Layperson-Administered Naloxone Trends

Did you know that layperson-administered naloxone (LAN) increased by over 43% in just two years? This week on From Science to the Scene, Jacob Kamholz discusses a major study that uses national EMS data to track how often the public intervenes during an overdose, before EMS arrives. While overall naloxone administration by EMS Clinicians actually decreased 6% over this period, the rise in LAN supports public health efforts and over-the-counter access initiatives aimed at getting this life-saving medication into the hands of the community, and the community is responding! The research notes that these interventions frequently occur in urban homes and residences, which are the very settings where rapid assistance is most critical. Check out the full episode to learn how EMS data is informing public health policy and highlighting community-led interventions.

Read the study here: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2824732

Transcript

SPEAKER_00 0:14

Hey everyone, welcome back. I'm Jacob Camholtz, your EMS and public health policy researcher, and today I want to talk about something deeply relevant to both public health and the street level work that we do every day in EMS, and that is naloxone. In this episode, we will explore the use of naloxone by the public, not by EMS clinicians. Of course, EMS does have a role in this story, so let's dig in. Our discussion is rooted in the work done by Chris Gage and his team as presented in the JAMA Network Open Publication, Layperson Administered Naloxone Trends Reported in EMS Activations 2020 to 2022. Since this journal publishes all manuscripts as open access, anyone can read the research for free. No subscription or payment needed. So click the link and follow along if you'd like. We've all seen it. Somebody overdoses, and before EMS even gets there, a layperson, sometimes a friend or a bystander, or even the patient themselves, is already given naloxone. And that's what this study is about. And what it tells us is both encouraging and urgent. As most of you know, naloxone is given to reverse opioid overdoses and potentially save lives. Really quick, some of you might be thinking, what about Narcan? That's one of the many available name brands that all contain the medication naloxone. Although it's been around for decades, layperson administered naloxone, or LAN, has only recently become a large-scale public health strategy. We're talking about those take-home kits or the option to buy over-the-counter and good Samaritan protections. And these are all policy levers designed to ensure anyone can intervene before EMS arrives. But how often is LAN actually happening? We don't really know, and we don't really know if it's easing the burden on EMS while saving more lives. Gage and his colleagues set out to measure that using Nempsys, the National EMS Information System. And this is a massive data set, over 65 million EMS 911 activations between June of 2020 and June of 2022. If you're following along, the specifics of inclusion and exclusion are shown in the flow chart, which is figure one. From there, they pulled every case where naloxone was administered and then narrowed it down to about 25,000 cases where the naloxone was given by a layperson before EMS arrival. For those following along with the manuscript, you can see the annual call and patient characteristics broken down in table one. So finding the approximately 25,000 cases meant that about 3.5% of EMS reported naloxone events involved LAN. Remember, that's the layperson administered naloxone. That number by itself might seem pretty small, but let's take a look at the trend. In 2020, there were 30 LAN events per 100,000 EMS activations. However, by 2022, that rose to 43 per 100,000, which is a 43.5% increase in just two years. If you check out table two and figure two, you can see more specifics on the rise. Interestingly, these massive increases in LAN from 2020 through 2022 happened, while the overall EMS naloxone administration rate actually dropped by about 6%. So what's really happening here? The authors suggest that this combination of changes indicates that more laypersons intervene earlier, particularly in that window before EMS arrives. This is precisely what public health campaigns have been aiming for. It validates the idea that take home or over-the-counter naloxone is being used to reach the people who really need it. But who are these people? According to Table 1's demographics, which you may have already glanced at, most LAN recipients were male with a median age of 35 and treated in urban and residential settings. In fact, over 85% were in urban areas, and more than half occurred in homes. And that tells us something important. LAN often occurs in urban homes and residences, the very settings where opioid overdoses frequently take place. These environments may not always allow for rapid overdose identification and EMS access, making the early intervention by lay people potentially lifesaving. What about EMS in this situation? What about our median response time? Well, in this case, it was six minutes. Six valuable minutes that matter when you think about a patient with ineffective or absent breathing. But even more striking is this. When layperson naloxone was used, EMS charted a suspected overdose impression about 58% of the time, which is much higher than in the clinician-administered group. Bystanders are doing a pretty darn good job of recognizing overdose symptoms, thereby saving the lives before we even get on scene. So what's the big takeaway here? This paper shows that layperson naloxone use is increasing, at least in part, public health investments in naloxone distribution are working. But it also raises some fundamental questions too. Despite all the progress, LAN only accounts for a small slice of the total naloxone use, about 3.5%. Even though we know that someone had to call 911 for the patient and possibly had a chance to intervene. That means there is plenty of room for growth. It might also mean that there's a gap between access and action. And what are some possible reasons for that gap? Probably a mix that might include a couple different things. Limited availability of naloxone in rural areas, stigma around drug use and carrying naloxone, might be something as simple as lack of training or even fear of legal consequences despite those good sabaritan laws. As all good research should, the authors acknowledge limitations in their data. Since about 50% of the race and ethnicity fields were considered missing, they were not able to evaluate any trends along those lines. Also, since NemSys does not have patient outcomes, what happened at the hospital or after, we were not able to evaluate the lasting effects of the LAN treatments. But that is definitely not a reason to stop. It's a reason to improve our surveillance and tracking systems. And let's not forget about the policy implications. In 2023, naloxone nasal spray became available over the counter nationwide. That's huge for public health and safety, but it won't help unless accompanied by targeted education, community partnerships, and breaking the stigma. The study also serves as significant evidence that reinforces the role of EMS as a surveillance system. We are the eyes in the streets, and how we document things like land really matters because it feeds into public health care and research. So my call to action is this clinicians, be diligent with your documentation. Record all of your treatments and interventions as accurately as possible and report what you see and do. Agencies, consider start using this data for quality improvement and community engagement. To our public health leaders, keep investing in access, but don't stop at distribution. Education, stigma reduction, and support services must also come along with that. For everybody, realize that there's someone who saves a life with the lock, so might not be wearing a uniform, and that's okay. That's the point. Please share this research, discuss it with your colleagues, and consider how we as EMS clinicians can support and not just respond to community led overdose interventions. So, until next time, whether you're hitting the books or hitting the streets, stay safe, stay curious, and keep bringing science to the scene.