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Jones CM, Shoff C, Blanco C, Losby JL, Ling SM, Compton WM. Overdose, Behavioral Health Services, and Medications for Opioid Use Disorder After a Nonfatal Overdose. JAMA Intern Med 2024; 184:954-962. [PMID: 38884975 PMCID: PMC11184500 DOI: 10.1001/jamainternmed.2024.1733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/28/2024] [Indexed: 06/18/2024]
Abstract
Importance Recognizing and providing services to individuals at highest risk for drug overdose are paramount to addressing the drug overdose crisis. Objective To examine receipt of medications for opioid use disorder (MOUD), naloxone, and behavioral health services in the 12 months after an index nonfatal drug overdose and the association between receipt of these interventions and fatal drug overdose. Design, Setting, and Participants This cohort study was conducted in the US from January 2020 to December 2021 using claims, demographic, mortality, and other data from the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and other sources. The cohort comprised Medicare fee-for-service beneficiaries aged 18 years or older with International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes for a nonfatal drug overdose. Data analysis was performed from February to November 2023. Exposures Demographic and clinical characteristics, substance use disorder, and psychiatric comorbidities. Main Outcomes and Measures Receipt of MOUD, naloxone, and behavioral health services as well as subsequent nonfatal and fatal drug overdoses. Results The cohort consisted of 136 762 Medicare beneficiaries (80 140 females [58.6%]; mean (SD) age of 68.2 [15.0] years) who experienced an index nonfatal drug overdose in 2020. The majority of individuals had Hispanic (5.8%), non-Hispanic Black (10.9%), and non-Hispanic White (78.8%) race and ethnicity and lived in metropolitan areas (78.9%). In the 12 months after their index nonfatal drug overdose, 23 815 beneficiaries (17.4%) experienced at least 1 subsequent nonfatal drug overdose and 1323 (1.0%) died of a fatal drug overdose. Opioids were involved in 72.2% of fatal drug overdoses. Among the cohort, 5556 (4.1%) received any MOUD and 8530 (6.2%) filled a naloxone prescription in the 12 months after the index nonfatal drug overdose. Filling a naloxone prescription (adjusted odds ratio [AOR], 0.70; 95% CI, 0.56-0.89), each percentage of days receiving methadone (AOR, 0.98; 95% CI, 0.98-0.99) or buprenorphine (AOR, 0.99; 95% CI, 0.98-0.99), and receiving behavioral health assessment or crisis services (AOR, 0.25; 95% CI, 0.22-0.28) were all associated with reduced adjusted odds of fatal drug overdose in the 12 months after the index nonfatal drug overdose. Conclusions and Relevance This cohort study found that, despite their known association with reduced risk of a fatal drug overdose, only a small percentage of Medicare beneficiaries received MOUD or filled a naloxone prescription in the 12 months after a nonfatal drug overdose. Efforts to improve access to behavioral health services; MOUD; and overdose-prevention strategies, such as prescribing naloxone and linking individuals to community-based health care settings for ongoing care, are needed.
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Affiliation(s)
- Christopher M. Jones
- Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, Rockville, Maryland
| | - Carla Shoff
- Office of the Administrator, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Carlos Blanco
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Jan L. Losby
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shari M. Ling
- Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Wilson M. Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
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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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Mohtarami SA, Mostafazadeh B, Shadnia S, Rahimi M, Evini PET, Ramezani M, Borhany H, Fathy M, Eskandari H. Prediction of naloxone dose in opioids toxicity based on machine learning techniques (artificial intelligence). Daru 2024:10.1007/s40199-024-00518-x. [PMID: 38771458 DOI: 10.1007/s40199-024-00518-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 04/30/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Treatment management for opioid poisoning is critical and, at the same time, requires specialized knowledge and skills. This study was designed to develop and evaluate machine learning algorithms for predicting the maintenance dose and duration of hospital stay in opioid poisoning, in order to facilitate appropriate clinical decision-making. METHOD AND RESULTS This study used artificial intelligence technology to predict the maintenance dose and duration of administration by selecting clinical and paraclinical features that were selected by Pearson correlation (filter method) (Stage 1) and then the (wrapper method) Recursive Feature Elimination Cross-Validated (RFECV) (Stage2). The duration of administration was divided into two categories: A (which includes a duration of less than or equal to 24 h of infusion) and B (more than 24 h of naloxone infusion). XGBoost algorithm model with an accuracy rate of 91.04%, a prediction rate of 91.34%, and a sensitivity rate of 91.04% and area under the Curve (AUC) 0.97 was best model for classification patients. Also, the best maintenance dose of naloxone was obtained with XGBoost algorithm with R2 = 0.678. Based on the selected algorithm, the most important features for classifying patients for the duration of treatment were bicarbonate, respiration rate, physical sign, The partial pressure of carbon dioxide (PCO2), diastolic blood pressure, pulse rate, naloxone bolus dose, Blood Creatinine(Cr), Body temperature (T). The most important characteristics for determining the maintenance dose of naloxone were physical signs, bolus dose of 4.5 mg/kg, Glasgow Coma Scale (GCS), Creatine Phosphokinase (CPK) and intensive care unit (ICU) add. CONCLUSION A predictive model can significantly enhance the decision-making and clinical care provided by emergency physicians in hospitals and medical settings. XGBoost was found to be the superior model.
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Affiliation(s)
| | - Babak Mostafazadeh
- Clinical Research Development Unit (CRDU) of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran.
| | - Shahin Shadnia
- Clinical Research Development Unit (CRDU) of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Mitra Rahimi
- Clinical Research Development Unit (CRDU) of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Peyman Erfan Talab Evini
- Clinical Research Development Unit (CRDU) of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Maral Ramezani
- Department of Pharmacology, School of Medicine, Arak University of Medical Sciences, Arak, Iran
- Traditional and Complementary Medicine Research Center, Arak University of Medical Sciences, Arak, Iran
| | - Hamed Borhany
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Mobin Fathy
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Hamidreza Eskandari
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
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Cerdá M, Hamilton AD, Hyder A, Rutherford C, Bobashev G, Epstein JM, Hatna E, Krawczyk N, El-Bassel N, Feaster DJ, Keyes KM. Simulating the Simultaneous Impact of Medication for Opioid Use Disorder and Naloxone on Opioid Overdose Death in Eight New York Counties. Epidemiology 2024; 35:418-429. [PMID: 38372618 DOI: 10.1097/ede.0000000000001703] [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: 02/20/2024]
Abstract
BACKGROUND The United States is in the midst of an opioid overdose epidemic; 28.3 per 100,000 people died of opioid overdose in 2020. Simulation models can help understand and address this complex, dynamic, and nonlinear social phenomenon. Using the HEALing Communities Study, aimed at reducing opioid overdoses, and an agent-based model, Simulation of Community-Level Overdose Prevention Strategy, we simulated increases in buprenorphine initiation and retention and naloxone distribution aimed at reducing overdose deaths by 40% in New York Counties. METHODS Our simulations covered 2020-2022. The eight counties contrasted urban or rural and high and low baseline rates of opioid use disorder treatment. The model calibrated agent characteristics for opioid use and use disorder, treatments and treatment access, and fatal and nonfatal overdose. Modeled interventions included increased buprenorphine initiation and retention, and naloxone distribution. We predicted a decrease in the rate of fatal opioid overdose 1 year after intervention, given various modeled intervention scenarios. RESULTS Counties required unique combinations of modeled interventions to achieve a 40% reduction in overdose deaths. Assuming a 200% increase in naloxone from current levels, high baseline treatment counties achieved a 40% reduction in overdose deaths with a simultaneous 150% increase in buprenorphine initiation. In comparison, low baseline treatment counties required 250-300% increases in buprenorphine initiation coupled with 200-1000% increases in naloxone, depending on the county. CONCLUSIONS Results demonstrate the need for tailored county-level interventions to increase service utilization and reduce overdose deaths, as the modeled impact of interventions depended on the county's experience with past and current interventions.
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Affiliation(s)
- Magdalena Cerdá
- From the Department of Population Health, New York University School of Medicine, New York, NY
| | - Ava D Hamilton
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Ayaz Hyder
- Division of Environmental Health Sciences, College of Public Health, Ohio State University, Columbus, OH
| | - Caroline Rutherford
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Georgiy Bobashev
- Center for Data Science, RTI International, Research Triangle Park, NC
| | - Joshua M Epstein
- Department of Epidemiology, New York University School of Global Public Health, New York, NY
| | - Erez Hatna
- Department of Epidemiology, New York University School of Global Public Health, New York, NY
| | - Noa Krawczyk
- From the Department of Population Health, New York University School of Medicine, New York, NY
| | | | - Daniel J Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Saari TI, Strang J, Dale O. Clinical Pharmacokinetics and Pharmacodynamics of Naloxone. Clin Pharmacokinet 2024; 63:397-422. [PMID: 38485851 PMCID: PMC11052794 DOI: 10.1007/s40262-024-01355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 04/29/2024]
Abstract
Naloxone is a World Health Organization (WHO)-listed essential medicine and is the first choice for treating the respiratory depression of opioids, also by lay-people witnessing an opioid overdose. Naloxone acts by competitive displacement of opioid agonists at the μ-opioid receptor (MOR). Its effect depends on pharmacological characteristics of the opioid agonist, such as dissociation rate from the MOR receptor and constitution of the victim. Aim of treatment is a balancing act between restoration of respiration (not consciousness) and avoidance of withdrawal, achieved by titration to response after initial doses of 0.4-2 mg. Naloxone is rapidly eliminated [half-life (t1/2) 60-120 min] due to high clearance. Metabolites are inactive. Major routes for administration are intravenous, intramuscular, and intranasal, the latter primarily for take-home naloxone. Nasal bioavailability is about 50%. Nasal uptake [mean time to maximum concentration (Tmax) 15-30 min] is likely slower than intramuscular, as reversal of respiration lag behind intramuscular naloxone in overdose victims. The intraindividual, interindividual and between-study variability in pharmacokinetics in volunteers are large. Variability in the target population is unknown. The duration of action of 1 mg intravenous (IV) is 2 h, possibly longer by intramuscular and intranasal administration. Initial parenteral doses of 0.4-0.8 mg are usually sufficient to restore breathing after heroin overdose. Fentanyl overdoses likely require higher doses of naloxone. Controlled clinical trials are feasible in opioid overdose but are absent in cohorts with synthetic opioids. Modeling studies provide valuable insight in pharmacotherapy but cannot replace clinical trials. Laypeople should always have access to at least two dose kits for their interim intervention.
