EMS Runs for Suspected Opioid Overdose: Implications for Surveillance and Prevention

Abstract

Objective Opioid (including prescription opiate) abuse and overdose rates in the US have surged in the past decade. The dearth and limitations of opioid abuse and overdose surveillance systems impede the development of interventions to address this epidemic. We explored evidence to support the validity of emergency medical services (EMS) data on naloxone administration as a possible proxy for estimating incidence of opioid overdose. Methods We reviewed data from Baltimore City Fire Department EMS patient records matched with dispatch records over a thirteen month time period (2008-2009), and census 2008 data. We calculated incidence rates and patient demographic and temporal patterns of naloxone administration, and examined patient evaluation data associated with naloxone administration. Results were compared to the demographic distributions of the EMS patient and city population and to prior study findings. Results Of 116,910 EMS incidents during the study period for patients 15 years and older, EMS providers administered naloxone 1,297 times (1.1% of incidents), an average of 100 administrations per month. Overall incidence was 1.87 administrations per 1,000 population per year. Findings indicated naloxone administration peaked in summer months (31% of administrations), weekends (32%), and late afternoon (4-5:00pm [8%]); and there was a trend toward peaking in the first week of the month. The incidence of suspected opioid overdose was highest among males, whites, and those in the 45-54 year age group. Findings on temporal patterns were comparable to findings from prior studies. Demographic patterns of suspected opioid overdose were similar to medical examiner reports of demographic patterns of fatal drug or alcohol related overdoses in Baltimore in 2008-9 (88% of which involved opioids). The findings on patient evaluation data suggest some inconsistencies with previously recommended clinical indications of opioid overdose. Conclusions While our findings suggest limitations of EMS naloxone administration data as a proxy indicator of opioid overdose, the results provide partial support of the data for estimating opioid overdose incidence and suggest ways to improve such data. The study findings have implications for an EMS role in conducting real-time surveillance and treatment and prevention of opioid abuse and overdose.

Management of Suspected Opioid Overdose With Naloxone by Emergency Medical Services Personnel

“…After dual review of abstracts and titles, 202 articles were selected for full-text dual review, and 13 studies were determined to meet inclusion criteria and were included in this review. We identified three RCTs (n=100 to 182) [37][38][39] and four cohort studies (n=93 to 609) [40][41][42][43] that compared different routes of naloxone administration.…”

“…One trial evaluated IN naloxone at a concentration lower (2 mg/5 mL) than used off-label in the United States (2 mg/2 mL) 37 and another trial evaluated IN naloxone at a concentration (2 mg/1 mL) that appears to have been formulated specifically for that study, and is not available in any product otherwise. 38 Studies indicate very high usability rates (>90%) with the auto-injector and FDA-approved IN naloxone, even without prior training, compared with older/off-label devices. 51,52 The settings of some studies may also limit applicability to use of naloxone in U.S. field settings by EMS personnel.…”

“…38 Although another trial found the same dose of IN naloxone using a lower concentration formulation (2 mg/5 mL) to be less effective than IM naloxone, 37 these findings are of limited applicability to ES-9 the United States, where off-label IN naloxone is typically given at a concentration of 2 mg/2 mL and FDA-approved concentrations are 4 or 2 mg/0.1 mL. Evidence regarding other route of administration comparisons is even more limited, with one trial of IN compared with IV naloxone conducted in an Iranian ED setting (SOE: insufficient).…”

“…[37][38][39] Among the three trials, two compared IN versus IM naloxone 37,38 and one trial evaluated IN versus IV naloxone. 39 No trial evaluated the recently FDA-approved naloxone auto-injector for IM administration or highly concentrated (4 mg/0.1 mL or 2 mg/0.1 mL) IN formulations of naloxone.…”

“…After dual review of abstracts and titles, 202 articles were selected for full-text dual review, and 13 studies were determined to meet inclusion criteria and were included in this review. We identified three RCTs (n=100 to 182) [37][38][39] and four cohort studies (n=93 to 609) 40-43 that compared different routes of naloxone administration.• o One trial conducted in an Iranian ED setting found that IN naloxone (0.4 mg, administered as a 0.4 mg/2 mL formulation) was associated with a greater likelihood than IV naloxone (0.4 mg) of an adequate response (defined as level of consciousness following naloxone of lethargic or conscious, 100% vs. 60%, RR 1.7, 95% CI 1.3 to 2.1) and lower likelihood of agitation than IV naloxone (0% vs. 24%, RR 0.04, 95% CI 0.002 to 0.66). The SOE was insufficient, due to moderate study limitations, inability to assess consistency, and indirectness (poor applicability to U.S. field settings due to high proportion of overdoses related to use of opium and ED setting).…”