Abstract
Objective:
To help understand whether decreased emergency medical services (EMS) utilization due to the COVID-19 pandemic contributed to increased accidental fatal drug overdoses, we characterized recent EMS utilization history among people who had an accidental opioid-involved fatal drug overdose in Rhode Island.
Methods:
We identified accidental opioid-involved fatal drug overdoses among Rhode Island residents that occurred from January 1, 2018, through December 31, 2020. We linked decedents by name and date of birth to the Rhode Island EMS Information System to obtain EMS utilization history.
Results:
Among 763 people who had an accidental opioid-involved fatal overdose, 51% had any EMS run and 16% had any opioid overdose–related EMS run in the 2 years before death. Non-Hispanic White decedents were significantly more likely than decedents of other races and ethnicities to have any EMS run (P < .001) and any opioid overdose–related EMS run (P = .05) in the 2 years before death. Despite a 31% increase in fatal overdoses from 2019 through 2020, corresponding with the onset of the COVID-19 pandemic, EMS utilization in the prior 2 years, prior 180 days, or prior 90 days did not vary by time frame of death.
Conclusion:
In Rhode Island, decreased EMS utilization because of the COVID-19 pandemic was not a driving force behind the increase in overdose fatalities observed in 2020. However, with half of people who had an accidental opioid-involved fatal drug overdose having an EMS run in the 2 years before death, emergency care is a potential opportunity to link people to health care and social services.
Keywords: opioid overdose, emergency medical services, health care utilization, COVID-19
The United States, including Rhode Island, experienced a dramatic increase in the number of accidental fatal drug overdoses in 2020.1,2 The extent to which the COVID-19 pandemic contributed to the increase in fatal overdoses is uncertain. The pandemic also contributed to mental stress, loss of employment and/or health insurance, social isolation and loss of social support, and changes in the drug supply chain, all of which can lead to increased risk of opioid overdose.3,4 Nationally, the utilization of emergency medical services (EMS) decreased in March and April 2020, 5 corresponding with the early months of the COVID-19 pandemic in the United States 6 and an increase in drug overdose deaths.1,7 However, it is unknown whether a decrease in the utilization of EMS for overdoses led to the increase in drug overdose deaths, particularly given other factors such as increasing fentanyl in the illicit drug supply.8,9
Our prior work suggested that, in Rhode Island, the demographic characteristics and overdose location of people who had accidental fatal drug overdoses in 2020 were similar to prior years, 10 that is, with no major shift occurring in people who had accidental fatal drug overdoses in 2020. To help understand whether decreased EMS utilization potentially affected accidental fatal drug overdoses, we characterized recent EMS utilization history among people who had an accidental opioid-involved fatal drug overdose in Rhode Island, overall and by year of death.
Methods
We used statewide data from the Rhode Island Department of Health (RIDOH) to conduct a retrospective cohort study. The RIDOH Institutional Review Board reviewed and approved this study.
First, we obtained data from the RIDOH Office of State Medical Examiners to identify all accidental opioid-involved fatal drug overdoses that occurred in Rhode Island among Rhode Island residents from January 1, 2018, through December 31, 2020. Second, we used data from the Rhode Island EMS Information System 11 to identify all EMS runs that occurred in Rhode Island from January 1, 2016, through December 31, 2020. For each database, we generated a unique identifier based on the first 5 letters of the last name, the first 3 letters of the first name, and the date of birth. We used the unique identifier to link data from the RIDOH Office of State Medical Examiners with data from the Rhode Island EMS Information System.
Using the linked dataset, we identified all EMS runs that occurred in the 2 years before the date of death of each person who had an accidental opioid-involved fatal drug overdose to ensure a consistent “look-back” period. To avoid counting EMS runs for a decedent’s accidental fatal drug overdose as part of the decedent’s prior EMS utilization history, we excluded from our analysis any EMS runs occurring within 1 day of death. We defined opioid overdose–related EMS runs using a case definition previously developed by RIDOH. 11 We defined an EMS run as nonfatal opioid overdose–related if it met 1 of 5 criteria: (1) the primary or secondary impression was overdose related and naloxone was given, (2) the primary or secondary impression was overdose related and terms for both naloxone and unresponsive were in the narrative report, (3) naloxone was in the dropdown field for medication given and medication response was improved, (4) the terms for both naloxone and unresponsive were in the narrative report and medication response was undocumented (excludes values of no change or worse), or (5) naloxone was given before EMS arrival and the person who administered it was not a null value. 11
We compared overdose decedents (1) with and without any prior EMS run and (2) with and without a prior opioid overdose–related EMS run in the 2 years before death by sociodemographic characteristic (age, sex, race and ethnicity, county) and year of death (2018, 2019, 2020) using Pearson χ2 tests and Fisher exact tests (when cell counts were <10). Counts <5 were suppressed in accordance with RIDOH’s small numbers policy. 12 To better understand the effects of the COVID-19 pandemic, we conducted a sensitivity analysis of EMS runs in the 180 days and 90 days before death by 6-month and 3-month date of death intervals, respectively, using Pearson χ2 tests, with P < .05 considered significant. We used SAS version 9.4 (SAS Institute Inc) for our analyses.