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Affiliation(s)
- Teijo I Saari
- Department of Anaesthesiology and Intensive Care, University of Turku, Turku, Finland
- Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - John Strang
- National Addiction Centre, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, SE5 8BB, UK
| | - Ola Dale
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Dailey MW, Hayashi W. "EMS Electronic Health Records - An Opportunity for Integration to Improve Care" Commentary on Kamta et al. PREHOSP EMERG CARE 2023; 28:513-514. [PMID: 37478004 DOI: 10.1080/10903127.2023.2234995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/23/2023]
Affiliation(s)
| | - Warren Hayashi
- Department of Emergency Medicine, Albany Medical College
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Speakman EM, Hillen P, Heyman I, Murray J, Dougall N, Aston EV, McAuley A. 'I'm not going to leave someone to die': carriage of naloxone by police in Scotland within a public health framework: a qualitative study of acceptability and experiences. Harm Reduct J 2023; 20:20. [PMID: 36805681 PMCID: PMC9938955 DOI: 10.1186/s12954-023-00750-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 02/03/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Scotland has one of the highest rates of drug-related deaths (DRDs) per capita in Europe, the majority of which involve opioids. Naloxone is a medication used to reverse opioid-related overdoses. In efforts to tackle escalating DRDs in many countries, naloxone is increasingly being provided to people who are likely first responders in overdose situations. This includes non-healthcare professionals, such as police officers. A pilot exercise to test the carriage and administration of naloxone by police officers was conducted in selected areas of Scotland between March and October 2021. The aim of the study was to explore the acceptability and experiences of naloxone carriage and administration by police in Scotland. METHODS The study comprised of two stages. Stage 1 involved in-depth one-to-one qualitative interviews with 19 community stakeholders (people with lived experience, family members, support workers). Stage 2 involved a mixture of in-depth one-to-one interviews and focus groups with 41 police officers. Data were analysed thematically, and the findings from the two stages were triangulated to develop overarching themes and subthemes. RESULTS By the end of the pilot, 808 police officers had been trained in the use of intranasal naloxone. Voluntary uptake of naloxone kits among police officers who completed training was 81%. There were 51 naloxone administration incidents recorded by police officers at suspected opioid-related overdose incidents during the pilot. Most officers shared positive experiences of naloxone administration. Naloxone as a first aid tool suited their role as first responders and their duty and desire to preserve life. Perceived barriers included concerns about police undertaking health-related work, potential legal liabilities and stigmatising attitudes. The majority of participants (and all community stakeholders) were supportive of the pilot and for it to be expanded across Scotland. CONCLUSIONS Police carriage of naloxone is an acceptable and potentially valuable harm reduction tool to help tackle the DRDs crisis in Scotland. However, it requires appropriate integration with existing health and social care systems. The intervention lies at the intersection between public health and policing and implies a more explicit public health approach to policing.
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Affiliation(s)
| | - Peter Hillen
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Inga Heyman
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Jennifer Murray
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Nadine Dougall
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Elizabeth V. Aston
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Andrew McAuley
- grid.5214.20000 0001 0669 8188School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Post-overdose follow-up in the community with peer recovery specialists: the Lake Superior Diversion and Substance Use Response Team. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100139. [PMID: 36994366 PMCID: PMC10040321 DOI: 10.1016/j.dadr.2023.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 02/03/2023]
Abstract
Background As the overdose epidemic continues to worsen, nonfatal overdose calls for service represent a critical touchpoint for intervention. While most studies have focused on law enforcement led post-overdose follow-up, the current study describes the programmatic characteristics and outcomes of a non-law enforcement post overdose program comprised of peer specialists embedded within a local police department. Methods We examined information on 341 follow-up responses occurring over a 16-month study period using administrative data. We assessed programmatic characteristics including demographic information on clients, referral source, engagement type, and goal completion. Results The results indicate that over 60% of client referrals ended in the goal of in-person contact. Of those, about 80% went on to complete an engagement goal with the peer specialist. We found no significant variation in client demographics and referral source or follow-up engagement (in-person or not); however, client referrals from law enforcement first responders, the most common source, are significantly less likely to result in an in-person contact, though, if contact is made, similarly likely to complete an engagement goal. Conclusions Post overdose response programs that do not involve law enforcement are exceedingly rare. Given that some research has shown that police involvement in post overdose response can have unexpected, associated harms, it is important to assess the effectiveness of post overdose programs that do not involve the police. Findings here suggest that this type of program is successful at locating and engaging community members into recovery support services who have experienced an overdose.
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Ajumobi O, Verdugo SR, Labus B, Reuther P, Lee B, Koch B, Davidson PJ, Wagner KD. Identification of Non-Fatal Opioid Overdose Cases Using 9-1-1 Computer Assisted Dispatch and Prehospital Patient Clinical Record Variables. PREHOSP EMERG CARE 2022; 26:818-828. [PMID: 34533427 PMCID: PMC9043039 DOI: 10.1080/10903127.2021.1981505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/11/2021] [Accepted: 09/11/2021] [Indexed: 10/20/2022]
Abstract
Background: The current epidemic of opioid overdoses in the United States necessitates a robust public health and clinical response. We described patterns of non-fatal opioid overdoses (NFOODs) in a small western region using data from the 9-1-1 Computer Assisted Dispatch (CAD) record and electronic Patient Clinical Records (ePCR) completed by EMS responders. We determined whether CAD and ePCR variables could identify NFOOD cases in 9-1-1 data for intervention and surveillance efforts. Methods: We conducted a retrospective analysis of 1 year of 9-1-1 emergency medical CAD and ePCR (including naloxone administration) data from the sole EMS provider in the response area. Cases were identified based on clinician review of the ePCR, and categorized as definitive NFOOD, probable NFOOD, or non-OOD. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) of the most prevalent CAD and ePCR variables were calculated. We used a machine learning technique-Random-Forests (RF) modeling-to optimize our ability to accurately predict NFOOD cases within census blocks. Results: Of 37,960 9-1-1 calls, clinical review identified 158 NFOOD cases (0.4%), of which 123 (77.8%) were definitive and 35 (22.2%) were probable cases. Overall, 106 (67.1%) received naloxone from the EMS responder at the scene. As a predictor of NFOOD, naloxone administration by paramedics had 67.1% sensitivity, 99.6% specificity, 44% PPV, and 99.9% NPV. Using CAD variables alone achieved a sensitivity of 36.7% and specificity of 99.7%. Combining ePCR variables with CAD variables increased the diagnostic accuracy with the best RF model yielding 75.9% sensitivity, 99.9% specificity, 71.4% PPV, and 99.9% NPV. Conclusion: CAD problem type variables and naloxone administration, used alone or in combination, had sub-optimal predictive accuracy. However, a Random Forests modeling approach improved accuracy of identification, which could foster improved surveillance and intervention efforts. We identified the set of NFOODs that EMS encountered in a year and may be useful for future surveillance efforts.
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Affiliation(s)
| | | | - Brian Labus
- School of Public Health, University of Nevada Las Vegas, Nevada
| | | | - Bradford Lee
- Regional Emergency Medical Services Authority, Reno, Nevada
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Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin. Drug Alcohol Depend 2022; 236:109478. [PMID: 35588609 PMCID: PMC9235402 DOI: 10.1016/j.drugalcdep.2022.109478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality. METHODS We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted. RESULTS Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone. CONCLUSIONS Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.
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Smiley-McDonald HM, Attaway PR, Richardson NJ, Davidson PJ, Kral AH. Perspectives from law enforcement officers who respond to overdose calls for service and administer naloxone. HEALTH & JUSTICE 2022; 10:9. [PMID: 35212812 PMCID: PMC8874742 DOI: 10.1186/s40352-022-00172-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 02/02/2022] [Indexed: 05/27/2023]
Abstract
BACKGROUND Many law enforcement agencies across the United States equip their officers with the life-saving drug naloxone to reverse the effects of an opioid overdose. Although officers can be effectively trained to administer naloxone, and hundreds of law enforcement agencies carry naloxone to reverse overdoses, little is known about what happens on scene during an overdose call for service from an officer's perspective, including what officers perceive their duties and responsibilities to be as the incident evolves. METHODS The qualitative study examined officers' experiences with overdose response, their perceived roles, and what happens on scene before, during, and after an overdose incident. In-person interviews were conducted with 17 officers in four diverse law enforcement agencies in the United States between January and May 2020. RESULTS Following an overdose, the officers described that overdose victims are required to go to a hospital or they are taken to jail. Officers also described their duties on scene during and after naloxone administration, including searching the belongings of the person who overdosed and seizing any drug paraphernalia. CONCLUSION These findings point to a pressing need for rethinking standard operating procedures for law enforcement in these situations so that the intentions of Good Samaritan Laws are upheld and people get the assistance they need without being deterred from asking for future help.
