EMS Naloxone
Leave-Behind
Project
Preliminary Data Review
and Project Summary
Background:
Deaths by
Opiate
Overdose in
Vermont
• 2019 Vermont Opiate-related Deaths (ADAP Report): 114
• 2020 Vermont Opiate-related Deaths (ADAP Report): 157
• 2021 (January-March) Vermont Opiate-related Deaths
Documented in SIREN data for NLB Program Dataset: 27
- October 2020-March 2021: 50
- Demographics of EMS Opiate-Related Deaths October 2020 through
March 2021
- Age
-
<20 years old: 1 (2%)
-
20-29: 10 (20%)
-
30-39: 19 (38%)
-
40-49: 13 (26%)
-
50+: 7 (14%)
- Gender:
-
Female: 19 38%)
-
Male: 31 (62%)
Vermont’s Opiate Overdose Prevention
and Reversal Project (OOPRP)
- OOPRP is a group that distributes Naloxone
Rescue Kits to Individuals at risk of overdose
- OOPRP has distributed 39,965 naloxone kits
since it began in 2014 (12).
Although the OOPRP delivers their rescue
kits via different avenue than EMS kits
are delivered, this chart shows how rescue
kit recipients are using the kits in the
community
Opiates continue to
be a large public
health problem here
in Vermont, and when
kits are provided, they
are used to save lives
EMS
Administration
of Naloxone
(12)
2019: 671 doses of naloxone were
administered to 465 individual
patients (VDH, ADAP, March 2021)
2020: 546* doses of naloxone were
administered to 554 individual
patients (VDH, ADAP, March 2021)
• *there were less than 6 incidents per quarter where
Narcan was administered 4 or more times to the same
patient, thus this data was suppressed in the report
Patient
Attitudes
Towards
Calling 911 for
Opiate
Overdose
Pacific Institute for Research and Evaluation (PIRE) conducted
the Vermont Opioid Use Harm Reduction Evaluation between
June 2018 and November 2019 in Franklin, Rutland and
Windham Counties, Vermont.
Subjects: 80 current or former opioid users
Study Design: each participant completed an interview and a
questionnaire
Patient Attitudes Survey on Calling 911 for an
Overdose
- Fear of getting into trouble by calling 911, either from having an illegal substance or by
having baseline legal troubles such as active warrants or bad rapport with law
enforcement
- Additionally, this survey showed that there was a lack of awareness and widespread skepticism of
the Good Samaritan Law and what exactly it entails
• Desire to avoid interactions with law enforcement and EMS for fear of judgement and
stigmatization
• Some described that a peer administering naloxone is preferable to calling 911
• Some described that they would administer naloxone and/or call 911 if witnessing an
active overdose, but would not wait on scene for EMS or law enforcement to arrive for
fear of speaking to the police
• Some patients reported stating an alternative complaint to the 911 dispatcher, so that
EMS was sent without law enforcement. Patients perceive that if the dispatcher is
informed the call is an overdose, that law enforcement will preferentially accompany
EMS to the call, which some patients view negatively.
Naloxone
Leave Behind
Program
What is the
Naloxone
Leave-Behind
Protocol
On October 1, 2020, Vermont EMS agencies began carrying
naloxone “leave-behind” kits on ambulances for EMS incidents
where patients identified by EMS as high-risk for opiate overdose
that were not transported to a hospital could be provided a kit at
no cost to the patient
High Risk patients are those that have just experienced an
overdose, or those with other signs of Opiate Use Disorder
All patients that received naloxone prior to EMS arrival or by EMS
are always encouraged to be transported to the hospital for
evaluation
The kits are able to be left with the patient themselves, a
bystander, or a family member in instances where the patient is
not transported
Another State’s Experience with EMS-Based Naloxone
Leave-Behind Kits:
Howard County, Maryland from 06/2018-06/2019 (8)
• From June 2018 to June 2019, Howard County Department of Fire and Rescue Services responded to 239 overdose
calls and distributed 120 naloxone kits to individuals on the scene of an overdose, a 50.21% distribution rate.
• Their program allowed EMS to leave behind naloxone kits and peer support contact information with all patients
(or their family/friends on scene) after experiencing an opiate overdose, regardless of whether the patient was
transported or not.
• Other notable outcomes of their program:
• 143 patients (59.83%) were connected to peer recovery specialists
• Among the 143 patients linked to peer recovery support specialist services, 87 (60.84%) had accepted an
NLB kit from EMS.
