EMS naloxone administration as non‐fatal opioid overdose surveillance: 6‐year outcomes in Marion County, Indiana

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.

Two‐year outcomes following naloxone administration by police officers or emergency medical services personnel

“…Finally, we found no differences in mortality outcomes between individuals who received a police or EMS response. The overall mortality rate was slightly higher than found by prior research on mortality following EMS administration of naloxone in this same jurisdiction, in which 9.4% died during an average two-year follow-up (Ray, Lowder, Kivisto, Phalen, & Gil, 2018). However, the police naloxone program was targeted specifically to a police district with higher rates of fatal overdose, suggesting participants in the present study may have been at higher risk overall.…”

“…However, the police naloxone program was targeted specifically to a police district with higher rates of fatal overdose, suggesting participants in the present study may have been at higher risk overall. Indeed, we found a high proportion of deaths were drug-related (91.5%) relative to prior investigations on mortality following nonfatal overdose in this jurisdiction (34.7%; see Ray et al, 2018) and others (26.2%; see Olfson et al, 2018). Despite concerns among criminal justice practitioners about its potential to encourage illicit drug use, naloxone has been regarded as a key prevention strategy to reduce fatal opioid-involved overdose (Beletsky et al, 2012;Levine & Fraser, 2018).…”

Individual and county-level variation in outcomes following non-fatal opioid-involved overdose

“…A small, but clinically significant, portion of non-fatal overdose patients (1 in 10) were at risk for repeat non-fatal overdose over a multiyear period; roughly 1 in 50 patients were at risk for fatal overdose. More broadly, patients with repeat non-fatal overdoses are at heightened risk of drug-related death and are unlikely to receive evidence-based treatment for opioid use disorder following non-fatal overdose,33 highlighting the critical role of emergency medical settings in the identification and treatment engagement of high-risk patients 34 35…”

Comparing the predictive capability of self-report and medically-verified non-fatal overdose in adults released from prison: A prospective data linkage study

“…Response to naloxone in ambulance or other medical care has also been used as a proxy measure for overdose (Dietze et al, 2000;Gunasekaran et al, 2018;Ray et al, 2018). However, the use of naloxone may be low (Darke and Ross, 1996;Darke et al, 2007;McGregor et al, 1998;Yin et al, 2007), the decision to administer naloxone can be subjective (Sumner et al, 2016), and, by definition, response to naloxone limits NFOD to events involving opioids.…”