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Affiliation(s)
- Hope M Smiley-McDonald
- Division for Applied Justice Research, RTI International, Research Triangle Park, North Carolina, USA.
| | - Peyton R Attaway
- Division for Applied Justice Research, RTI International, Research Triangle Park, North Carolina, USA
| | - Nicholas J Richardson
- Division for Applied Justice Research, RTI International, Research Triangle Park, North Carolina, USA
| | - Peter J Davidson
- Department of Medicine, Division Global Public Health, University of California, San Diego, La Jolla, California, USA
| | - Alex H Kral
- Community Health Research Division, RTI International, Berkeley, California, USA
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13
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Beauchamp GA, Cuadrado HM, Campbell S, Eliason BB, Jones CL, Fedor AT, Grantz L, Roth P, Greenberg MR. A Study on the Efficacy of a Naloxone Training Program. Cureus 2021; 13:e19831. [PMID: 34963847 PMCID: PMC8697700 DOI: 10.7759/cureus.19831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: The use of naloxone to reverse a potentially fatal opioid overdose is a harm reduction strategy that reduces mortality and increases the potential for referral to substance use treatment for affected individuals. In the setting of outreach performed by a street medicine team, we aimed to determine the effectiveness of an educational intervention involving distribution of naloxone accompanied by a brief instructive session about opioids, opioid overdose, and medication administration. Methods: Our street medicine outreach team distributed 200 naloxone kits to clinicians and volunteers involved in caring for patients on ‘street rounds,’ as well as in shelters, soup kitchens, and street medicine clinic settings. Those receiving a naloxone kit engaged in a peer-reviewed presentation on how to safely use the medication to reverse a potentially fatal opioid overdose. The study team developed and administered a pre- and post-survey of 10 multiple choice questions on material covered in the educational training. The pre- and post-survey scores were compared to assess the effectiveness of implementing this training. Results were stratified by participant gender and age group. Results: Out of the 200 participants, six were excluded from the analysis due to completely missing data from one or both surveys. The mean age of participants was 40.2±12.5 years; 120 (65.6%) were female, 62 (33.9%) were male, and 1 (0.6%) identified as nonbinary. Every survey question had an increase in correct responses from pre-survey to post-survey (identified by an increase in the percentage of correct responses). The mean survey total score increased from 5.5±1.6 to 7.5±1.3. Within the sample of 194, the mean difference in scores from pre-survey to post-survey was 2.02 points (95% CI [1.77, 2.26]), p<0.0001. Males had a mean increase in the total score from 5.6±1.8 to 7.4±1.1. Females had a mean increase in the total score from 5.5±1.5 to 7.5±1.3. The difference in total scores in males was 1.89 points (95% CI [1.42, 2.35]), p<0.0001, and in females was 2.02 points (95% CI [1.71, 2.32]), p<0.0001. Post-test scores improved in all age groups. Conclusion: The educational training on opioids, opioid overdose, and the use of naloxone was an effective adjunct to naloxone kit distribution to volunteers and clinicians caring for people experiencing homelessness.
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Affiliation(s)
- Gillian A Beauchamp
- Emergency and Hospital Medicine, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA
| | - Hoonani M Cuadrado
- Street Medicine, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA.,Street Medicine, Valley Health Partners, Allentown, USA
| | - Seth Campbell
- Street Medicine, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA.,Street Medicine, Valley Health Partners, Allentown, USA
| | - Bennie B Eliason
- Street Medicine, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA.,Street Medicine, Valley Health Partners, Allentown, USA
| | - Chase L Jones
- Emergency and Hospital Medicine, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA
| | - Aaron T Fedor
- Emergency and Hospital Medicine, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA
| | - Lauren Grantz
- Pharmacy, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA
| | - Paige Roth
- Emergency and Hospital Medicine, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA
| | - Marna Rayl Greenberg
- Emergency and Hospital Medicine, Lehigh Valley Health Network Campus/University of South Florida Morsani College of Medicine, Allentown, USA
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Gormley MA, Pericot-Valverde I, Diaz L, Coleman A, Lancaster J, Ortiz E, Moschella P, Heo M, Litwin AH. Effectiveness of peer recovery support services on stages of the opioid use disorder treatment cascade: A systematic review. Drug Alcohol Depend 2021; 229:109123. [PMID: 34700201 DOI: 10.1016/j.drugalcdep.2021.109123] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Peer recovery support services (PRSS) have been increasingly incorporated during the recovery process for opioid use disorder (OUD), yet little is known about the effects of PRSS on clinical outcomes of individuals who misuse opioids. This study systematically synthesized existing literature reporting the effectiveness of PRSS interventions on stages of the OUD treatment cascade. METHODS A search conducted on five databases identified studies from database inception to January 26th 2021 that evaluated the effects of PRSS on PRSS engagement, medication for OUD (MOUD) initiation, MOUD retention, opioid and non-opioid misuse, and remission. Characteristics of PRSS interventions, study design, and clinical outcomes were extracted. Methodological quality was assessed with the quality assessment tool for quantitative studies by the Effective Public Health Practice Project. RESULTS Of 123 titles, 22 were subjected to full-text review and 12 ultimately met inclusion criteria. Only two studies were randomized control trials, half compared the outcomes of PRSS participants to those of a counterfactual group. Most PRSS were unstandardized and broadly described, involving linkage to treatment (91.7%) or follow-up support (91.7%). MOUD initiation was reported the most often (66.7%), followed by PRSS engagement (33.3%) and opioid use (25.0%). No studies reported findings for MOUD retention or remission. Findings for available outcomes were inconsistent and difficult to compare due to the heterogeneity of PRSS interventions and methodological limitations. CONCLUSION Effectiveness of PRSS interventions on stages of the OUD treatment cascade remain inconclusive. Additional research is necessary before supporting the implementation of PRSS on a broad scale.
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Affiliation(s)
- Mirinda Ann Gormley
- Clemson University College of Behavioral, Social, and Health Science, Department of Public Health Sciences, 503 Edwards Hall, Clemson SC, 29631, USA; Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA.
| | - Irene Pericot-Valverde
- Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA; Clemson University School of Health Research, 605 Grove Road Suite 301, Clemson, SC, 29605, USA
| | - Liam Diaz
- Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA; Greenville County Behavioral Health AmeriCorps VISTA Program, 130 Industrial Dr. Suite B, Greenville, SC, 29607, USA
| | - Ashley Coleman
- Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA
| | - Jonathan Lancaster
- Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA; Clemson University College of Behavioral, Social, and Health Science, Department of Psychology, 418 Brackett Hall, Clemson SC, 29634, USA
| | - Erik Ortiz
- Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA
| | - Phillip Moschella
- Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA; Prisma Health Department of Emergency Medicine, 701 Grove Rd., Greenville, SC, 29605, USA; University of South Carolina School of Medicine Greenville, Department of Medicine, 701 Grove road, Greenville, SC, 29605, USA
| | - Moonseong Heo
- Clemson University College of Behavioral, Social, and Health Science, Department of Public Health Sciences, 503 Edwards Hall, Clemson SC, 29631, USA; Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA
| | - Alain H Litwin
- Prisma Health Addiction Research Center, 605 Grove Rd. Suite 205, Greenville, SC, 29605, USA; University of South Carolina School of Medicine Greenville, Department of Medicine, 701 Grove road, Greenville, SC, 29605, USA; Clemson University School of Health Research, 605 Grove Road Suite 301, Clemson, SC, 29605, USA; Prisma Health Department of Internal Medicine, 876 W Faris Rd., Greenville, SC, 29605, USA
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Refusal to accept emergency medical transport following opioid overdose, and conditions that may promote connections to care. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 97:103296. [PMID: 34062289 DOI: 10.1016/j.drugpo.2021.103296] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/10/2021] [Accepted: 04/14/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Opioid overdose is a leading cause of death in the United States. Emergency medical services (EMS) encounters following overdose may serve as a critical linkage to care for people who use drugs (PWUD). However, many overdose survivors refuse EMS transport to hospitals, where they would presumably receive appropriate follow-up services and referrals. This study aims to (1) identify reasons for refusal of EMS transport after opioid overdose reversal; (2) identify conditions under which overdose survivors might be more likely to accept these services; and (3) describe solutions proposed by both PWUD and EMS providers to improve post-overdose care. METHODS The study comprised 20 semi-structured, qualitative in-depth interviews with PWUD, followed by two semi-structured focus groups with eight EMS providers. RESULTS PWUD cited intolerable withdrawal symptoms; anticipation of inadequate care upon arrival at the hospital; and stigmatizing treatment by EMS and hospital providers as main reasons for refusal to accept EMS transport. EMS providers corroborated these descriptions and offered solutions such as titration of naloxone to avoid harsh withdrawal symptoms; peer outreach or community paramedicine; and addressing provider burnout. PWUD stated they might accept EMS transport after overdose reversal if they were offered ease for withdrawal symptoms, at either a hospital or non-hospital facility, and treated with respect and empathy. CONCLUSION Standard of care by EMS and hospital providers following overdose reversal should include treatment for withdrawal symptoms, including buprenorphine induction; patient-centered communication; and effective linkage to prevention, treatment, and harm reduction services.
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16
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Davis CS, Carr DH, Glenn MJ, Samuels EA. Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder. Ann Emerg Med 2021; 78:102-108. [PMID: 33781607 DOI: 10.1016/j.annemergmed.2021.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/29/2020] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
Treatment with buprenorphine significantly reduces both all-cause and overdose mortality among individuals with opioid use disorder. Offering buprenorphine treatment to individuals who experience a nonfatal opioid overdose represents an opportunity to reduce opioid overdose fatalities. Although some emergency departments (EDs) initiate buprenorphine treatment, many individuals who experience an overdose either refuse transport to the ED or are transported to an ED that does not offer buprenorphine. Emergency medical services (EMS) professionals can help address this treatment gap. In this Concepts article, we describe the federal legal landscape that governs the ability of EMS professionals to administer buprenorphine treatment, and discuss state and local regulatory considerations relevant to this promising and emerging practice.