Results
From January 1, 2018, through December 31, 2020, 763 Rhode Island residents had an accidental opioid-involved fatal drug overdose in Rhode Island (Table 1). Overall, most decedents were aged 25-54 years (73%), male (77%), non-Hispanic White (78%), and residents of Providence County (70%). In 2018, 2019, and 2020, there were 242, 226, and 295 accidental opioid-involved fatal drug overdoses, respectively, with a 31% increase in fatal overdoses from 2019 to 2020.
Table 1.
Utilization history of emergency medical services (EMS) in the prior 2 years among Rhode Island residents who had an accidental opioid-involved fatal drug overdose in Rhode Island, by sociodemographic characteristics and year of death, January 1, 2018, through December 31, 2020 a
| Characteristic | Total no. (%) of deaths from opioid overdose (N = 763) | No. (%) of people utilizing EMS for any reason in the 2-year period before their death b | No. (%) of people utilizing EMS for opioid overdose in the 2 years before their death b | ||||
|---|---|---|---|---|---|---|---|
| Prior EMS (n = 386) | No prior EMS (n = 377) | P value c | Prior EMS (n = 119) | No prior EMS (n = 644) | P value c | ||
| Age group, y | .42 | .07 d | |||||
| 18-24 | 45 (6) | 23 (51) | 22 (49) | 8 (18) | 37 (82) | ||
| 25-34 | 188 (25) | 101 (54) | 87 (46) | 37 (20) | 151 (80) | ||
| 35-44 | 208 (27) | 107 (51) | 101 (49) | 28 (13) | 180 (87) | ||
| 45-54 | 158 (21) | 70 (44) | 88 (56) | 26 (16) | 132 (84) | ||
| 55-64 | 135 (18) | 73 (54) | 62 (46) | 20 (15) | 115 (85) | ||
| ≥65 | 29 (4) | 12 (41) | 17 (59) | 0 | 29 (100) | ||
| Sex | .02 | .71 | |||||
| Female | 176 (23) | 103 (59) | 73 (41) | 29 (16) | 147 (84) | ||
| Male | 587 (77) | 283 (48) | 304 (52) | 90 (15) | 497 (85) | ||
| Race and ethnicity | <.001 d | .04 d | |||||
| Hispanic (any race) | 96 (13) | 30 (31) | 66 (69) | 9 (9) | 87 (91) | ||
| Non-Hispanic Black | 66 (9) | 34 (52) | 32 (48) | 5 (8) | 61 (92) | ||
| Non-Hispanic White | 593 (78) | 321 (54) | 272 (46) | 104 (18) | 489 (82) | ||
| Other e | 8 (1) | <5 f | 7 (88) | <5 f | 7 (88) | ||
| County of residence | .41 d | .18 d | |||||
| Bristol | 19 (2) | 11 (58) | 8 (42) | <5 e | 16 (84) | ||
| Kent | 118 (15) | 63 (53) | 55 (47) | 24 (20) | 94 (80) | ||
| Newport | 32 (4) | 17 (53) | 15 (47) | <5 e | 30 (94) | ||
| Providence | 533 (70) | 271 (51) | 262 (49) | 77 (14) | 456 (86) | ||
| Washington | 61 (8) | 24 (39) | 37 (61) | 13 (21) | 48 (79) | ||
| Year of death | .13 | .21 | |||||
| 2018 | 242 (32) | 131 (54) | 111 (46) | 46 (19) | 196 (81) | ||
| 2019 | 226 (30) | 102 (45) | 124 (55) | 31 (14) | 195 (86) | ||
| 2020 | 295 (39) | 153 (52) | 142 (48) | 42 (14) | 253 (86) | ||
Percentages may not sum to 100 because of rounding. Data source: Rhode Island Office of the State Medical Examiners, Rhode Island Emergency Medical Services Information System.
