Real-world study of multiple naloxone administrations for opioid overdose reversal among emergency medical service providers

Identification of Naloxone in Emergency Medical Services Data Substantially Improves by Processing Unstructured Patient Care Narratives

OBJECTIVES

Structured data fields, including medication fields involving naloxone, are routinely used to identify opioid overdoses in emergency medical services (EMS) data; between January 2021 and March 2024, there were approximately 1.2 million instances of naloxone administration in the United States. To improve the accuracy of naloxone reporting, we developed methodology for identifying naloxone administration using both structured fields and unstructured patient care narratives for events documented by EMS.

METHODS

We randomly sampled 30,000 records from Kentucky's state-wide EMS database during 2019. We applied regular expressions (RegEx) capable of recognizing naloxone-related text patterns in each EMS patient's case narrative. Additionally, we applied natural language processing (NLP) techniques to extract important contextual factors such as route and dosage from these narratives. We manually reviewed cases where the structured data and unstructured data disagreed and developed an aggregate indicator for naloxone administration using either structured or unstructured data for each patient case.

RESULTS

There were 437 (1.45%) records with structured documentation of naloxone. Our RegEx method identified 547 naloxone administrations in the narratives; after manual review, we determined RegEx yielded acceptable false positives (N = 31, 5.6%), false negatives (N = 23, 4.2%) and performance (precision = 0.94, recall = 0.93). In total, 552 patients had naloxone administered after combining indicators from both structured fields and verified results from unstructured narratives. The NLP approach also identified 246 (47.4%) records that specified route of administration and 358 (69.0%) records with dosage delivered.

CONCLUSIONS

An additional 115 (26.3%) patients receiving naloxone were identified by using unstructured case narratives compared to structured data. New surveillance methods that incorporate unstructured EMS narratives are critically needed to avoid substantial underestimation of naloxone utilization and enumeration of opioid overdoses.

A Comparison of Pediatric Prehospital Opioid Encounters and Social Vulnerability

OBJECTIVES

This study explores the relationship between socioeconomic factors and pediatric opioid-related emergencies requiring naloxone administration in the prehospital setting, an escalating public health concern.

METHODS

A retrospective analysis of the National Emergency Medical Services Information System (NEMSIS) database was conducted, examining data from pediatric opioid-related EMS activations between January 2018 and December 2021. The Social Vulnerability Index (SVI) was used to gauge each incident's socioeconomic context and assess correlations between SVI scores and the likelihood of opioid-related activations and naloxone interventions.

RESULTS

A total of 7,789 pediatric opiate-related EMS activations were identified. Lower socioeconomic status (SES) areas (higher SVI scores) exhibited a decreased rate of opioid-related activations compared to lower SVI-scored areas but an increased frequency of naloxone administration. The analysis demonstrated that as socioeconomic status (SES) improves, the likelihood of opioid-related activations increases significantly supported by a significant negative linear trend (Estimate = -0.2971, SE = 0.1172, z = -2.54, p = 0.0112. On the other hand, naloxone administration was more frequently required in lower SES areas, suggesting an increased emergency response in these (Estimate = 0.05806, SE = 0.2403, z = 0.24, p = 0.8091).

CONCLUSIONS

The analysis highlights a statistically significant correlation between the SES of an area and pediatric opioid-related EMS activations, yet an inverse correlation with the likelihood of naloxone administration. These findings demonstrate that in lower socioeconomic areas, the total number of opiate-related EMS activations is lower; however, naloxone was more likely to be deployed during those activations. This underscores the need for further research to understand the disparities in opioid crisis management across different socioeconomic landscapes.