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Affiliation(s)
- Corey S Davis
- Harm Reduction Legal Project, Network for Public Health Law, Los Angeles, CA.
| | | | - Melody J Glenn
- Department of Emergency Medicine, University of Arizona, and Banner University Medical Center Tucson, Tucson, AZ
| | - Elizabeth A Samuels
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
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17
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Bauer C, Champagne-Langabeer T, Bakos-Block C, Zhang K, Persse D, Langabeer JR. Patterns and risk factors of opioid-suspected EMS overdose in Houston metropolitan area, 2015-2019: A Bayesian spatiotemporal analysis. PLoS One 2021; 16:e0247050. [PMID: 33705402 PMCID: PMC7951926 DOI: 10.1371/journal.pone.0247050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/29/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Opioid-related overdose deaths are the top accidental cause of death in the United States, and development of regional strategies to address this epidemic should begin with a better understanding of where and when overdoses are occurring. METHODS AND FINDINGS In this study, we relied on emergency medical services data to investigate the geographical and temporal patterns in opioid-suspected overdose incidents in one of the largest and most ethnically diverse metropolitan areas (Houston Texas). Using a cross sectional design and Bayesian spatiotemporal models, we identified zip code areas with excessive opioid-suspected incidents, and assessed how the incidence risks were associated with zip code level socioeconomic characteristics. Our analysis suggested that opioid-suspected overdose incidents were particularly high in multiple zip codes, primarily south and central within the city. Zip codes with high percentage of renters had higher overdose relative risk (RR = 1.03; 95% CI: [1.01, 1.04]), while crowded housing and larger proportion of white citizens had lower relative risks (RR = 0.9; 95% CI: [0.84, 0.96], RR = 0.97, 95% CI: [0.95, 0.99], respectively). CONCLUSIONS Our analysis illustrated the utility of Bayesian spatiotemporal models in assisting the development of targeted community strategies for local prevention and harm reduction efforts.
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Affiliation(s)
- Cici Bauer
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
- * E-mail:
| | - Tiffany Champagne-Langabeer
- ACE Research Lab, School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Christine Bakos-Block
- ACE Research Lab, School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Kehe Zhang
- Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - David Persse
- Office of Emergency Medical Services, City of Houston Fire Department, Houston, Texas, United States of America
| | - James R. Langabeer
- ACE Research Lab, School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
- Department of Emergency Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
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Dezfulian C, Orkin AM, Maron BA, Elmer J, Girotra S, Gladwin MT, Merchant RM, Panchal AR, Perman SM, Starks MA, van Diepen S, Lavonas EJ. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836-e870. [PMID: 33682423 DOI: 10.1161/cir.0000000000000958] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.
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Zozula A, Neth MR, Hogan AN, Stolz U, McMullan J. Non-transport after Prehospital Naloxone Administration Is Associated with Higher Risk of Subsequent Non-fatal Overdose. PREHOSP EMERG CARE 2021; 26:272-279. [PMID: 33535012 DOI: 10.1080/10903127.2021.1884324] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: U.S. opioid overdoses increased nearly sixfold from 1999 to 2018, and greater than 1% of all emergency medical services (EMS) encounters now involve naloxone administration. While "treat and release" protocols may have low short-term mortality, the risk of subsequent non-fatal overdoses is not known. This study compares the risk of repeat overdose encounters between patients transported to an emergency department (ED) and those who refused transport after prehospital naloxone administration. Methods: All EMS charts within a large single-tier fire-based urban EMS system between January 1 and August 31, 2018 were reviewed if either naloxone administration or a clinical impression related to opioid overdose was documented. Charts were excluded if there was no documented evidence of an opioid toxidrome (respiratory depression or altered mental status), if there was another clear explanation for the symptoms (e.g., hypoglycemia), or if naloxone was not administered. Ten percent of charts were reviewed by a second author to assess reliability. Cox regression (survival analysis) was used to estimate the risk of a subsequent EMS encounter with naloxone administration following an index encounter with naloxone administration. Results: Of the 2143 charts reviewed, 1311 unique patients with 1600 overdose encounters involving naloxone administration were identified. Inter-rater reliability for chart inclusion was strong [κ = 0.83 (95% CI: 0.72-0.90)]. Police/bystanders administered naloxone in 208/1600 (13.0%) encounters. A substantial proportion of encounters resulted in transport refusal (674/1600, 42.1%). The final Cox model included only refusal vs. acceptance of transport to an ED during the index EMS encounter. Patient age, gender, and naloxone administration prior to EMS arrival were not statistically significant in univariate or multivariable analyses, nor were they significant confounders. Refusal of transport was associated with a hazard ratio of 1.66 (95% CI: 1.23-2.23) for subsequent EMS encounters with naloxone administration. Conclusions: Non-transport after prehospital naloxone administration is associated with an increased risk of subsequent non-fatal overdose requiring EMS intervention. Limitations include the use of a single EMS agency as patients may have had uncaptured overdose encounters in neighboring municipalities.
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Affiliation(s)
- Alexander Zozula
- Department of Emergency Medicine, Division of Prehospital and Disaster Medicine, UMMS-Baystate, Springfield, MA (AZ);; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR (MRN);; Department of Emergency Medicine, Division of EMS, University of Texas Southwestern Medical Center, Dallas, TX (ANH);; Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH (US);; Department of Emergency Medicine, Division of EMS, University of Cincinnati, Cincinnati, OH (JM)
| | - Matthew R Neth
- Department of Emergency Medicine, Division of Prehospital and Disaster Medicine, UMMS-Baystate, Springfield, MA (AZ);; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR (MRN);; Department of Emergency Medicine, Division of EMS, University of Texas Southwestern Medical Center, Dallas, TX (ANH);; Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH (US);; Department of Emergency Medicine, Division of EMS, University of Cincinnati, Cincinnati, OH (JM)
| | - Andrew N Hogan
- Department of Emergency Medicine, Division of Prehospital and Disaster Medicine, UMMS-Baystate, Springfield, MA (AZ);; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR (MRN);; Department of Emergency Medicine, Division of EMS, University of Texas Southwestern Medical Center, Dallas, TX (ANH);; Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH (US);; Department of Emergency Medicine, Division of EMS, University of Cincinnati, Cincinnati, OH (JM)
| | - Uwe Stolz
- Department of Emergency Medicine, Division of Prehospital and Disaster Medicine, UMMS-Baystate, Springfield, MA (AZ);; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR (MRN);; Department of Emergency Medicine, Division of EMS, University of Texas Southwestern Medical Center, Dallas, TX (ANH);; Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH (US);; Department of Emergency Medicine, Division of EMS, University of Cincinnati, Cincinnati, OH (JM)
| | - Jason McMullan
- Department of Emergency Medicine, Division of Prehospital and Disaster Medicine, UMMS-Baystate, Springfield, MA (AZ);; Department of Emergency Medicine, Oregon Health & Science University, Portland, OR (MRN);; Department of Emergency Medicine, Division of EMS, University of Texas Southwestern Medical Center, Dallas, TX (ANH);; Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH (US);; Department of Emergency Medicine, Division of EMS, University of Cincinnati, Cincinnati, OH (JM)
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20
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Formica SW, Waye KM, Benintendi AO, Yan S, Bagley SM, Beletsky L, Carroll JJ, Xuan Z, Rosenbloom D, Apsler R, Green TC, Hunter A, Walley AY. Characteristics of post-overdose public health-public safety outreach in Massachusetts. Drug Alcohol Depend 2021; 219:108499. [PMID: 33421800 DOI: 10.1016/j.drugalcdep.2020.108499] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND As a response to mounting overdose fatalities, cross-agency outreach efforts have emerged to reduce future risk among overdose survivors. We aimed to characterize such programs in Massachusetts, with focus on team composition, approach, services provided, and funding. METHODS We conducted a two-phase cross-sectional survey of public health and safety providers in Massachusetts. Providers in all 351 municipalities received a screening survey. Those with programs received a second, detailed survey. We analyzed responses using descriptive statistics. RESULTS As of July 2019, 44 % (156/351) of Massachusetts municipalities reported post-overdose outreach programs, with 75 % (104/138) formed between 2016-2019. Teams conducted home-based outreach 1-3 days following overdose events. Police departments typically supplied location information on overdose events (99 %, 136/138) and commonly participated in outreach visits (86 %, 118/138) alongside public health personnel, usually from community-based organizations. Teams provided or made referrals to services including inpatient addiction treatment, recovery support, outpatient medication, overdose prevention education, and naloxone. Some programs deployed law enforcement tools, including pre-visit warrant queries (57 %, 79/138), which occasionally led to arrest (11 %, 9/79). Many programs (81 %, 112/138) assisted families with involuntary commitment to treatment - although this was usually considered an option of last resort. Most programs were grant-funded (76 %, 104/136) and engaged in cross-municipal collaboration (94 %, 130/138). CONCLUSIONS Post-overdose outreach programs have expanded, typically as collaborations between police and public health. Further research is needed to better understand the implications of involving police and to determine best practices for increasing engagement in treatment and harm reduction services and reduce subsequent overdose.
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Affiliation(s)
- Scott W Formica
- Social Science Research and Evaluation, Inc., 21-C Cambridge Street, Burlington, MA 01803, USA.
