We described the change in drug overdoses during the COVID-19 pandemic in one urban emergency medical services (EMS) system. Data was collected from Marion County, Indiana (Indianapolis), including EMS calls for service (CFS) for suspected overdose, CFS in which naloxone was administered, and fatal overdose data from the County Coroner's Office. With two sample t tests and ARIMA time series forecasting, we showed changes in the daily rates of calls (all EMS CFS, overdose CFS, and CFS in which naloxone was administered) before and after the stay-at-home order in Indianapolis. We further showed differences in the weekly rate of overdose deaths. Overdose CFS and EMS naloxone administration showed an increase with the social isolation of the Indiana stay-at-home order, but a continued increase after the stay-at-home order was terminated. Despite a mild 4% increase in all EMS CFS, overdose CFS increased 43% and CFS with naloxone administration increased 61% after the stay-athome order. Deaths from drug overdoses increased by 47%. There was no change in distribution of age, race/ethnicity, or zip code of those who overdosed after the stay-at-home order was issued. We hope this data informs policy-makers preparing for future COVID-19 responses and other disaster responses.

BackgroundTo reduce fatal drug overdoses, two approaches many states have followed is to pass laws expanding naloxone access and Good Samaritan protections for lay persons with high likelihood to respond to an opioid overdose. Most prior research has examined attitudes and knowledge among lay responders in large metropolitan areas who actively use illicit substances. The present study addresses current gaps in knowledge related to this issue through an analysis of data collected from a broader group of lay responders who received naloxone kits from 20 local health departments across Indiana.MethodsPostcard surveys were included inside naloxone kits distributed in 20 Indiana counties, for which 217 returned cards indicated the person completing it was a lay responder. The survey captured demographic information and experiences with overdose, including the use of 911 and knowledge about Good Samaritan protections.ResultsFew respondents had administered naloxone before, but approximately one third had witnessed a prior overdose and the majority knew someone who had died from one. Those who knew someone who had overdosed were more likely to have obtained naloxone for someone other than themselves. Also, persons with knowledge of Good Samaritan protections or who had previously used naloxone were significantly more likely to have indicated calling 911 at the scene of a previously witnessed overdose. Primary reasons for not calling 911 included fear of the police and the person who overdosed waking up on their own.ConclusionsKnowing someone who has had a fatal or non-fatal overdose appears to be a strong motivating factor for obtaining naloxone. Clarifying and strengthening Good Samaritan protections, educating lay persons about these protections, and working to improve police interactions with the public when they are called to an overdose scene are likely to improve implementation and outcomes of naloxone distribution and opioid-related Good Samaritan laws.

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Objectives. To demonstrate the severity of undercounting opioid-involved deaths in a local jurisdiction with a high proportion of unspecified accidental poisoning deaths. Methods. We matched toxicology data to vital records for all accidental poisoning deaths (n = 1238) in Marion County, Indiana, from January 2011 to December 2016. From vital records, we coded cases as opioid involved, specified other substance, or unspecified. We extracted toxicology data on opioid substances for unspecified cases, and we have reported corrected estimates of opioid-involved deaths after accounting for toxicology findings. Results. Over a 6-year period, 57.7% of accidental overdose deaths were unspecified and 34.2% involved opioids. Toxicology data showed that 86.8% of unspecified cases tested positive for an opioid. Inclusion of toxicology results more than doubled the proportion of opioid-involved deaths, from 34.2% to 86.0%. Conclusions. Local jurisdictions may be undercounting opioid-involved overdose deaths to a considerable degree. Toxicology data can improve accuracy in identifying opioid-involved overdose deaths. Public Health Implications. Mandatory toxicology testing and enhanced training for local coroners on standards for death certificate reporting are needed to improve the accuracy of local monitoring of opioid-involved accidental overdose deaths.

Fentanyl has increasingly been detected in fatal overdose deaths in Marion County. Policy and program responses must focus on education for those at highest risk of fentanyl exposure and death. These responses should also be tailored to meet the unique needs of high-risk demographics.