Marin County
Preventing the Next Opioid Overdose

The best predictor of a fatal overdose is a prior non-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)

National Data:

Opioid overdose deaths across the country have skyrocketed even as other major causes of death--such as firearm-related homicides-- have not seen as large an increase.

Marin Data: 

State Data:

This map shows the total number of opioid-related overdose deaths for many counties in California from 1999 to 2017. Figures for counties with fewer than 10 deaths are not reported by the CDC.

Hover over counties to see their figures, and drag the slider to see how the statistics have changed since 1999. There has been a dramatic increase in opioid deaths since 1999.

Opioid Overdose Deaths (per 100,000 residents) in California Counties, by Year

Source: CDC Wonder

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 occurred 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. 

The frequency of suspected opioid overdoses varies by day of the week. 

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


Almost 40% of patients with contact information were successfully contacted by Bright Heart Health for screening, brief intervention, and Narcan distribution. Over half of those successfully contacted agreed to further contact.

Connection to Treatment and Detox

*May 2018 is the start of the intervention

**Partial data will be updated when available



To evaluate the utility of this program in connecting patients to treatment, historic EMS records were analyzed for events that would have been referred to BHH, had the program been in place at the time.    Through a partnership with Marin County Division of Behavioral Health and Recovery Services (BHRS), it was possible to quantify the proportion of MediCAL eligible individuals identified by the algorithm in historic EMS records who engaged with a treatment provider within 7 days of experiencing a non-fatal opioid overdose.  These data were compared to the proportion of MediCAL eligible patients who engaged with a treatment provider within 7 days of experiencing a non-fatal opioid overdose.  The findings show a significant difference in accessing treatment before and after program implementation.  

Naloxone Administration

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. 

Cost-Effectiveness Analysis

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)

Sources:

1. https://www.cdc.gov/drugoverdose/data/statedeaths.html

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.