| | - Katherine M Waye
- Grayken Center for Addiction and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - Allyn O Benintendi
- Grayken Center for Addiction and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - Shapei Yan
- Grayken Center for Addiction and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - Sarah M Bagley
- Grayken Center for Addiction and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118, USA; Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, MA 02118, USA
| | - Leo Beletsky
- Northeastern University School of Law and Bouve College of Health Sciences, 350 Huntington Avenue, Boston, MA 02115, USA; Division of Infectious Diseases and Global Public Health, University of California at San Diego School of Medicine, La Jolla, CA, USA
| | - Jennifer J Carroll
- Elon University, Department of Sociology and Anthropology, 2035 Campus Box, Elon, NC 27244, USA; Warren Alpert School of Medicine of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Ziming Xuan
- Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, Boston, MA 02118, USA
| | - David Rosenbloom
- Boston University School of Public Health, Department of Health Law, Policy and Management, Talbot Building, 715 Albany Street, Boston, MA 02118, USA
| | - Robert Apsler
- Social Science Research and Evaluation, Inc., 21-C Cambridge Street, Burlington, MA 01803, USA
| | - Traci C Green
- Warren Alpert School of Medicine of Brown University, 222 Richmond Street, Providence, RI 02903, USA; Brandeis University, The Heller School for Social Policy and Management, 415 South Street Waltham, MA 02453, USA; Center of Biomedical Research Excellence on Opioids and Overdose, Rhode Island Hospital, 8 Third Street, Second Floor, Providence, RI 02906, USA
| | - Allie Hunter
- Police Assisted Addiction and Recovery Initiative (PAARI), 253 Amory Street, Boston, MA 02130, USA
| | - Alexander Y Walley
- Grayken Center for Addiction and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118, USA
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Champagne‐Langabeer T, Bakos‐Block C, Yatsco A, Langabeer JR. Emergency medical services targeting opioid user disorder: An exploration of current out-of-hospital post-overdose interventions. J Am Coll Emerg Physicians Open 2020; 1:1230-1239. [PMID: 33392528 PMCID: PMC7771755 DOI: 10.1002/emp2.12208] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The opioid epidemic continues to escalate, and out-of-hospital emergency medical services (EMS) play a vital role in acute overdose reversal, but could serve a broader role post-incident for follow-up, outreach, and referrals. Our objective is to identify the scope and prevalence of community-based, post-opioid overdose EMS programs across the United States. METHODS We used a narrative review of prior studies in PubMed and Scopus for the last 20 years (1999-2020) to identify relevant medical literature and a web search to identify gray literature of EMS interventions involving opioids. RESULTS Out of nearly 22,000 EMS agencies across the United States, we found evidence of only 27 programs published in medical or gray literature involving post-overdose interventions. They were most commonly found in the north and eastern region of the country. Although most of these programs incorporate harm reduction and education, other more innovative aspects such as linkage to outpatient addiction treatment or peer support services, are much less common. The most comprehensive programs involved combinations of innovative outreach, specialized referrals, integration with police and criminal justice, peer support, and even treatment initiation. CONCLUSIONS Out-of-hospital emergency care has the potential to provide more comprehensive care after drug overdose, but many programs either do not currently have such an intervention in place, or are not disseminating their practices for other agencies to assimilate. EMS protocols and policies that encourage greater adoption of active community paramedicine practices for opioids should be encouraged.
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Affiliation(s)
- Tiffany Champagne‐Langabeer
- Houston Emergency Opioid Engagement SystemSchool of Biomedical InformaticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Christine Bakos‐Block
- Houston Emergency Opioid Engagement SystemSchool of Biomedical InformaticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Andrea Yatsco
- Houston Emergency Opioid Engagement SystemSchool of Biomedical InformaticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - James R. Langabeer
- Houston Emergency Opioid Engagement SystemSchool of Biomedical InformaticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
- Department of Emergency Medicine, McGovern Medical SchoolThe University of Texas Health Science Center at HoustonHoustonTexasUSA
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Glenn MJ, Rice AD, Primeau K, Hollen A, Jado I, Hannan P, McDonough S, Arcaris B, Spaite DW, Gaither JB. Refusals After Prehospital Administration of Naloxone during the COVID-19 Pandemic. PREHOSP EMERG CARE 2020; 25:46-54. [PMID: 33054530 DOI: 10.1080/10903127.2020.1834656] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine if COVID-19 was associated with a change in patient refusals after Emergency Medical Services (EMS) administration of naloxone. METHODS This is a retrospective cohort study in which the incidence of refusals after naloxone administration in a single EMS system was evaluated. The number of refusals after naloxone administration was compared across the before-pandemic interval (01/01/20 to 02/15/20) and the during-pandemic interval (03/16/20 to 04/30/20). For comparison the incidence of all other patient refusals before and during COVID-19 as well as the incidences of naloxone administration before and during COVID-19 were also reported. RESULTS Prior to the widespread knowledge of the COVID-19 pandemic, 24 of 164 (14.6%) patients who received naloxone via EMS refused transport. During the pandemic, 55 of 153 (35.9%) patients who received naloxone via EMS refused transport. Subjects receiving naloxone during the COVID-19 pandemic were at greater risk of refusal of transport than those receiving naloxone prior to the pandemic (RR = 2.45; 95% CI 1.6-3.76). Among those who did not receive naloxone, 2067 of 6956 (29.7%) patients were not transported prior to the COVID-19 pandemic and 2483 of 6016 (41.3%) were not transported during the pandemic. Subjects who did not receive naloxone with EMS were at greater risk of refusal of transport during the COVID-19 pandemic than prior to it (RR = 1.39; 95% CI 1.32-1.46). CONCLUSION In this single EMS system, more than a two-fold increase in the rate of refusal after non-fatal opioid overdose was observed following the COVID-19 outbreak.
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Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S469-S523. [PMID: 33081526 DOI: 10.1161/cir.0000000000000901] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, Lavonas EJ, Magid DJ. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S337-S357. [DOI: 10.1161/cir.0000000000000918] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Joiner A, Kumar L, Barhorst B, Braithwaite S. The Role of Emergency Medical Services in the Opioid Epidemic. PREHOSP EMERG CARE 2020; 25:462-464. [PMID: 32795103 DOI: 10.1080/10903127.2020.1810372] [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: 10/23/2022]
Abstract
The opioid crisis is an ongoing public health concern and EMS agencies are in a critical position to reach at-risk populations. The traditional role of EMS in treating acute opioid overdoses has expanded to include preventative strategies as well as long-term treatment and recovery options. EMS agencies are uniquely positioned to partner with local community resources and hospitals to combine efforts in implementing harm-reduction strategies.
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Glober NK, Hern G, McBride O, Mercer MP. Variations in the California Emergency Medical Services Response to Opioid Use Disorder. West J Emerg Med 2020; 21:671-676. [PMID: 32421518 PMCID: PMC7234694 DOI: 10.5811/westjem.2019.12.45189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/08/2019] [Indexed: 01/24/2023] Open
Abstract
Introduction Opioids contributed to over 300,000 deaths in the United States in the past 10 years. Most research on drug use occurs in clinics or hospitals; few studies have evaluated the impact of opioid use on emergency medical services (EMS) or the EMS response to opioid use disorder (OUD). This study describes the perceived burden of disease, data collection, and interventions in California local EMS agencies (LEMSA). Methods We surveyed medical directors of all 33 California LEMSAs with 25 multiple-choice and free-answer questions. Results were collected in RedCap and downloaded into Excel (Microsoft Corporation, Redmond WA). This study was exempt from review by the Alameda Health System - Highland Hospital Institutional Review Board. Results Of the 33 California LEMSAs, 100% responded, all indicating that OUD significantly affects their patients. Most (91%) had specific protocols directing care of those patients and repeat naloxone dosing. After naloxone administration, none permitted release to law enforcement custody, 6% permitted patient refusal of care, and 45% directed base hospital contact for refusal of care. Few protocols directed screening or treatment of OUD or withdrawal symptoms. Regular data collection occurred in 76% of LEMSAs, with only 48% linking EMS data with hospital or coroner outcomes. In only 30% did the medical director oversee regular quality improvement meetings. Of respondents, 64% were aware of public health agency-based outreach programs and 42% were aware of emergency department BRIDGE programs (Medication Assisted Treatment and immediate referral). Only 9% oversaw naloxone kit distribution (all under the medical director), and 6% had EMS-based outreach programs. In almost all (94%), law enforcement officers carried naloxone and administered it anywhere from a few times a year to greater than 200 in one LEMSA. Conclusion This study represents an important description of EMS medical directors’ approaches to the impact of OUD as well as trends in protocols and interventions to treat and prevent overdoses. Through this study, we can better understand the variable response to patients with OUD across California.
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Affiliation(s)
- Nancy K Glober
- Indiana University, Department of Emergency Medicine, Indianapolis, Indiana
| | - Gene Hern
- Alameda Health System-Highland Hospital, Department of Emergency Medicine, Oakland, California
| | - Owen McBride
- Alameda Health System-Highland Hospital, Department of Emergency Medicine, Oakland, California
| | - Mary P Mercer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
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Weiner SG, Baker O, Bernson D, Schuur JD. One year mortality of patients treated with naloxone for opioid overdose by emergency medical services. Subst Abus 2020; 43:99-103. [PMID: 32242763 PMCID: PMC7541791 DOI: 10.1080/08897077.2020.1748163] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Study objective: Prehospital use of naloxone for presumed opioid overdose has increased markedly in recent years because of the current opioid overdose epidemic. In this study, we determine the 1-year mortality of suspected opioid overdose patients who were treated with naloxone by EMS and initially survived. Methods: This was a retrospective observational study of patients using three linked statewide datasets in Massachusetts: emergency medical services (EMS), a master demographics file, and death records. We included all suspected opioid overdose patients who were treated with naloxone by EMS. The primary outcome measures were death within 3 days of treatment and between 4 days and 1 year of treatment. Results: Between July 1, 2013 and December 31, 2015, there were 9734 individuals who met inclusion criteria and were included for analysis. Of these, 807 (8.3% (95% confidence interval (CI) 7.7-8.8%)) died in the first 3 days, 668 (6.9% (95% CI 6.4-7.4%)) died between 4 days and 1 year, and 8259 (84.8% (95% CI 84.1-85.6%)) were still alive at 1 year. Excluding those who died within 3 days, 668 of the remaining 8927 individuals (7.5% (95% CI 6.9-8.0%)) died within 1 year. Conclusion: The 1-year mortality of those who are treated with naloxone for opioid overdose by EMS is high. Communities should focus both on primary prevention and interventions for this patient population, including strengthening regional treatment centers and expanding access to medication for opioid use disorder.
