick, Brunswick, NJ, USA
| | | | - Lillian Mela
- Department of Nursing, Simmons University Boston, Boston, MA, USA
| | - Rebecca P Lumia
- Department of Biology, Northeastern University Boston, Boston, MA, USA
| | - Rachel B Rudi
- EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA
| | - Barnita Haldar
- EMS Pandemic Response Research Laboratory Lawrenceville, Lawrenceville, NJ, USA
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham School of Medicine Birmingham, Birmingham, AL, USA
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10
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Hern HG, Lara V, Goldstein D, Kalmin M, Kidane S, Shoptaw S, Tzvieli O, Herring AA. Prehospital Buprenorphine Treatment for Opioid Use Disorder by Paramedics: First Year Results of the EMS Buprenorphine Use Pilot. PREHOSP EMERG CARE 2022; 27:334-342. [PMID: 35420925 DOI: 10.1080/10903127.2022.2061661] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Prehospital initiation of buprenorphine treatment for Opioid Use Disorder (OUD) by paramedics is an emerging potential intervention to reach patients at greatest risk for opioid-related death. Emergency Medical Services (EMS) patients who are at high risk for overdose deaths may never engage in treatment as they frequently refuse transport to the hospital after naloxone reversal. The potentially important role of EMS as the initiator for medication for opioid use disorder (MOUD) in the most high-risk patients has not been well described. Setting: This project relies on four interventions: a public access naloxone distribution program, an electronic trigger and data sharing program, an "Overdose Receiving Center," and a paramedic initiated buprenorphine treatment. For the final intervention, paramedics followed a protocol based pilot which had an EMS physician consultation prior to administration. Results: There were 36 patients enrolled in the trial study in the first year who received buprenorphine. Of those patients receiving buprenorphine, only one patient signed out against medical advice on scene. All other patients were transported to an emergency department and their clinical outcome and 7 and 30 day follow ups were determined by the substance use navigator (SUN.) 36 of 36 patients had follow up data obtained in the short term and none experienced any precipitated withdrawal or other adverse outcomes. Patients had a 50% (18/36) rate of treatment retention at 7 days and 36% (14/36) were in treatment at 30 days. Conclusion: In this small pilot project, paramedic initiated buprenorphine in the setting of data sharing and linkage with treatment appears to be a safe intervention with a high rate of ongoing outpatient treatment for risk of fatal opioid overdoses.
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Affiliation(s)
- H Gene Hern
- Alameda Health System, Highland Hospital, Emergency Medicine, Oakland, California
| | - Vanessa Lara
- Emergency Medical Services Division, Oakland, California
| | | | - M Kalmin
- UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California
| | - S Kidane
- Emergency Medical Services, Contra Costa County, California
| | - S Shoptaw
- UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California
| | - Ori Tzvieli
- Public Health Agency, Contra Costa County, California
| | - Andrew A Herring
- Alameda Health System, Highland Hospital, Emergency Medicine, Oakland, California
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11
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Choi NG, Choi BY, DiNitto DM, Marti CN, Baker SD. Naloxone therapy for prescription and illicit opioid poisoning cases aged 50 + in the national poison data system, 2015-2020. Clin Toxicol (Phila) 2022; 60:499-506. [PMID: 34554013 PMCID: PMC9904880 DOI: 10.1080/15563650.2021.1981362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
CONTEXT Older adults are less likely than younger adults to receive naloxone therapy. Given high rates of prescription opioid use/misuse and increasing illicit opioid use among older adults, factors associated with naloxone administration for older opioid poisoning cases need examination. METHODS We analyzed the 83,135 opioid-involved cases aged 50+ from the 2015-2020 National Poison Data System. Single-variable logistic regression was used to examine associations of naloxone administration with demographic factors, exposure site/reason, medical outcomes, management site/level of care, clinical effects, and other interventions. Multivariable logistic regression models were fit to examine associations of naloxone administration with different types of opioids. RESULTS Over the six years, the proportion of prescription opioid cases that received naloxone therapy increased steadily from 21.9% to 28.4%. The proportion of illicit opioid cases that received naloxone therapy was 51.9% in 2015 and 59.8% in 2020 with a high of 64.4% in 2019. In 2020, the death rate for illicit opioid cases without naloxone therapy was 31.4% compared to 2.3% for those with the therapy. Cases managed at healthcare facilities (HCF) had higher odds of receiving naloxone therapy. Among prescription opioid cases, naloxone therapy rates among older and female cases and those managed at non-HCF settings were especially low even for major medical outcomes. Cases involving oxycodone, morphine, methadone, prescription fentanyl, hydromorphone, oxymorphone, and other/unknown opioids had higher odds of naloxone administration. DISCUSSION Rates of naloxone therapy for older prescription opioid poisoning cases need improvement. While rates were higher among illicit opioid cases, the drop in 2020 and the sharp increase in deaths among illicit opioid cases without naloxone therapy confirm the importance of access to this life-saving intervention. CONCLUSIONS Increased naloxone co-prescribing and other means of facilitating access to naloxone are needed to prevent opioid poisoning deaths among older adults who use prescription opioids.
