The imperative of comprehensive care for EMS-administered naloxone-reversed overdose survivors
In the ongoing and evolving opioid crisis, the administration of naloxone has emerged as a necessary resource against a relentlessly stubborn death toll. Naloxone, a potent opioid receptor antagonist, possesses the remarkable ability to reverse the life-threatening effects of opioid overdoses rapidly, saving countless lives. As knowledge of and access to naloxone increase, it is reasonable to expect that a greater number of reversals may be carried out by the public in addition to those provided by emergency responses services, whose capacity for immediate response is limited, and which, because of its implication for illegal behavior, people may be hesitant to call upon in the event of a suspected overdose.
However, the story does not end with the revival of an overdose survivor through the administration of naloxone. Rather, an overdose reversal may be viewed as a flag in a much larger narrative, one that underscores the imperative of providing comprehensive care and support, preemptively and reactively, to those at greatest risk, especially to those whose risk is compounded by drug-related or non-drug-related criminal/legal involvement. Those at greatest risk may not be identifiable or self-identify readily, making targeting this vulnerable group for care and assessing that care challenging. EMS encounters with people who have overdosed on opioids offer an opportunity for assessment and intervention.
Through a MODA-funded study, we record-linked jail records and Rapid Opioid Dependence Screenings (RODS) offered during booking with a statewide EMS record system (MI-EMSIS) as well as with Medicaid and TEDS billing records and Michigan State Police records for a cohort of 2,511 individuals who were booked into four county jails across Michigan between 7/1/2020 and 9/30/2020; this presented a rare window into the status of care for and risk identification made of a cohort of EMS-attended overdose survivors booked into jail. Given the linkage of information over a study period spanning from six months before the target booking date up until six months following the respective release date, we were able to look at who among those booked into the jail had experienced an EMS-attended opioid overdose (n=38) during that period. Having targeted this high-risk group, we explored measures of OUD risk identification prior to and at jail booking as well as at OUD treatment provided prior to jail, in the jail, and following release.
We found that fewer than half were identified by the jail: 42% scored negative on the RODS for OUD risk and an additional 16% refused the RODS and were not otherwise identified as at risk. Of those identified, just one received treatment in jail, which was continuation of treatment received prior to jail and was continued following release. Of those identified but not treated in jail, 13 (87%) had been receiving treatment prior to booking and 12 (80%) received treatment following release. Among these 38 experiencing opioid overdose, the average length of time between jail release and first mental or behavioral health service was 34 days (ranging from 0 to 182 days, StdD=49 days). Finally, we found that of 17 individuals experiencing an opioid overdose following release, three (17.6%) were among those having had a nonfatal overdose prior to booking; fortunately, none of these overdoses, either initial or repeated, were fatal.