Denominators used to calculate the percentages are based on totals from the individual sociodemographic characteristic or year of death subgroups.
Determined by Pearson χ2 test; P < .05 considered significant.
The Fisher exact test was used because of small cell sizes.
Other includes people with unknown race and ethnicity.
Counts of <5 were suppressed in accordance with Rhode Island Department of Health’s small numbers policy. 12
More than half (51%) of decedents had an EMS run in the 2 years before their death. Compared with decedents without a prior EMS run (n = 377), those with any prior EMS run (n = 386) were more likely to be female than male (59% of females vs 48% of males; P = .02) and more likely to be non-Hispanic White than another race or ethnicity (P < .001). However, decedents with and without an EMS run in the 2 years before their death were similar with respect to age group (P = .42), county of residence (P = .41), and year of death (P = .13). In 2018, 2019, and 2020, 54%, 45%, and 52% of decedents, respectively, had an EMS run in the 2 years before death.
Overall, 16% of decedents had any nonfatal opioid overdose–related EMS run in the 2 years before death. Compared with decedents without a prior nonfatal opioid overdose–related EMS run (n = 644), those with any prior nonfatal opioid overdose–related EMS run (n = 119) were more likely to be non-Hispanic White than another race or ethnicity (P = .04). Decedents with and without any prior nonfatal opioid overdose–related EMS runs were similar by age group (P = .07), sex (P = .71), county of residence (P = .18), and year of death (P = .21).
In our sensitivity analyses, 30% (228 of 763) of decedents had any EMS run and 9% (70 of 763) had any nonfatal opioid overdose–related EMS run in the 180 days before their death (Table 2), whereas 21% (157 of 763) of decedents had any EMS run and 7% (53 of 763) had any nonfatal opioid overdose–related EMS run in the 90 days before their death (Table 3). When we categorized date of death into 6-month and 3-month intervals, we observed no significant changes in prior EMS utilization history over time.
Table 2.
Utilization history of emergency medical services (EMS) in the prior 180 days among Rhode Island residents who had an accidental opioid-involved fatal drug overdose in Rhode Island, by 6-month time frame of death, January 1, 2018, through December 31, 2020 a
| 6-month time frame of death | Total no. (%) of deaths from opioid overdose (N = 763) | No. (%) of people utilizing EMS for any reason in the 180 days before their death b | No. (%) of people utilizing EMS for opioid overdose in the 180 days before their death b | ||||
|---|---|---|---|---|---|---|---|
| Prior EMS (n = 228) | No prior EMS (n = 535) | P value c | Prior EMS (n = 70) | No prior EMS (n = 693) | P value c | ||
| January–June 2018 | 119 (16) | 40 (34) | 79 (66) | .65 | 15 (13) | 104 (87) | .22 |
| July–December 2018 | 123 (16) | 42 (34) | 81 (66) | 14 (11) | 109 (89) | ||
| January–June 2019 | 111 (15) | 28 (25) | 83 (75) | 6 (5) | 105 (95) | ||
| July–December 2019 | 115 (15) | 34 (30) | 81 (70) | 14 (12) | 101 (88) | ||
| January–June 2020 | 156 (20) | 45 (29) | 111 (71) | 11 (7) | 145 (93) | ||
| July–December 2020 | 139 (18) | 39 (28) | 110 (72) | 10 (7) | 129 (93) | ||
Data source: Rhode Island Office of the State Medical Examiners, Rhode Island Emergency Medical Services Information System.
Denominators used to calculate the percentages are based on total numbers from each time frame subgroup.
Determined by Pearson χ2 test; P < .05 considered significant.
Table 3.
