Patient-Level and County-Level Trends in Nonfatal Opioid…
Discussion
This report highlights several findings: 1) rates of nonfatal opioid-involved overdose EMS encounters per 10,000 total EMS encounters increased steadily from 2018 through the onset of the COVID-19 pandemic; 2) nonfatal opioid-involved overdose rates increased for both sexes, all age groups except persons aged 15–24 years, and all racial and ethnic groups except NH/OPI; 3) nonfatal opioid-involved overdose rates increased among all quartiles of county-level characteristics, except for counties with the lowest percentage of uninsured persons; and 4) higher nonfatal opioid-involved overdose rates and rate increases were observed in urban counties and in counties with higher unemployment rates.
Increases in nonfatal opioid-involved overdose EMS encounters through Q3 2020 are consistent with increases in nonfatal opioid-involved overdoses treated in EDs (1) and synthetic opioid-involved overdose deaths.**** Nonfatal opioid-involved overdose rates in this study remained stable during Q3 2020–Q1 2022, which is consistent with opioid-involved overdose ED visits in CDC’s Drug Overdose Surveillance and Epidemiology system.†††† However, this finding is unlike those for mortality data, which have demonstrated increases in opioid-involved overdose deaths during this period. Further exploration into the types of opioids (e.g., fentanyl, heroin, and prescribed opioids) contributing to overdoses and the shifting drug supply will assist in better interpretation of these differences.
The increase in nonfatal opioid-involved overdose rates for most demographic groups is similar to findings from ED data (4). Although rates were highest among White and NH/OPI persons, rate increases were largest among Black, followed by Hispanic persons. According to a recent study, Black persons experienced the largest increase in fatal all-drug overdoses during 2019–2020 (5). Structural barriers, mistrust in the health care system, and other disparities that contribute to overdose risk underscore the need to address inequities, particularly among minority populations, as part of a comprehensive response to the U.S. drug overdose crisis (5).
This report highlights community characteristics that are associated with higher nonfatal opioid-involved overdose rates, such as county-level unemployment. This finding is consistent with a systematic review that reported that recessions and unemployment increased psychological stress and subsequent illegal drug use (6,7). Counties with the lowest percentage of uninsured persons represented the only quartile without a significant increase in the rate of nonfatal opioid-involved overdoses. A previous study found that drug overdose mortality was elevated in U.S. Census Bureau tracts with higher rates of uninsured persons (8); however, in the current analysis, the quartile with the second highest percentage of uninsured persons had the highest rate and largest overall rate increase in nonfatal opioid-involved overdoses. Persons who are uninsured might be less likely to use EMS after an overdose; a study in Wisconsin found that Medicaid expansion resulted in an increase in the share of opioid-related ED visits covered by Medicaid among men aged 19–49 and women aged 19–29 years (9). In contrast to previous research reporting a higher rate of nonfatal opioid-involved overdose ED discharges in rural areas with lower levels of educational attainment (10), rates in the current analysis were lowest in counties with the smallest proportions of high school graduates. This divergent finding might be because of moderation by urbanicity or differences between ED discharge and EMS data (10).
The findings in this report are subject to at least five limitations. First, analyses are not nationally representative; therefore, the results cannot be generalized. Second, there are no toxicology results in EMS records to confirm the substance involved in suspected overdoses; however, EMS providers are trained to recognize the signs and symptoms of an opioid overdose so that they can administer appropriate treatment.§§§§ Third, analyses were not able to identify reasons a person might or might not have been transported by EMS after an encounter. It is possible persons who were transported were more likely to be in critical condition (e.g., unconscious) compared with those not transported, and nontransport could have been because of factors other than refusal (e.g., hospitals were at capacity). Fourth, despite only including counties with consistent data coverage, during the onset of the COVID-19 pandemic in March 2020, total EMS encounters decreased by 12.6% in Q2 2020 compared with the previous quarter, and nonfatal opioid-involved EMS encounters increased 15.2%; thus, nonfatal opioid-involved overdose rates might be inflated during this time. Finally, quality and completeness of EMS data might vary by period, reporting agency, and location.
These findings illustrate the utility of EMS data to monitor nonfatal opioid-involved overdose trends, especially given past research findings indicating that persons are increasingly refusing EMS transport to EDs after an overdose (2). A study in Kentucky found that during January 14‒April 26, 2020, 19.8% of patients treated by EMS for an opioid overdose refused transport to an ED, increasing from 16.4% before the onset of the COVID-19 pandemic to 22.4% after the onset (2). This analysis of nonfatal opioid-involved overdose trends highlights the need for increased access to services (e.g., harm reduction) among all populations, and also identifies characteristics of communities that are disproportionately affected by overdoses, such as those with higher unemployment rates. These data can guide public health efforts to ensure implementation of equitable prevention and response initiatives; for example, counties with higher unemployment rates might benefit from increased access to harm reduction services (e.g., naloxone and fentanyl test strip distribution), treatment (e.g., medications for opioid use disorder¶¶¶¶), and behavioral health services. Systems of care, which include EMS, mobile-integrated health, and community paramedicine, could collectively deploy to improve access to treatment and promote harm reduction strategies. For example, the Studying the PhilAdelphia Resilience Project as a Response to Overdose (SPARRow) program has staff members who accompany ambulances responding to overdoses and deliver harm reduction and care linkage to persons who refuse hospital transport.***** EMS data can also improve understanding of prehospital trends in nonfatal opioid-involved overdoses in near real time to guide tailored public health response and prevention efforts.
