Marin CountyPreventing the Next Opioid Overdose
A non-fatal opioid overdose is a strong predictor of a fatal overdose.
The number of opioid overdose deaths throughout the country continues to rise. Between 1999 and 2016, the number of fatal opioid overdoses nationwide increased five times. In 2017, opioids were involved in and estimated 67.8% of all drug overdose deaths. (1) This epidemic exists at a national and local level. Mirroring national trends, the leading cause of accidental death in Marin County is drug overdose with a majority of these involving opioids. (2) Additional trend data can be found in https://discovery.cdph.ca.gov/CDIC/ODdash/.
The Pilot Project in Marin County
Testing the timely identification of non-fatal opioid overdoses using EMS data
Beginning in May 2018, the Marin County Department of Health & Human Services (HHS) implemented a system for identifying and connecting survivors of an opioid overdose with substance abuse treatment. The pilot program utilizes Marin County Emergency Medical Services (EMS) ambulance records to rapidly identify potential opioid overdose incidents and contact survivors within a week of the incident. Research shows that patients may be more receptive to substance use interventions in the immediate aftermath of an overdose. (3) By intervening within a few days of the incident, we can support patients at their most vulnerable time and decrease the chances of a subsequent, fatal overdose.
Public health officials can also use the EMS identification system to monitor the use of opioids in the community and identify trends, such as patient age and the location of incidents.
*The graphs in this section represent all EMS calls suspected to involve an opioid overdose in patients 18 years and older, since the implementation of the pilot program. Counts include fatal overdose cases and other patients that may be ineligible for outreach (e.g., prison inmate). Note that these data are updated in real time so the current month will be incomplete.
The accuracy, specificity, and completeness of data depends on documentation by EMS personnel.
Most suspected opioid overdoses identified by
the EMS system occur in Novato and San Rafael. These suspected overdoses occur in different
settings including homes, assisted living facilities, and jails. Examining patient characteristics, such as age and sex, creates better
understanding of the communities in Marin County at risk of opioid overdose. Examining trends in the day of the week provide insight into potential patterns of harmful opioid use or EMS utilization for opioid-related harms by day.
Outreach and Treatment
Connecting opioid overdose survivors to treatment
Opioid overdose survivors are at greater risk of future overdose. (3) Marin County HHS has partnered with Bright Heart Health, a telemedicine program, to contact individuals after an overdose to verify access to naloxone, a drug that can reverse an opioid overdose, and discuss substance use treatment. Bright Heart Health connects patients to medication-assisted treatment (MAT) and naloxone. People living in residential or correctional facilities are not eligible for this outreach program. Marin County is tracking the program’s success in making contact within one to seven days post-overdose.
Connection to Screening and Brief Intervention
Between May 2018 through April 2019, almost 30% of patients with contact information were successfully contacted by Bright Heart Health for screening, brief intervention, and naloxone
Approximately 40% of those successfully contacted agreed to further contact.
Connection to Treatment and Detoxification Services
To evaluate the utility of this program in connecting patients to treatment, we reviewed historic EMS records or events before the start of the intervention--May 2018. The historic records were analyzed for events that would have been referred to Bright Heart Health (BHH), had the program been in place at the time. Through a partnership with Marin County Division of Behavioral Health and Recovery Services (BHRS), we quantified the proportion of Medi-Cal clients identified by the algorithm as eligible for outreach who engaged with a treatment provider within 7 days of experiencing a non-fatal opioid overdose. These data are compared quarterly to the proportion of Medi-Cal clients eligible for outreach who engaged with a treatment provider within 7 days of experiencing a non-fatal opioid overdose. The findings show a promising trend in accessing treatment after program implementation. The graph on the left shows the comparison of a time period prior to the start of the intervention, (Jul 2017-Mar2018), and time period after the intervention (May2018-Jun2019) to date. Note that all data are provisional and updated when available.
Encouraging the use of life-saving naloxone
Naloxone (Narcan®) is a medication that can reverse an opioid overdose and prevent death when it is administered shortly after an overdose. EMS providers are trained to administer naloxone when an overdose is suspected. Marin HHS is leading efforts to distribute naloxone in the community and encourage others to administer the medication in an emergency.
By equipping police
officers, family members, friends, and bystanders with naloxone and appropriate
training, more lives can be saved from potentially fatal opioid overdoses.
RxSafe Marin has prioritized distribution of naloxone throughout the community. Increasing every year, more victims of overdose are rescued by non-emergency medical service professional prior to the arrived of the ambulance.
Note: The cases in this section were from suspected opioid overdose calls between 2015-2018.
Weighing program costs and benefits to evaluate impact
A cost-effectiveness analysis was conducted to evaluate this EMS Outreach and Treatment Program in comparison to the Standard of Care (passive treatment seeking or referral through standard channels). All costs were from the perspective of those accrued by Marin County and included costs associated with drug poisoning hospitalizations, EMS visits, incarceration, opioid use disorder treatment, and staff time to run the program. The incremental cost effectiveness ratio (ICER) is a ratio of the difference in costs to the difference in effectiveness between two interventions. The ICER was used to summarize the cost per life-year saved for the EMS Outreach and Treatment Program in comparison to the standard of care.
The EMS Outreach and Treatment Program was found to be highly cost-effective, resulting in only $1,387 spent per life-year-saved. In the US, less than $50,000 spent per life-year saved is considered to be cost-effective. (4)
2. California Opioid Overdose Surveillance Dashboard [https://discovery.cdph.ca.gov/CDIC/ODdash/]
3. Substance Abuse and Mental Health Services Administration [https://www.samhsa.gov/capt/sites/default/files/capt_resource/risk-factor-mapping-tool.pdf]. Accessed on: 2/1/2019.
4. Dubois RW. Cost-effectiveness thresholds in the USA: Are they coming? Are they already here? J Comp Eff Res. 2016;5(1):9-11. doi:10.2217/cer.15.50.