Utilization history of emergency medical services (EMS) in the prior 90 days among Rhode Island residents who had an accidental opioid-involved fatal drug overdose in Rhode Island, by 3-month time frame of death, January 1, 2018, through December 31, 2020 a
| 3-month time frame of death | Total no. (%) of deaths from opioid overdose (N = 763) | No. (%) of people utilizing EMS for any reason in the 90 days before their death b | No. (%) of people utilizing EMS for opioid overdose in the 90 days before their death b | ||||
|---|---|---|---|---|---|---|---|
| Prior EMS (n = 157) | No prior EMS (n = 606) | P value c | Prior EMS (n = 53) | No prior EMS (n = 710) | P value c | ||
| January–March 2018 | 50 (7) | 11 (22) | 39 (78) | .72 | <5 d | 46 (92) | .70 |
| April–June 2018 | 69 (9) | 17 (25) | 52 (75) | 7 (10) | 62 (90) | ||
| July–September 2018 | 53 (7) | 15 (28) | 38 (72) | <5 d | 50 (94) | ||
| October–December 2018 | 70 (9) | 15 (21) | 55 (79) | 7 (10) | 63 (90) | ||
| January–March 2019 | 59 (8) | 15 (25) | 44 (75) | <5 d | 55 (93) | ||
| April–June 2019 | 52 (7) | 7 (13) | 45 (87) | <5 d | 51 (98) | ||
| July–September 2019 | 55 (7) | 10 (18) | 45 (82) | 6 (11) | 49 (89) | ||
| October–December 2019 | 60 (8) | 12 (20) | 48 (80) | 6 (10) | 54 (90) | ||
| January–March 2020 | 72 (9) | 14 (19) | 58 (81) | <5 d | 68 (94) | ||
| April–June 2020 | 84 (11) | 13 (15) | 71 (85) | <5 d | 80 (95) | ||
| July–September 2020 | 82 (11) | 19 (23) | 63 (77) | <5 d | 78 (95) | ||
| October–December 2020 | 57 (7) | 9 (16) | 48 (84) | <5 d | 54 (95) | ||
Data source: Rhode Island Office of the State Medical Examiners, Rhode Island Emergency Medical Services Information System.
Denominators used to calculate the percentages are based on total numbers from each time frame subgroup.
Determined by Pearson χ2 test and Fisher exact test when cell counts were <10; P < .05 considered significant.
Counts of <5 are suppressed in accordance with the Rhode Island Department of Health’s policy on small numbers. 12
Discussion
Among Rhode Island residents who had an accidental opioid-involved fatal drug overdose in Rhode Island from 2018 through 2020, 51% had any EMS run and 16% had any nonfatal opioid overdose–related EMS run in the 2 years before death. Decedents with any prior EMS run and any prior nonfatal opioid overdose–related EMS run were more likely to be non-Hispanic White than another race or ethnicity, and decedents with any prior EMS run (but not any prior nonfatal opioid overdose–related EMS run) were more likely to be female than male. Despite a 31% increase in accidental opioid-involved fatal drug overdoses from 2019 through 2020, corresponding with the onset of the COVID-19 pandemic, we did not identify significant or meaningful changes in EMS utilization in the 2 years, 180 days, or 90 days before death from 2018 through 2020. These findings suggest that, on average, interactions in 2020 with EMS from all causes and opioid overdoses among opioid overdose decedents were similar to interactions in previous years.
With the onset of the COVID-19 pandemic in early 2020, some people delayed or avoided medical care because of concerns of acquiring COVID-19 in medical settings and because of difficulty in seeking care as the medical system was overwhelmed with COVID-19 patients. By June 30, 2020, an estimated 12% of adults in the United States had delayed or avoided emergency care, with the percentages highest among non-Hispanic Black adults (23%), Hispanic adults (25%), and young adults (31%; aged 18-24 years). 13 As data emerged suggesting that the number of fatal overdoses was increasing throughout 2020,1,2 concern increased that people witnessing or experiencing overdoses may be delaying or avoiding emergency care because of COVID-19, thus leading to more overdoses becoming fatal. Our study suggests that people who experienced fatal overdoses in 2020 did not have lower EMS utilization compared with utilization in 2018 and 2019.
We were not able to estimate the percentage of decedents who had EMS called before death for the overdose that was ultimately fatal. Limited data are available on the timing of EMS arrival relative to death (ie, we could not differentiate reliably whether 911 was called before or after death). Thus, detection of a relationship between decreased EMS utilization for overdose care and an increase in opioid overdose fatalities would depend on the percentage of decedents who had previously experienced an overdose. In our study, only 16% of decedents had a nonfatal opioid overdose–related EMS run in the 2 years before death, suggesting that (1) most decedents had a fatal first overdose and/or (2) most of the decedents’ prior overdoses were managed without calling 911. Survey data collected by RIDOH among illicit drug users in Rhode Island found that in 2021, half of individuals called 911 at the most recent overdose they witnessed (Hallowell, internal meeting communication on the Harm Reduction Surveillance System, June 2022). Data are not available from prior years.