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Affiliation(s)
- Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Olesya Baker
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dana Bernson
- Office of Population Health, Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Jeremiah D Schuur
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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A descriptive study of racial and ethnic differences of drug overdoses and naloxone administration in Pennsylvania. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 78:102718. [PMID: 32199352 DOI: 10.1016/j.drugpo.2020.102718] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/21/2020] [Accepted: 02/25/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Drug overdose is a significant public health problem, yet little is known about racial/ethnic differences in drug overdose rates and/or in responses to a drug overdose following naloxone administration. This paper examines differences in rates of survivorship, response, revival and administration of naloxone by race and ethnicity among those who experienced a drug overdose in Pennsylvania between January 1, 2018 and December 31, 2019. Spatio-temporal variations in drug overdose locations were examined to facilitate understanding of service development, planning, and delivery of effective treatment need. METHODS Ten thousand two hundred and ninety drug overdose incidents were analyzed from the Pennsylvania Overdose Information Network (ODIN). The ODIN is a centralized repository that contains information on drug overdoses victims including age, gender and race/ethnicity, naloxone administrations and survivorship, drug(s) suspected of causing the overdose, victim outcomes (e.g. hospitalizations and arrests) and average naloxone dosage per victim. Between group differences were tested using χ2 -tests of independence. Multivariate logistic regression was used to estimate the predicted probability of survivorship according to victim characteristics. All statistical analyses and mapping were performed using the R statistical programming environment. RESULTS About eighty-seven percent of drug overdose response victims were white, and seventy-one percent were between the ages of 20-39. White females were more likely to receive an overdose response compared to black or Hispanic females. A non-opioid was indicated more frequently in overdoses involving black victims compared to either whites or Latinos. Latinos and blacks were more likely to survive a drug overdose. However, following naloxone administration, no racial or ethnic differences in survivorship were noted. Differences in responsiveness to naloxone and transitions to care following the drug overdose event were also found. Finally, overdoses among Blacks and Latinos demonstrated a stronger spatial patterning across counties compared to whites. CONCLUSIONS This study found a significant, disparate impact of race/ethnicity on fatal drug overdoses when naloxone is not administered. Further, individuals who were administered naloxone and subsequently received medical care in a hospital experienced lower drug-related mortality, suggesting that first responders are critical intervention points for individuals in need of medical treatment following a drug overdose. However, while naloxone administration is a necessary first step in the recovery process, longitudinal pathways towards treatment are critical to stem the drug overdose crisis.
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Leece P, Chen C, Manson H, Orkin AM, Schwartz B, Juurlink DN, Gomes T. One-Year Mortality After Emergency Department Visit for Nonfatal Opioid Poisoning: A Population-Based Analysis. Ann Emerg Med 2020; 75:20-28. [DOI: 10.1016/j.annemergmed.2019.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/10/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
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Scott CK, Dennis ML, Grella CE, Nicholson L, Sumpter J, Kurz R, Funk R. Findings from the recovery initiation and management after overdose (RIMO) pilot study experiment. J Subst Abuse Treat 2020; 108:65-74. [PMID: 31493942 PMCID: PMC6893133 DOI: 10.1016/j.jsat.2019.08.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 07/17/2019] [Accepted: 08/06/2019] [Indexed: 01/24/2023]
Abstract
This pilot study evaluated the feasibility of the Recovery Initiation and Management after Overdose (RIMO) intervention to link individuals to medication-assisted treatment (MAT) following an opioid overdose. The study team worked with the Chicago Fire Department to train Emergency Medical Service (EMS) teams to request permission from individuals after an opioid overdose reversal to release their contact information; individuals were subsequently contacted by the study team for participation. A mixed-methods study design comprised: (1) an experimental pilot study that examined participation at each stage of the intervention and compared the odds of treatment received for individuals who were randomly assigned to either the RIMO intervention (n = 16) or a passive referral control (n = 17); and (2) a focus group that was subsequently conducted with participants in the RIMO group to obtain their feedback on the intervention components. Quantitative data was collected on participant characteristics at study intake and treatment received was based on self-report at a 30-day follow-up. The RIMO group had higher odds of receiving any treatment for opioid use (OR = 7.94) and any MAT (OR = 20.2), and received significantly more days of opioid treatment (Ms=15.2 vs. 3.4) and more days of MAT in the 30 days post-randomization (Ms=11.2 vs. 0.76), relative to the control group (all p < .05). Qualitative data illustrated that participants valued the assertive outreach, engagement, and persistent follow-up components of RIMO, which differed from their prior experiences. The pilot study suggests that the RIMO intervention is able to address the challenges of linking and engaging individuals into MAT after an opioid overdose.
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Affiliation(s)
- Christy K Scott
- Lighthouse Institute, Chestnut Health Systems, Chicago, IL 221 W. Walton, Chicago, IL 60610, United States of America.
| | - Michael L Dennis
- Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761, United States of America.
| | - Christine E Grella
- Chestnut Health Systems, Chicago, IL 221 W. Walton, Chicago, IL 60610, United States of America.
| | - Lisa Nicholson
- Chestnut Health Systems, Chicago, IL 221 W. Walton, Chicago, IL 60610, United States of America.
| | - Jamie Sumpter
- Chestnut Health Systems, Chicago, IL 221 W. Walton, Chicago, IL 60610, United States of America.
| | - Rachel Kurz
- Chestnut Health Systems, Chicago, IL 221 W. Walton, Chicago, IL 60610, United States of America.
| | - Rod Funk
- Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761, United States of America.
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Lim JK, Forman LS, Ruiz S, Xuan Z, Callis BP, Cranston K, Walley AY. Factors associated with help seeking by community responders trained in overdose prevention and naloxone administration in Massachusetts. Drug Alcohol Depend 2019; 204:107531. [PMID: 31526959 DOI: 10.1016/j.drugalcdep.2019.06.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Community overdose responders do not always seek help from emergency services when administering naloxone. We aimed to identify responder, overdose event, and community characteristics associated with help seeking from emergency services during overdoses reported by Massachusetts Overdose Education and Naloxone Distribution (OEND) enrollees, and to assess trends in help seeking over time. METHODS We analyzed overdose reports submitted between 2007 and 2017 to the Massachusetts Department of Public Health. We used logistic regression, stratified by responder drug use status, to assess associations of characteristics with help seeking during an overdose. RESULTS From January 2007 through December 2017, there were 69,870 OEND enrollees. 5,588 enrollees reported 10,246 overdoses. Help seeking was more likely among responders who did not use drugs. Among responders who did not use drugs, help seeking was more likely when: the responder was older or female, the victim was a stranger or client, and when naloxone did not work. Among responders who used drugs, help seeking was more likely when: the responder was female or had not previously reported responding to an overdose, the victim was a stranger or client or did not use fentanyl, naloxone took a longer time to work, and when the overdose was public or occurred more recently. The percentage of overdoses where help seeking occurred reached a maximum in 2016 at 50%. CONCLUSIONS Help seeking by OEND enrollees was significantly associated with several responder, victim, and event characteristics. Targeted interventions to promote help seeking are warranted, particularly as the lethality of opioid supplies rises.
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Affiliation(s)
- Jamie K Lim
- Department of Pediatrics, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, 02118, USA.
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, 715 Albany St., Boston, MA, 02118, USA.
| | - Sarah Ruiz
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, 305 South St., Jamaica Plain, MA, 02130, USA; Bureau of Substance Addiction Services, Massachusetts Department of Public Health, 250 Washington Street, Boston, MA, 02108, USA.
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA; Grayken Center for Addiction, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave., Boston, MA, 02118, USA.
| | - Barry P Callis
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, 305 South St., Jamaica Plain, MA, 02130, USA.
| | - Kevin Cranston
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, 305 South St., Jamaica Plain, MA, 02130, USA.
| | - Alexander Y Walley
- Grayken Center for Addiction, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave., Boston, MA, 02118, USA; Bureau of Substance Addiction Services, Massachusetts Department of Public Health, 250 Washington Street, Boston, MA, 02108, USA.
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Yeung T, Shannon B, Perillo S, Nehme Z, Jennings P, Olaussen A. Review article: Outcomes of patients who are not transported following ambulance attendance: A systematic review and meta‐analysis. Emerg Med Australas 2019; 31:321-331. [DOI: 10.1111/1742-6723.13288] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 02/24/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - Brendan Shannon
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
- Ambulance Victoria Melbourne Victoria Australia
| | - Samuel Perillo
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
| | - Ziad Nehme
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
- Ambulance Victoria Melbourne Victoria Australia
| | - Paul Jennings
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
- Ambulance Victoria Melbourne Victoria Australia
| | - Alexander Olaussen
- Alfred Hospital Melbourne Victoria Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University Melbourne Victoria Australia
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Greene JA, Deveau BJ, Dol JS, Butler MB. Incidence of mortality due to rebound toxicity after ‘treat and release’ practices in prehospital opioid overdose care: a systematic review. Emerg Med J 2018; 36:219-224. [DOI: 10.1136/emermed-2018-207534] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 10/24/2018] [Accepted: 12/02/2018] [Indexed: 11/04/2022]
Abstract
IntroductionDeath due to opioid overdose was declared a public health crisis in Canada in 2015. Traditionally, patients who have overdosed on opioids that are managed by emergency medical services (EMS) are treated with the opioid antagonist naloxone, provided ventilatory support and subsequently transported to hospital. However, certain EMS agencies have permitted patients who have been reversed from opioid overdose to refuse transport, if the patient exhibits capacity to do so. Evidence on the safety of this practice is limited. Therefore, our intent was to examine the available literature to determine mortality and serious adverse events within 48 hours of EMS treat and release due to suspected rebound opioid toxicity after naloxone administration.MethodsA systematic search was performed on 11 May 2017 in PubMed, Cochrane Central, Embase and CINHAL. Studies that reported on the outcome of patients treated with prehospital naloxone and released at the scene were included. Analyses for incidence of mortality and adverse events at the scene were conducted. Risk of bias and assessment of publication bias was also done.Results1401 records were screened after duplicate removal. Eighteen full-text studies were reviewed with seven selected for inclusion. None were found to be high risk of bias. In most studies, heroin was the source of the overdose. Mortality within 48 hours was infrequent with only four deaths among 4912 patients ﴾0.081%﴿ in the seven studies. Only one study reported on adverse events and found no incidence of adverse events from their sample of 71 released patients.ConclusionMortality or serious adverse events due to suspected rebound toxicity in patients released on scene post-EMS treatment with naloxone were rare. However, studies involving longer-acting opioids were rare and no study involved fentanyl.