• Person that the kit was left with on scene impacted the likelihood of patient being connected to follow-up
services as compared to those who did not accept a kit
• Kit left with a family member: 5.16 times more likely to be connected to peer support specialists
• Left with a friend: 3.69 times more likely to be connected to peer support specialists
• Left directly with the patient: 2.37 times more likely to be connected to peer support specialists
• Conclusions: “Engaging an individual's family and social network when offering connections to treatment and
recovery resources. NLB initiatives can potentially augment existing community-based naloxone training structures,
thus widening the scope of the life-saving drug and reaching those most at risk of dying from an opioid overdose.”
Methods of
This Project
• Data collected from the state-wide EMS incident reporting
tool, SIREN, containing electronic records of all EMS
encounters throughout the state
• Deidentified data was pulled by the Vermont Department
of Health from all EMS encounters involving opiates or
where the provider documented known substance use or
drug paraphernalia on the scene
• The data was pulled from a period of time 1 year prior to
the naloxone leave-behind protocol going live (October
2019-September 2020), and the study timeline includes a
year period after the initiation of the protocol (October
2020-September 2021)
• Data identified by a unique incident ID, however the
date was de-identified to include only month and year,
such that specific incidents would not be identifiable
Data Fields
Included in
the
De-Identified
Data Set
• Incident ID (Number)
• Incident Month, Incident Year
• Incident County, Incident District
• Patient Age, Gender, Race
• Race is not a required data field, thus is rarely filled out by EMS
• Complaint Type (e.g.Primary Complaint), Complaint Statement (Chief Complaint)
• Primary Symptom
• Working Diagnosis, Other Diagnosis
• Signs of Suspected Alcohol/Drug Use (Alcohol Containers/Paraphernalia at Scene, Drug
Paraphernalia at Scene, Patient Admits to Drug Use, Patient Admits to Alcohol Use)
• Initial Patient Acuity, Final Patient Acuity
• Incident/Patient Disposition
• Medication Administered Prior To EMS Unit Care
• Medication Name, Dosage, Dosage Unit, Route of Administration, Response to Medication
• SQ System If an at-risk person was identified, was a Naloxone Leave Behind kit left with a
person on scene?
Limitations
• Some incidents were pulled by criteria which do not specify that
an opiate was involved, including:
• Patient admitted to drug use (SIREN does not specify which
substance was used)
• Drug Paraphernalia on Scene (SIREN does not specify which
substance suspected by EMS)
• Working Diagnosis of Overdose of medication or substance,
which is not specified.
• Some incidents where this was documented also documented
improvement after naloxone administration, thus these incidents were
included in the analysis
• Difficult to see how many doses of Naloxone were given by EMS,
especially when the provider noted that medications were
administered prior to EMS arrival.
• De-Identified Data does not allow us to interpret whether specific
patients were repeatedly showing up in the data set or if a small
group of patients represent most of the data points in this data
set
• Race was only filled out by providers 20.8% of the time, thus is
not representative of actual patient race
Limitations
Continued
• Incident/Patient Disposition is not necessarily representative
of true disposition.
• For example, a patient treated with multiple doses of
naloxone by EMS with a chief complaint of “opiate
overdose” and a primary symptom of “apnea” or “cardiac
arrest” does not necessarily fit the disposition of “Patient
Evaluated, No Treatment/Transport Required, as the
patient clearly required treatment (and likely transport).
• There are 4 dispositions in which patients that are alive
do not undergo transport to the hospital: AMA refusal,
refusal to be evaluated by EMS (e.g. patient refuses to
talk to EMS), patient evaluated without treatment or
transport required, or patient treated and released per
protocol.
Retrospective
Data Review
10/1/19-09/30/20
• 195 patients identified as “at risk” for an opioid overdose
• A Naloxone Leave-Behind Kit would have been indicated
in these patients
• Incident Dispositions of these patients:
• 29 Patient Treated, Released (per protocol)
• 31 Patient Evaluated, No Treatment/Transport Required
• 53 Patient Refused Evaluation/Care (Without Transport)
• 78 Patient Evaluated, Released (AMA)
• Chief Complaint listed:
• “Overdose / Abuse of Opiate”: 148/195 (75.9%)
• Overdose / Abuse of Other Illicit Drug or Misuse of Meds:
18/195 (9.2%)
• Other Chief Complaint or “No Signs of Symptoms” 29/195
(14.9)
Retrospective
Data Review
Continued
- 195 Patients High-Risk for Opiate OD who were not
transported to a hospital
- 50 patients received naloxone from the responding EMS
agency
- 7 of these patients had also already received naloxone
prior to EMS arrival on scene
- 10 patients received naloxone prior to EMS arrival, but did not
require any additional doses from EMS
PRELIMINARY
Prospective Data Review
10/01/20-03/15/21
119 Patients were “at risk”
for opioid overdose
• This time period reflects
only the first 6 months of
the leave behind
program being in effect
• There were 195 patients
identified during the
12-month retrospective
time period
• Is this reflective of more
overdoses or
documentation being
more thoroughly
completed?