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Affiliation(s)
- Namkee G. Choi
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - Bryan Y. Choi
- Department of Emergency Medicine, Philadelphia College of Osteopathic Medicine & Bayhealth Medical Center, Dover, DE, USA
| | - Diana M. DiNitto
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - C. Nathan Marti
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
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Hern HG, Goldstein D, Kalmin M, Kidane S, Shoptaw S, Tzvieli O, Herring AA. Prehospital Initiation of Buprenorphine Treatment for Opioid Use Disorder by Paramedics. PREHOSP EMERG CARE 2021; 26:811-817. [PMID: 34505820 DOI: 10.1080/10903127.2021.1977440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractPrehospital initiation of buprenorphine treatment for Opioid Use Disorder (OUD) by paramedics is an emerging potential intervention. Many patients who may be at high risk for overdose deaths may never engage in treatment because they frequently refuse transport. Recent data have demonstrated a significant increase in both short and long term mortality following an opioid overdose. We describe 3 preliminary cases with a novel intervention of initiating Buprenorphine in the prehospital setting for symptoms of opioid withdrawal, regardless of etiology. In addition, we describe tracking of long term engagement in additional services as part of an integrated approach to combatting the opioid epidemic through EMS focused interventions.
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Affiliation(s)
- H Gene Hern
- Received June 7, 2021 from Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, California (HGH, AAH); Emergency Medical Services, Contra Costa County, Martinez, California(DG, SK); UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California(MK, SS); Public Health Agency, Contra Costa County, Martinez, California(OT). Revision received August 16, 2021; accepted for publication September 1, 2021
| | - David Goldstein
- Received June 7, 2021 from Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, California (HGH, AAH); Emergency Medical Services, Contra Costa County, Martinez, California(DG, SK); UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California(MK, SS); Public Health Agency, Contra Costa County, Martinez, California(OT). Revision received August 16, 2021; accepted for publication September 1, 2021
| | - M Kalmin
- Received June 7, 2021 from Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, California (HGH, AAH); Emergency Medical Services, Contra Costa County, Martinez, California(DG, SK); UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California(MK, SS); Public Health Agency, Contra Costa County, Martinez, California(OT). Revision received August 16, 2021; accepted for publication September 1, 2021
| | - S Kidane
- Received June 7, 2021 from Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, California (HGH, AAH); Emergency Medical Services, Contra Costa County, Martinez, California(DG, SK); UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California(MK, SS); Public Health Agency, Contra Costa County, Martinez, California(OT). Revision received August 16, 2021; accepted for publication September 1, 2021
| | - S Shoptaw
- Received June 7, 2021 from Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, California (HGH, AAH); Emergency Medical Services, Contra Costa County, Martinez, California(DG, SK); UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California(MK, SS); Public Health Agency, Contra Costa County, Martinez, California(OT). Revision received August 16, 2021; accepted for publication September 1, 2021
| | - Ori Tzvieli
- Received June 7, 2021 from Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, California (HGH, AAH); Emergency Medical Services, Contra Costa County, Martinez, California(DG, SK); UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California(MK, SS); Public Health Agency, Contra Costa County, Martinez, California(OT). Revision received August 16, 2021; accepted for publication September 1, 2021
| | - Andrew A Herring
- Received June 7, 2021 from Emergency Medicine, Alameda Health System - Highland Hospital, Oakland, California (HGH, AAH); Emergency Medical Services, Contra Costa County, Martinez, California(DG, SK); UCLA Center for Behavioral and Addiction Medicine, Los Angeles, California(MK, SS); Public Health Agency, Contra Costa County, Martinez, California(OT). Revision received August 16, 2021; accepted for publication September 1, 2021
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Affiliation(s)
- Laura G Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jose F Figueroa
- Harvard Medical School, Boston, Massachusetts
- Department of Health Policy & Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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14
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Abstract
PURPOSE OF REVIEW The international, public health crisis caused by the rapid spread of SARS-CoV-2 has resulted in unforeseen medical and psychiatric consequences. We reviewed publications from January 2020 to January 2021, given that earlier documents were not relevant, to review findings on changes in substance use and overdoses during the pandemic. Additionally, this review of the literature also documents advocacy efforts, health service modification and challenges, as well as COVID-related health complications associated with substance use. RECENT FINDINGS Recent work focused on identifying changes in the distribution and use of substances as well as the unique challenges to promoting the health of persons who use substances in the current pandemic. Although COVID-19 has triggered unprecedented innovations in the organizational and public policy, the use of certain substances (alcohol, cannabis, cigarettes, fentanyl, heroin, and opiates) is increasing internationally. Unique associations between substance use and pandemic-related adverse health outcomes were identified. In addition, the pandemic precipitated significant barriers and disruptions to care. SUMMARY Given increased overdose rates and infections among people who use drugs, continued surveillance and vigilance are needed to assess changes and reduce use and adverse consequences during the continuing COVID-19 crisis. Changes are urgently needed to reduce adverse health outcomes because of treatment barriers and lack of adequate treatment options. Additionally, integrative approaches are necessary to promote the public health of persons who use substances.