High-dose naloxone formulations are not as essential as we thought

Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review investigates the adequacy of two doses of standard IM or IN naloxone in reversing fentanyl overdoses compared to newer high-dose naloxone formulations. Moreover, our initiative incorporates the experiences of people who use drugs, enabling a more practical and contextually-grounded analysis. The evidence indicates that the vast majority of fentanyl overdoses can be successfully reversed using two standard IM or IN dosages. Exceptions include cases of carfentanil overdose, which necessitates ≥ 3 doses for reversal. Multiple studies documented the risk of precipitated withdrawal using ≥ 2 doses of naloxone, notably including the possibility of recurring overdose symptoms after resuscitation, contingent upon the half-life of the specific opioid involved. We recommend distributing multiple doses of standard IM or IN naloxone to bystanders and educating individuals on the adequacy of two doses in reversing fentanyl overdoses. Individuals should continue administration until the recipient is revived, ensuring appropriate intervals between each dose along with rescue breaths, and calling emergency medical services if the individual is unresponsive after two doses. We do not recommend high-dose naloxone formulations as a substitute for four doses of IM or IN naloxone due to the higher cost, risk of precipitated withdrawal, and limited evidence compared to standard doses. Future research must take into consideration lived and living experience, scientific evidence, conflicts of interest, and the bodily autonomy of people who use drugs.

Metabolic management of accidental intoxication

PURPOSE OF REVIEW

Unintentional intoxication comprises a major chunk of all intoxications. Most patients are in the pediatric age group with another set of patients being the elderly. Substances found to cause accidental intoxication vary from country to country and even within different regions of a country. Frequent reviews of current literature are needed to be abreast of trends.

RECENT FINDINGS

Prescription drugs and household chemicals are major culprits when it comes to accidental intoxication. Acetaminophen, digoxin and metformin are some of the prominent prescription drugs frequently associated with unintentional intoxications. Increasingly alcohol based hand sanitizers are becoming an important etiology of these events, following their increased usage during the COVID-19 pandemic. Pattern recognition to identify class of intoxicant and supportive care including prevention of further absorption and increased excretion are cornerstones of therapy. Antidote when available should be used promptly.

SUMMARY

Knowledge about current epidemiology of accidental intoxications, toxidrome pattern recognition and appropriate antidote usage beside adequate and timely supportive care help in successful management of the unfortunate victim of accidental intoxication.

Real-world study of multiple naloxone administration for opioid overdose reversal among bystanders

Background

The increasing prevalence of highly potent, illicitly manufactured fentanyl and its analogues (IMF) in the USA is exacerbating the opioid epidemic which has worsened during the COVID-19 pandemic. Narcan® (naloxone HCl) Nasal Spray has been approved by the US Food and Drug Administration as a treatment for opioid-related overdoses. Due to the high potency of IMF, multiple naloxone administrations (MNA) may be needed per overdose event. It is essential to determine the patterns of naloxone use, including MNA, and preferences among bystanders who have used naloxone for opioid overdose reversal.

Methods

A cross-sectional web-based survey was administered to 125 adult US residents who administered 4 mg Narcan® Nasal Spray during an opioid overdose in the past year. The survey asked about the most recent overdose event, the use of Narcan® during the event and the associated withdrawal symptoms, and participant preferences regarding dosages of naloxone nasal spray. An open-ended voice survey was completed by 35 participants.

Results

Participants were mostly female (70%) and white (78%), while reported overdose events most frequently occurred in people who were males (54%) and white (86%). Most events (95%) were successfully reversed, with 78% using ≥ 2 doses and 30% using ≥ 3 doses of Narcan® Nasal Spray. Over 90% were worried that 1 Narcan® box may not be enough for a successful future reversal. Reported withdrawal symptoms were similar in overdose events where 1 versus ≥ 2 sprays were given. Eighty-six percent of participants reported more confidence in an 8 mg versus a 4 mg naloxone nasal spray and 77% reported a stronger preference for 8 mg over 4 mg.

Conclusions

MNA occurred in most overdose events, often involving more sprays than are provided in one Narcan® nasal spray box, and participants predominantly expressed having a stronger preference for and confidence in an 8 mg compared to a 4 mg nasal spray. This suggests the need and desire for a higher dose naloxone nasal spray formulation option. Given that bystanders may be the first to administer naloxone to someone experiencing an opioid overdose, ensuring access to an adequate naloxone supply is critical in addressing the opioid overdose epidemic.