59/119 (49.6%) were
provided a naloxone
leave-behind kit
10/119 (8.4%) explicitly
did not receive a naloxone
leave-behind kit
• 5 patients declined the
kit
• 4 incidents did not have
documentation of why
no kit was left behind
• 1 incident documented
not having a kit in stock
on ambulance at time of
incident
51/119 (42.9%) no
documentation on
whether a kit was left
• 15 refused EMS
evaluation altogether
• 20 were either “treated
and released per
protocol” or were
evaluated with No
Treatment/Transport
Required
• 24 refused
treatment/transport
against medical advice
(AMA)
Characteristics of the Patients Identified as High-Risk for
OUD/Overdose that were not transported to a hospital
Patient Age
Gender
• Male: 74 (61.7%)
• Female: 46 (38.3%)
0 10 20 30 40 50 60 <10 years old 10-19 years old 20-29 years old 30-39 years old 40-49 years old >50 years old 1 1 29 58 16 15 N u m b er o f P at ie n ts Patient AgePatient Age for EMS Encounters where a Naloxone
Leave-Behind Kit Was Indicated
Race
• White: 25 (20.8%)
0 5 10 15 20 25 30 35
Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21
Frequency of Kit Being Offered by Month When High-Risk Patient is Identified
At Risk Patients Identified Patients who were offered a kit
Prospective Data: How often are we offering kits to those who need
them?
Month of Active NLB Program At Risk Patients Identified Patients who were offered a kit October 2020 30 18 (60%) November 2020 17 11 (65%) December 2020 20 10 (50%) January 2021 20 12 (60%) February 2021 15 10 (66%) March 2021 16 6 (37.5%)Encounters that did not offer or did not
document a Naloxone Leave-Behind Kit
13 7 10 42 6 17 0 5 10 15 20 25 30 35 40 45
October November December January February March
N u m b er o f E n cou n ters
Month of Active Naloxone Leave-Behind Program
Incidence of Missing Naloxone Leave-Behind Data
0 5 10 15 20 25 District 01 District 02 District 03 District 04 District 05 District 06 District 07 District 08 District 09 District 10 District 11 District 12 District 13 N u m b er o f E n cou n ters
Takeaways thus far
• Opiate Use Disorder is still a big problem in Vermont, despite widespread
availability of medication-assisted treatment and increased community Naloxone
distribution sites
• Vermont EMS administered approximately 100 more doses of naloxone in 2020 than in 2019.
There were also 38% more deaths due to opiates in 2020 than in 2019.
• In it’s first 6 months, the naloxone leave behind program has offered naloxone
leave-behind kits to 57.5% (69/120) of patients identified as high risk for opiate
overdose who did not undergo transport to a hospital
• When offered, kits were accepted 85.5% of the time
• 46% of patients identified as high risk for opiate overdose who were not transported to a
hospital did NOT receive a kit for an un-documented reason or there was no documentation
of a kit at all (which likely indicates that a kit was not offered or left on scene)
• Demographics of at-risk patients are similar to those previously reported to the
state of Vermont: males, ages 30-49
Future Aims
• Complete the full prospective data set to include 12 full months of the
naloxone leave-behind program being active to assess how many patients
are reached by overdose rescue kits and addiction support information
• To improve frequency that kits are offered to at risk patients (currently
offered 57.5% of the time to at risk patients), increased training and
awareness of the new protocol could be encouraged by Vermont EMS
agencies. It does not appear that any specific district fails to offer a NLB kit
disproportionately.
• Additionally, in incidents where a patient was administered naloxone or has
a chief complaint of opiate overdose, SIREN could possibly format the
incident report such that the patient provider must document status of a
leave-behind kit in order to complete the report.