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Rege SV, Ngo DA, Ait-Daoud N, Sharma S, Verplancken E, Holstege CP. Trends and characteristics of naloxone therapy reported to US poison centers. Addiction 2018; 113:2309-2315. [PMID: 29989286 DOI: 10.1111/add.14378] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/24/2018] [Accepted: 07/04/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS In the United States, access to naloxone has been expanded as a measure to address growing opioid overdose mortality. The study aimed to describe the national trends in naloxone use as reported to the US poison centers (PCs). METHODS The National Poison Data System (NPDS) was queried for cases reporting naloxone therapy from 1 January 2001 to 31 December 2016. Demographic and clinical characteristics were assessed descriptively. Trends in naloxone reports were evaluated by using generalized linear mixed models that were adjusted for age, gender and random effects of the geographical census region. Cumulative incidence rates (CIR) of naloxone reports at the state- and national-level were calculated. RESULTS There were 304 249 cases reporting naloxone therapy during the study period. The frequency of naloxone reports increased from 9498 in 2000 to 26 826 in 2016. The proportion of cases where naloxone was used prior to PC recommendation increased from 59.8% in 2000 to 81.5% in 2016. The mean number of NPDS naloxone reports per 100 000 human exposures increased from 9.6 [95% confidence interval (CI) = 6.4-14.2] to 31.7 (95% CI = 21.4-46.9, P < 0.001). Among the cases, 52.4% were female and the most frequent age group was 20-39 years (39.1%). The principal reason for a toxic exposure resulting in a naloxone report was suspected suicide (55.0%). Life-threatening symptoms were seen in one-fifth of the cases, with 53.9% cases being admitted to critical care units. Opioids (59.7% cases), were the most commonly reported exposure agents, with hydrocodone being most frequently reported. The national CIR of naloxone reports to the US PCs was 6.3 cases per 100 000 population, with West Virginia demonstrating the highest incidence. CONCLUSIONS Analysis of calls to the United States poison centers indicates an increasing trend of naloxone use from 2000 to 2016.
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Affiliation(s)
- Saumitra V Rege
- Department of Emergency Medicine, Division of Medical Toxicology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Duc Anh Ngo
- Department of Emergency Medicine, Division of Medical Toxicology, University of Virginia School of Medicine, Charlottesville, VA, USA.,Department of Student Health, Division of Student Affairs, University of Virginia, Charlottesville, VA, USA
| | - Nassima Ait-Daoud
- Department of Student Health, Division of Student Affairs, University of Virginia, Charlottesville, VA, USA.,Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Sana Sharma
- Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Evan Verplancken
- Department of Emergency Medicine, Division of Medical Toxicology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Christopher P Holstege
- Department of Emergency Medicine, Division of Medical Toxicology, University of Virginia School of Medicine, Charlottesville, VA, USA.,Department of Student Health, Division of Student Affairs, University of Virginia, Charlottesville, VA, USA
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Ray BR, Lowder EM, Kivisto AJ, Phalen P, Gil H. EMS naloxone administration as non-fatal opioid overdose surveillance: 6-year outcomes in Marion County, Indiana. Addiction 2018; 113:2271-2279. [PMID: 30255531 DOI: 10.1111/add.14426] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/13/2018] [Accepted: 08/20/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS Despite rising rates of opioid overdose in the United States, few studies have examined the frequency of non-fatal overdose events or mortality outcomes following resuscitation. Given the widespread use of naloxone to respond to overdose-related deaths, naloxone administration may provide a useful marker of overdose events to identify high-risk users at heightened risk of mortality. We used naloxone administration by emergency medical services as a proxy measure of non-fatal overdose to examine repeat events and mortality outcomes during a 6-year period. METHODS We conducted a retrospective investigation of all cases in Marion County, Indiana between January 2011 and December 2016 where emergency medical services used naloxone to resuscitate a patient. Cases were linked to vital records to assess mortality and cause of death during the same time-period. We used Cox regression survival analysis to assess whether repeat non-fatal overdose events during the study period were associated with the hazard of mortality, both overall and by cause of death. RESULTS Of 4726 patients administered naloxone, 9.4% (n = 444) died an average of 354 days [standard deviation (SD) = 412.09, range = 1-1980] following resuscitation. Decedents who died of drug-related causes (34.7%, n = 154) were younger and more likely to have had repeat non-fatal overdose events. Patients with repeat non-fatal overdose events (13.4%, n = 632) had a ×2.07 [95% confidence interval (CI) = 1.59, 2.71] higher hazard of all-cause mortality and a ×3.06 (95% CI = 2.13, 4.40) higher hazard of drug-related mortality. CONCLUSIONS Among US emergency medical service patients administered naloxone for opioid overdose, those with repeat non-fatal opioid overdose events are at a much higher risk of mortality, particularly drug-related mortality, than those without repeat events.
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Affiliation(s)
- Bradley R Ray
- School of Public and Environmental Affairs, Indiana University, Purdue University Indianapolis, Indianapolis, IN, USA
| | - Evan M Lowder
- School of Public and Environmental Affairs, Indiana University, Purdue University Indianapolis, Indianapolis, IN, USA
| | - Aaron J Kivisto
- School of Psychological Sciences, University of Indianapolis, Indianapolis, IN, USA
| | - Peter Phalen
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Harold Gil
- Marion County Public Health Department, Indianapolis, IN, USA
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Madah-Amiri D, Skulberg AK, Braarud AC, Dale O, Heyerdahl F, Lobmaier P, Clausen T. Ambulance-attended opioid overdoses: An examination into overdose locations and the role of a safe injection facility. Subst Abus 2018; 40:383-388. [PMID: 29949448 DOI: 10.1080/08897077.2018.1485130] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background: Although the United States and numerous other countries are amidst an opioid overdose crisis, access to safe injection facilities remains limited. Methods: We used prospective data from ambulance journals in Oslo, Norway, to describe the patterns, severity, and outcomes of opioid overdoses and compared these characteristics among various overdose locations. We also examined what role a safe injection facility may have had on these overdoses. Results: Based on 48,825 ambulance calls, 1054 were for opioid overdoses from 465 individuals during 2014 and 2015. The rate of calls for overdoses was 1 out of 48 of the total ambulance calls. Males made up the majority of the sample (n = 368, 79%), and the median age was 35 (range: 18-96). Overdoses occurred in public locations (n = 530, 50.3%), the safe injection facility (n = 353, 33.5%), in private homes (n = 83, 7.9%), and other locations (n = 88, 8.3%). Patients from the safe injection facility and private homes had similarly severe initial clinical symptoms (Glasgow Coma Scale median =3 and respiratory frequency median =4 breaths per minute) when compared with other locations, yet the majority from the safe injection facility did not require further ambulance transport to the hospital (n = 302, 85.6%). Those overdosed in public locations (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.17-2.35), and when the safe injection facility was closed (OR =1.4, 95% CI =1.04-1.89), were more likely to receive transport for further treatment. Conclusions: Our findings suggest that the opening hours at the safe injection facility and the overdose location may impact the likelihood of ambulance transport for further treatment.
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Affiliation(s)
- Desiree Madah-Amiri
- The Norwegian Centre for Addiction Research, The University of Oslo, Oslo, Norway
| | - Arne Kristian Skulberg
- Department of Circulation and Medical Imaging, The Norwegian University of Science and Technology, Trondheim, Norway.,Department of Anesthesiology and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | - Ola Dale
- Department of Circulation and Medical Imaging, The Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, University Hospital of Trondheim, Trondheim, Norway
| | - Fridtjof Heyerdahl
- Department of Anesthesiology and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Philipp Lobmaier
- The Norwegian Centre for Addiction Research, The University of Oslo, Oslo, Norway.,Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| | - Thomas Clausen
- The Norwegian Centre for Addiction Research, The University of Oslo, Oslo, Norway
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Stam NC, Pilgrim JL, Drummer OH, Smith K, Gerostamoulos D. Catch and release: evaluating the safety of non-fatal heroin overdose management in the out-of-hospital environment. Clin Toxicol (Phila) 2018; 56:1135-1142. [DOI: 10.1080/15563650.2018.1478093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Nathan C. Stam
- Department of Forensic Medicine, Monash University, Melbourne, Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
| | | | - Olaf H. Drummer
- Department of Forensic Medicine, Monash University, Melbourne, Australia
| | - Karen Smith
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dimitri Gerostamoulos
- Department of Forensic Medicine, Monash University, Melbourne, Australia
- Victorian Institute of Forensic Medicine, Melbourne, Australia
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40
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Formica SW, Apsler R, Wilkins L, Ruiz S, Reilly B, Walley AY. Post opioid overdose outreach by public health and public safety agencies: Exploration of emerging programs in Massachusetts. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 54:43-50. [DOI: 10.1016/j.drugpo.2018.01.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 01/01/2018] [Accepted: 01/02/2018] [Indexed: 02/01/2023]
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Keane C, Egan JE, Hawk M. Effects of naloxone distribution to likely bystanders: Results of an agent-based model. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018. [PMID: 29524734 DOI: 10.1016/j.drugpo.2018.02.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioid overdose deaths in the US rose dramatically in the past 16 years, creating an urgent national health crisis with no signs of immediate relief. In 2017, the President of the US officially declared the opioid epidemic to be a national emergency and called for additional resources to respond to the crisis. Distributing naloxone to community laypersons and people at high risk for opioid overdose can prevent overdose death, but optimal distribution methods have not yet been pinpointed. METHODS We conducted a sequential exploratory mixed methods design using qualitative data to inform an agent-based model to improve understanding of effective community-based naloxone distribution to laypersons to reverse opioid overdose. The individuals in the model were endowed with cognitive and behavioral variables and accessed naloxone via community sites such as pharmacies, hospitals, and urgent-care centers. We compared overdose deaths over a simulated 6-month period while varying the number of distribution sites (0, 1, and 10) and number of kits given to individuals per visit (1 versus 10). Specifically, we ran thirty simulations for each of thirteen distribution models and report average overdose deaths for each. The baseline comparator was no naloxone distribution. Our simulations explored the effects of distribution through syringe exchange sites with and without secondary distribution, which refers to distribution of naloxone kits by laypersons within their social networks and enables ten additional laypersons to administer naloxone to reverse opioid overdose. RESULTS Our baseline model with no naloxone distribution predicted there would be 167.9 deaths in a six month period. A single distribution site, even with 10 kits picked up per visit, decreased overdose deaths by only 8.3% relative to baseline. However, adding secondary distribution through social networks to a single site resulted in 42.5% fewer overdose deaths relative to baseline. That is slightly higher than the 39.9% decrease associated with a tenfold increase in the number of sites, all distributing ten kits but with no secondary distribution. This suggests that, as long as multiple kits are picked up per visit, adding secondary distribution is at least as effective as increasing sites from one to ten. Combining the addition of secondary distribution with an increase in sites from one to ten resulted in a 61.1% drop in deaths relative to the baseline. Adding distribution through a syringe exchange site resulted in a drop of approximately 65% of deaths relative to baseline. In fact, when enabling distribution through a clean-syringe site, the secondary distribution through networks contributed no additional drops in deaths. CONCLUSION Community-based naloxone distribution to reverse opioid overdose may significantly reduce deaths. Optimal distribution methods may include secondary distribution so that the person who picks up naloxone kits can enable others in the community to administer naloxone, as well as targeting naloxone distribution to sites where individuals at high-risk for opioid overdose death are likely to visit, such as syringe-exchange programs. This study design, which paired exploratory qualitative data with agent-based modeling, can be used in other settings seeking to implement and improve naloxone distribution programs.