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Affiliation(s)
- Catherine W Striley
- Department of Epidemiology, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, Florida, USA
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Lindqvist K, Wallmofeldt C, Holmén E, Hammarberg A, Kåberg M. Health literacy and changes in pattern of drug use among participants at the Stockholm Needle Exchange Program during the COVID-19 pandemic. Harm Reduct J 2021; 18:52. [PMID: 33971892 PMCID: PMC8107802 DOI: 10.1186/s12954-021-00499-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/29/2021] [Indexed: 02/06/2023] Open
Abstract
Background and aims People who inject drugs may be particularly vulnerable to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to underlying health problems, stigma and social vulnerabilities. Harm reduction services, including needle exchange programs (NEP), have been subjected to varying degrees of disruption in the world, especially in the beginning of the coronavirus disease 2019 (COVID-19) pandemic. Compared to responses in other countries, Sweden’s initial strategy toward limiting the spread and impact of COVID-19 was less restrictive to its citizens with no imposed general societal lockdown. In this study, we investigate changes in drug use patterns, utilization of NEP associated health services, COVID-19 health literacy and the prevalence of SARS-CoV-2 antibodies among NEP clients in Stockholm during the COVID-19 pandemic.
Methods NEP visits and services provided (needles/syringes, HIV and hepatitis C tests and treatment, naloxone distributed) and overall mortality among NEP clients between January 1 and October 31, 2020, were used for trend analyses in comparison with corresponding 2019 data. Between July 27 and October 2, 2020, NEP clients (n = 232) responded to a 27 item COVID-19 Health Literacy Questionnaire. SARS CoV-2 IgG antibody tests (n = 779) were performed between June 15 and October 31, 2020. Results During the COVID-19 pandemic number of clients, client visits, naloxone distribution and HCV tests remained stable compared to 2019, while distribution of needles/syringes increased (p < 0.0001); number of HIV tests and HCV treatments decreased (p < 0.05); and mortality decreased (< 0.01). Overall, the level of health literacy concerning transmission routes and protective measures was high. SARS-CoV-2 antibody prevalence was 5.4% (95% CI 4.0–7.2). Conclusions The Stockholm NEP managed to maintain a high level of clients and services during the pandemic. In general, COVID-19 health literacy was adequate and the overall SARS-CoV-2 antibody prevalence was low compared to the general population, which highlights a need for prioritized and targeted COVID-19 vaccination among PWID.
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Affiliation(s)
- K Lindqvist
- Stockholm Needle Exchange, Stockholm Centre for Dependency Disorders, Stockholm, Sweden
| | - C Wallmofeldt
- Norra Stockholms Psykiatri (Psychiatry of Northern Stockholm), S:t Görans Hospital, Stockholm, Sweden
| | - E Holmén
- Stockholm Needle Exchange, Stockholm Centre for Dependency Disorders, Stockholm, Sweden.,Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - A Hammarberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Stockholm Centre for Dependency Disorders, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - M Kåberg
- Stockholm Needle Exchange, Stockholm Centre for Dependency Disorders, Stockholm, Sweden. .,Department of Medicine Huddinge, Division of Infection and Dermatology, Karolinska Institutet, Karolinska University Hospital Huddinge, Sprututbytet, S:t Görans sjukhus, Akutvägen 29, 112 81, Stockholm, Sweden.
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