Sources
1. Centers for Disease Control and Prevention. 2019 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States Surveillance Special Report. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published November 1, 2019. Accessed [date] from https://www. cdc.gov/drugoverdose/pdf/
pubs/2019-cdc-drug-surveillancereport.pdf.
2. Faul M, Lurie P, Kinsman JM, Dailey MW, Crabaugh C, Sasser SM. Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing. Prehosp Emerg Care. 2017;21(4):411–419. doi:10.1080/10903127.2017.1315203
3. Faul M, Lurie P, Kinsman JM, Dailey MW, Crabaugh C, Sasser SM. Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing. Prehosp Emerg Care. 2017;21(4):411–419. doi:10.1080/10903127.2017.1315203
4. Knowlton A, Weir BW, Hazzard F, et al. EMS runs for suspected opioid overdose: implications for surveillance and prevention. Prehosp Emerg Care. 2013;17(3):317-329.
5. Levine M, Sanko S, Eckstein M. Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care. Prehospital Emergency Care. 2016;20(5):566-569. doi: 10.3109/10903127.2016.1142626
6. Lindstrom HA , Clemency BM , Snyder R , Consiglio JD , May PR , Moscati RM . Prehospital Naloxone Administration as a Public Health Surveillance Tool: A Retrospective Validation Study. Prehosp Disaster Med. 2015;30(4):1–5. doi: 10.1017/S1049023X15004793
7. National Institute of Health. National Institute on Drug Abuse. 2017 Vermont Opioid Summary. Updated March 2019. Accessed 1/20/2020 from https://www.drugabuse.gov/node/pdf/21964/vermont-opioid-summary.
8. Scharf BM, Sabat DJ, Brothers JM, Margolis AM, Levy MJ. Best Practices for a Novel EMS-Based Naloxone Leave behind Program. Prehosp Emerg Care. 2020 Jun 23:1-9. doi: 10.1080/10903127.2020.1771490. Epub ahead of print. PMID: 32420791.
9. Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services
Administration. Retrieved from https://www.samhsa.gov/data/
10. Sumner SA, Mercado-Crespo MC, Spelke MB, et al. Use of Naloxone by Emergency Medical Services during Opioid Drug Overdose Resuscitation Efforts. Prehosp Emerg Care. 2016;20(2):220–225. doi:10.3109/10903127.2015.1076096
11. Vermont Department of Health. Alcohol and Drug Abuse Programs Data and Reports. https://www.healthvermont.gov/alcohol-drugs/reports/data-and-reports. 2010-2019. Updated 1/15/2020. Accessed 1/20/2020.
12. Vermont Department of Health, Division of Alcohol & Drug Abuse Programs. (2021). Naloxone Distribution and Administration.
https://www.healthvermont.gov/sites/default/files/documents/pdf/ADAP_Naloxone_Data_Brief_0.pdf. Updated 3/31/2021. Accessed 4/2/2021.
13. Vermont Department of Health, Division of Alcohol & Drug Abuse Programs and Pacific Institute for Research and Evaluation. (2021). Perspectives and Behaviors Related to Overdose, the Good Samaritan Law, and Harm Reduction Among Persons Who Use Opioids in Vermont. (2021).
https://www.healthvermont.gov/sites/default/files/documents/pdf/ADAPHarmReductionEval-Calling911.pdf. Accessed 4/2/2021.
14. Vermont Department of Health, Division of Alcohol & Drug Abuse Programs. (2021). Access to Medication Assisted Treatment. https://www.healthvermont.gov/sites/default/files/documents/pdf/ADAPHubSpokeTreatmentOpioids.pdf. Accessed 4/2/2021. 15. Vermont Department of Health, Division of Alcohol & Drug Abuse Programs. (2021). Monly Opioid Update.
https://www.healthvermont.gov/sites/default/files/documents/pdf/ADAP_Monthly_Opioid_Update.pdf . Updated 3/23/2021. Accessed 4/2/2021. 16. Vermont Department of Health, Division of Alcohol & Drug Abuse Programs. (2021). Substance Use in Vermont During COVID-19.
https://www.healthvermont.gov/sites/default/files/documents/pdf/ADAPSubstanceUseDuringCOVIDQ2.pdf. Updated 10/14/2020. Accessed 4/13/2021. 17. Vermont Department of Health, Division of Alcohol & Drug Abuse Programs. (2021). Opioid-Related Fatalities Among Vermonters 2020.