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Affiliation(s)
- Christopher Keane
- University of Pittsburgh, Graduate School of Public Health, Department of Behavioral and Community Health Sciences, 6124 Parran Hall, 130 DeSoto Street, Pittsburgh, PA, 15261, USA.
| | - James E Egan
- University of Pittsburgh, Graduate School of Public Health, Department of Behavioral and Community Health Sciences, 6124 Parran Hall, 130 DeSoto Street, Pittsburgh, PA, 15261, USA.
| | - Mary Hawk
- University of Pittsburgh, Graduate School of Public Health, Department of Behavioral and Community Health Sciences, 6124 Parran Hall, 130 DeSoto Street, Pittsburgh, PA, 15261, USA.
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Kinsman JM, Robinson K. National Systematic Legal Review of State Policies on Emergency Medical Services Licensure Levels' Authority to Administer Opioid Antagonists. PREHOSP EMERG CARE 2018; 22:650-654. [PMID: 29485328 DOI: 10.1080/10903127.2018.1439129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Previous research conducted in November 2013 found there were a limited number of states and territories in the United States (US) that authorize emergency medical technicians (EMTs) and emergency medical responders (EMRs) to administer opioid antagonists. Given the continued increase in the number of opioid-related overdoses and deaths, many states have changed their policies to authorize EMTs and EMRs to administer opioid antagonists. The goal of this study is to provide an updated description of policy on EMS licensure levels' authority to administer opioid antagonists for all 50 US states, the District of Columbia (DC), and the Commonwealth of Puerto Rico (PR). METHODS State law and scopes of practice were systematically reviewed using a multi-tiered approach to determine each state's legally-defined EMS licensure levels and their authority to administer an opioid antagonist. State law, state EMS websites, and state EMS scope of practice documents were identified and searched using Google Advanced Search with Boolean Search Strings. Initial results of the review were sent to each state office of EMS for review and comment. RESULTS As of September 1, 2017, 49 states and DC authorize EMTs to administer an opioid antagonist. Among the 40 US jurisdictions (39 states and DC) that define the EMR or a comparable first responder licensure level in state law, 37 states and DC authorize their EMRs to administer an opioid antagonist. Paramedics are authorized to administer opioid antagonists in all 50 states, DC, and PR. All 49 of the US jurisdictions (48 states and DC) that define the advanced emergency medical technician (AEMT) or a comparable intermediate EMS licensure level in state law authorize their AEMTs to administer an opioid antagonist. CONCLUSIONS 49 out of 52 US jurisdictions (50 states, DC, and PR) authorize all existing levels of EMS licensure levels to administer an opioid antagonist. Expanding access to this medication can save lives, especially in communities that have limited advanced life support coverage.
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Grover JM, Alabdrabalnabi T, Patel MD, Bachman MW, Platts-Mills TF, Cabanas JG, Williams JG. Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid Overdoses in a Large U.S. EMS System. PREHOSP EMERG CARE 2018; 22:281-289. [DOI: 10.1080/10903127.2017.1387628] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Rzasa Lynn R, Galinkin JL. Naloxone dosage for opioid reversal: current evidence and clinical implications. Ther Adv Drug Saf 2017; 9:63-88. [PMID: 29318006 DOI: 10.1177/2042098617744161] [Citation(s) in RCA: 202] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 11/03/2017] [Indexed: 12/18/2022] Open
Abstract
Opioid-related mortality is a growing problem in the United States, and in 2015 there were over 33,000 opioid-related deaths. To combat this mortality trend, naloxone is increasingly being utilized in a pre-hospital setting by emergency personnel and prescribed to laypersons for out-of-hospital administration. With increased utilization of naloxone there has been a subsequent reduction in mortality following an opioid overdose. Reversal of opioid toxicity may precipitate an opioid-withdrawal syndrome. At the same time, there is a risk of inadequate response or re-narcotization after the administration of a single dose of naloxone in patients who have taken large doses or long-acting opioid formulations, as the duration of effect of naloxone is shorter than that of many opioid agonists. As out-of-hospital use of this medication is growing, so too is concern about effective but safe dosing.
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Affiliation(s)
| | - J L Galinkin
- University of Colorado at Denver, Anschutz Medical Campus, 13123 East 16th Avenue, B090, Aurora, CO 80045-0508, USA
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45
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Gulec N, Lahey J, Suozzi JC, Sholl M, MacLean CD, Wolfson DL. Basic and Advanced EMS Providers Are Equally Effective in Naloxone Administration for Opioid Overdose in Northern New England. PREHOSP EMERG CARE 2017; 22:163-169. [DOI: 10.1080/10903127.2017.1371262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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46
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Faul M, Lurie P, Kinsman JM, Dailey MW, Crabaugh C, Sasser SM. Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing. PREHOSP EMERG CARE 2017; 21:411-419. [PMID: 28481656 PMCID: PMC6026856 DOI: 10.1080/10903127.2017.1315203] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 03/30/2017] [Accepted: 03/30/2017] [Indexed: 12/03/2022]
Abstract
BACKGROUND Opioid overdoses are at epidemic levels in the United States. Emergency Medical Service (EMS) providers may administer naloxone to restore patient breathing and prevent respiratory arrest. There was a need for contemporary data to examine the number of naloxone administrations in an EMS encounter. METHODS Using data from the National Emergency Medical Services Information System, we examined data from 2012-5 to determine trends in patients receiving multiple naloxone administrations (MNAs). Logistic regression including demographic, clinical, and operational information was used to examine factors associated with MNA. RESULTS Among all events where naloxone was administered only 16.7% of the 911 calls specifically identified the medical emergency as a drug ingestion or poisoning event. The percentage of patients receiving MNA increased from 14.5% in 2012 to 18.2% in 2015, which represents a 26% increase in MNA in 4 years. Patients aged 20-29 had the highest percentage of MNA (21.1%). Patients in the Northeast and the Midwest had the highest relative MNA (Chi Squared = 539.5, p < 0.01 and Chi Squared = 351.2, p < 0.01, respectively). The logistic regression model showed that the adjusted odds ratios (aOR) for MNA were greatest among people who live in the Northeast (aOR = 1.18, 95% CI = 1.13-1.22) and for men (aOR = 1.13, 95% CI = 1.10-1.16), but lower for suburban and rural areas (aOR = 0.76, 95% CI = 0.72-0.80 and aOR = 0.85, 95% CI = 0.80-0.89) and lowest for wilderness areas (aOR = 0.76, 95% CI = 0.68-0.84). Higher adjusted odds of MNA occurred when an advanced life support (ALS 2) level of service was provided compared to basic life support (BLS) ambulances (aOR = 2.15, 95% CI = 1.45-3.16) and when the dispatch complaint indicated there was a drug poisoning event (aOR = 1.12, 95% CI = 1.09-1.16). Reported layperson naloxone administration prior to EMS arrival was rare (1%). CONCLUSION This study shows that frequency of MNA is growing over time and is regionally dependent. MNA may be a barometer of the potency of the opioid involved in the overdose. The increase in MNA provides support for a dosage review. Better identification of opioid related events in the dispatch system could lead to a better match of services with patient needs.
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Weiner SG, Mitchell PM, Temin ES, Langlois BK, Dyer KS. Use of Intranasal Naloxone by Basic Life Support Providers. PREHOSP EMERG CARE 2017; 21:322-326. [DOI: 10.1080/10903127.2017.1282562] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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48
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Is a Prehospital Treat and Release Protocol for Opioid Overdose Safe? J Emerg Med 2017; 52:52-58. [DOI: 10.1016/j.jemermed.2016.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/07/2016] [Indexed: 11/20/2022]
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49
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Willman MW, Liss DB, Schwarz ES, Mullins ME. Do heroin overdose patients require observation after receiving naloxone? Clin Toxicol (Phila) 2016; 55:81-87. [DOI: 10.1080/15563650.2016.1253846] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Michael W. Willman
- Division of Emergency Medicine, Washington University, St. Louis, MO, USA
| | - David B. Liss
- Division of Emergency Medicine, Washington University, St. Louis, MO, USA
| | - Evan S. Schwarz
- Division of Emergency Medicine, Washington University, St. Louis, MO, USA
| | - Michael E. Mullins
- Division of Emergency Medicine, Washington University, St. Louis, MO, USA
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50
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Gjersing L, Jonassen K, Skurtveit S, Bramness J, Clausen T. Emergency service use is common in the year before death among drug users who die from an overdose. JOURNAL OF SUBSTANCE USE 2016. [DOI: 10.1080/14659891.2016.1208778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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