In our study, non-Hispanic White and female decedents were more likely than decedents from other racial or ethnic groups and male decedents, respectively, to have utilized EMS for any reason in the 2 years before their death. This finding is consistent with previous evidence that non-Hispanic White people and females are more likely than people from racial and ethnic minority groups and males, respectively, to utilize medical care overall in the United States, 14 which could be related to social and structural barriers to care (eg, higher out-of-pocket costs, discrimination, language barriers)15,16 and sex differences in health care needs and care-seeking behavior. 17 Differences in EMS utilization by race and ethnicity and gender are less well-understood,14,18 although some evidence suggests that non-Hispanic White women are more likely to utilize EMS than people from racial and ethnic minority groups and males, respectively. 19 In our study, non-Hispanic White decedents were also somewhat more likely than decedents in other racial and ethnic groups to have an opioid overdose–related EMS run in the 2 years before their death.
In addition to barriers to medical care for many racial and ethnic minority groups overall, non-Hispanic Black or African American and Hispanic people may be less likely than non-Hispanic White people to call EMS when witnessing an overdose because of fear of arrest, historically negative interactions with police, and distrust of police.20-23 Although Good Samaritan laws are intended to provide legal immunity to bystanders who call 911 for an overdose, some evidence suggests that these laws may have little influence on bystander decisions in practice because of distrust of police. 20 New approaches are needed to decrease the number of people using drugs alone and to increase the comfort in calling 911 when witnessing an overdose, particularly among people from racial and ethnic minority groups who may be hesitant to engage with police.
More than half of people in Rhode Island who had an accidental opioid-involved fatal overdose during the analysis period had ≥1 EMS run in the 2 years before their death, highlighting the importance of EMS and other emergency medical care as touchpoints for linking people at risk of fatal overdose to health care and social services. In Rhode Island, the ongoing statewide interventions connecting people who had an overdose to health care and social services are (1) the EMS naloxone “leave-behind” program (in which a naloxone kit is left in the household by EMS), 24 (2) the Hope Initiative, 25 and (3) the Levels of Care certification program for overdose and opioid use disorder care in emergency departments and hospitals. 26 However, given that only 16% of decedents in our study had a nonfatal opioid overdose–related EMS run in the 2 years before their death, broader initiatives to screen and connect people with health and social services at the point of emergency care may be needed to reach additional people at risk of fatal overdose. Studies to understand how to efficiently and effectively reach people at risk of fatal overdose during non–overdose-related emergency care would be useful.
Strengths and Limitations
Our study was strengthened by the linkage of statewide, person-level EMS and fatality data. This linkage was facilitated by the unified data system for all EMS agencies in Rhode Island. 11 However, our study also had 3 limitations. First, because of limited data on the timing of EMS arrival relative to death, we were not able to evaluate temporal trends in EMS care immediately before death for the fatal overdose. Second, Rhode Island is a small state in New England; our analyses may have been limited by the relatively small number of opioid overdose fatalities per year and may not be generalizable to other geographic areas. Third, statewide EMS data were available only starting in 2016, limiting us to a 2-year look-back period for each overdose decedent.
Conclusions
In Rhode Island, although the number of accidental opioid-involved fatal drug overdoses increased by 31% from 2019 to 2020, the recent past EMS utilization history of decedents in 2020 was similar to that of decedents in 2018 and 2019. Decedents with prior EMS runs were more often non-Hispanic White and female, suggesting that these groups have fewer barriers to care than people in racial and ethnic minority groups and males. Roughly half of overdose decedents had interacted with EMS in the 2 years before their death, highlighting the importance of EMS and other emergency medical care as touchpoints for linking people at risk of fatal overdose to health care and social services. New approaches are needed to decrease the number of people using drugs alone and to increase comfort in calling 911 when witnessing an overdose.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Rhode Island Department of Health and the Overdose Data to Action grant from the Centers for Disease Control and Prevention (NU17CE924967 to the Rhode Island Department of Health). Laura C. Chambers’s effort was supported by the National Institutes of Health (T32DA013911 and R25MH083620 trainee support).
ORCID iDs: Kailai Duan, PhD, MPH 
https://orcid.org/0000-0003-2107-7165
Benjamin D. Hallowell, PhD, MPH
https://orcid.org/0000-0002-6943-9615
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