Refusals After Prehospital Administration of Naloxone during the COVID-19 Pandemic

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 duringpandemic 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 ¼ 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 ¼ 1.39; 95% CI 1.32-1.46). Conclusion: In this single EMS system, more than a twofold increase in the rate of refusal after non-fatal opioid overdose was observed following the COVID-19 outbreak.

Illicit Substance Use and the COVID-19 Pandemic in the United States: A Scoping Review and Characterization of Research Evidence in Unprecedented Times

“…Broader state and nationwide data relating to other aspects of the treatment cascade, including referrals, prescription fillings, and general program capacities, indicate that the regulatory changes were not sufficient to mitigate disruptions of service access relating to the pandemic [ 41 , 42 , 43 , 44 ]. Similar patterns could be seen when examining other harm reduction services’ access, albeit with a narrower body of evidence concerning naloxone distribution or syringe services [ 25 , 46 ]. Overall, the evidence suggests relevant and timely policy changes, such as the loosening of buprenorphine regulations, can facilitate greater access to, and retention in, treatment among PWUD, but implementation science studies will be needed to conclusively inform their successful adaptation.…”

“…Jacka et al [ 25 ] highlighted difficulties in accessing naloxone and needle exchange among 7–8% of all participants in their study in New England. Furthermore, Glenn et al [ 46 ] found that patients who received naloxone via emergency medical services (EMS) in Tucson, Arizona were more likely to refuse transportation during the pandemic period (16 March 2020–30 April 2020) compared to pre-pandemic (1 January 2020–15 February 2020). However, Zubiago et al’s [ 47 ] study looking at hospitalized PWUD at Tufts Medical Center in Boston, Massachusetts, indicated greater odds of receiving an HIV test among patients with stimulant use (OR 2.7, 95% CI 1.9 to 3.81) and benzodiazepine use (OR 1.53, 95 % CI 1.03 to 2.23) versus pre-pandemic.…”

Emergency Medical Services Prehospital Response to the COVID-19 Pandemic in the US: A Brief Literature Review

“… Clinical Outcomes 40 Glenn et. al 52 Refusals After Prehospital Administration of Naloxone during the COVID-19 Pandemic Cohort Incidences of refusals following naloxone administration US ● The amount of patients that refused transport following prehospital administration of naloxone increased during the pandemic. ● During the COVID-19 pandemic, over twice as many patients who received naloxone in a prehospital setting refused transport than prior to the pandemic.…”

Converging public health crises: substance use during the coronavirus disease 2019 pandemic

“…In addition to structural challenges, other barriers to providing adequate and timely substance use treatment may include patient-level factors. A cohort study identified an increase in the proportion of patients seen by the Tucson Fire Department who refused transport to emergency departments during COVID-19 vs. pre-COVID-19 [ 29 ▪ ]. Among patients who received naloxone, the refusal rate more than doubled from before vs. during the pandemic [ 29 ▪ ].…”

“…A cohort study identified an increase in the proportion of patients seen by the Tucson Fire Department who refused transport to emergency departments during COVID-19 vs. pre-COVID-19 [ 29 ▪ ]. Among patients who received naloxone, the refusal rate more than doubled from before vs. during the pandemic [ 29 ▪ ]. This suggests that a myriad of challenges may be present, limiting the ability for persons who use substances to be able to receive appropriate treatment and management resources for their substance use.…”