Prior Emergency Medical Services Utilization Among People Who Had an Accidental Opioid-Involved Fatal Drug Overdose-Rhode Island, 2018-2020.

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.

Receipt of Prescription Psychostimulants and Stimulant-Involved Fatal Overdose: A Population-Based Case-Control Study.

Background: Rates of psychostimulant use, misuse, and hospitalization have increased markedly over the past decade. The objective of this study was to estimate the association between receipt of a psychostimulant prescription in the past year and fatal, unintentional psychostimulant-involved overdose. Methods: We conducted a population-based case-control study using linked, state-level databases from the Rhode Island Department of Health. Cases were defined as Rhode Island residents who experienced a fatal, unintentional drug overdose involving a psychostimulant, and controls included non-psychostimulant involved fatal overdoses occurring between May 1, 2017 and May 31, 2020 The primary exposure of interest was receipt of a psychostimulant prescription within 12 months prior to death, ascertained through linkage to the state's prescription drug monitoring program. Conditional logistic regression was used to estimate unadjusted and adjusted odds ratios. Results: Of 894 eligible overdose fatalities, the majority were white/non-Hispanic (72%), mean age was 43 years, and most resided in Providence County (69%). A total of 39 (4%) involved a psychostimulant. After adjusting for year of death and matching by sex, age, and county of residence, cases had 4.1 (95% confidence interval: 1.6, 10.6) times the odds of receiving a prescription stimulant in the past year compared to controls. Conclusions: Our findings suggest that there is a strong, positive association between prescription psychostimulant receipt and psychostimulant-involved fatal overdose. In response to an evolving polysubstance use landscape, current harm reductions measures, including naloxone training, fentanyl test strip distribution, and overdose education, should be expanded to include patients who receive psychostimulant prescriptions.

The estimated costs and benefits of a hypothetical supervised consumption site in Providence, Rhode Island.

BACKGROUND: Overdose deaths have increased dramatically in the United States, including in Rhode Island. In July 2021, the Rhode Island government passed legislation supporting a two-year pilot program authorizing supervised consumption sites (SCSs) in response to this crisis. We estimated the costs and benefits of a hypothetical SCS in Providence, Rhode Island. METHODS: We utilized a decision analytic mathematical model to compare costs and outcomes for people who inject drugs under two scenarios: (1) a SCS that includes syringe services provision, and (2) a syringe service program only (i.e., status quo). We assumed 0.95% of injections result in overdose, the SCS would serve 400 clients monthly and have a net cost of $783,899 annually, 46% of overdoses occurring outside of the SCS result in an ambulance run and 43% result in an emergency department (ED) visit, 0.79% of overdoses occurring within the SCS result in an ambulance run and ED visit, and the SCS would lead to a 25.7% reduction in fatal overdoses near the site. The model was developed from a modified societal perspective with a one-year time horizon. RESULTS: A hypothetical SCS in Providence would prevent approximately 2 overdose deaths, 261 ambulance runs, 244 ED visits, and 117 inpatient hospitalizations for emergency overdose care annually compared to a scenario that includes a syringe service program only. The SCS would save $1,104,454 annually compared to the syringe service program only, accounting only for facility costs and short-term costs of emergency overdose care and ignoring savings associated with averted deaths. Influential parameters included the percentage of injections resulting in overdose, the total annual injections at the SCS, and the percentage of overdoses outside of the SCS that result in an ED visit. CONCLUSION: A SCS in would result in substantial cost savings due to prevention of costly emergency overdose care.

A rapid ethnographic study of risk negotiation during the COVID-19 pandemic among unstably housed people who use drugs in Rhode Island.

BACKGROUND: The COVID-19 pandemic has greatly exacerbated the United States' overdose crisis. However, the overlapping impacts of COVID-19 and the overdose crisis have not been experienced equally, with unstably housed people who use drugs (PWUD) disproportionately impacted. Amid these changes, there is a need to understand how risk is experienced and managed among unstably housed PWUD to address health and social needs more effectively. METHODS: This project draws on ethnographic research conducted from June 2020 to April 2021 in Rhode Island. Data include 39 in-depth interviews with unstably housed PWUD and approximately 50 h of ethnographic fieldwork conducted alongside street-based outreach workers. RESULTS: COVID-19 risks were primarily contextualized in relation to participants' prior experiences of overdose events and adverse health outcomes. However, participants had varying levels of risk tolerance that were managed in ways that allowed them to reassert control and agency within the uncertainty of overlapping public health crises. Given participants' level of structural vulnerabilities, COVID-19 risk was managed alongside meeting their basic needs to survive. CONCLUSIONS: Findings demonstrate how COVID-related public health measures (e.g., stay-at-home orders, service closures) reinforced participants' structural vulnerabilities in ways that increased their risk of health and social harms. Implementing and scaling up programs that meet the basic needs of individuals, including permanent housing, social supports, and overdose prevention interventions (e.g., supervised consumption sites) is critically needed to address intersecting risks faced by unstably housed PWUD.

Comparison of Characteristics of Deaths From Drug Overdose Before vs During the COVID-19 Pandemic in Rhode Island.

Importance: The rate of deaths from overdose has increased during the COVID-19 pandemic, and recent US overdose mortality rates have been markedly high. However, scant data are available on the causes of this increase or subpopulations at elevated risk. Objective: To evaluate the rates and characteristics of deaths from drug overdose before vs during the COVID-19 pandemic. Design, Setting, and Participants: This retrospective, population-based cohort study used data from 4 statewide databases linked at the person level via the Rhode Island Data Ecosystem on adults with deaths due to overdose in Rhode Island from January 1 to August 31, 2019, and January 1 to August 31, 2020. Main Outcomes and Measures: The rates of unintentional deaths from drug-related overdose during the 2019 and 2020 observation periods overall and by sociodemographic characteristics, drugs contributing to the cause of death, location of death, and socioeconomic factors were evaluated. In subgroup analyses restricted to Medicaid beneficiaries (n = 271), the proportions of deaths from overdose by behavioral health treatment and diagnosis claims in the year before death were also examined. Results: A total of 470 adults who died of drug overdose were included in the analysis (353 men [75%]; mean [SD] age, 43.5 [12.1] years). The rate of deaths from overdose in Rhode Island increased 28.1%, from 29.2 per 100 000 person-years in 2019 to 37.4 per 100 000 person-years in 2020 (P = .009). Compared with 2019, rates of deaths due to overdose during 2020 were higher among men (43.2 vs 59.2 per 100 000 person-years; P = .003), non-Hispanic White individuals (31.0 vs 42.0 per 100 000 person-years; P = .005), single individuals (54.8 vs 70.4 per 100 000 person-years; P = .04), deaths involving synthetic opioids (20.8 vs 28.3 per 100 000 person-years; P = .005), and deaths occurring in a personal residence (13.2 vs 19.7 per 100 000 person-years; P = .003). A decrease in the proportion of deaths from overdose involving heroin (11 of 206 [5%] vs <2% [exact value suppressed]; P = .02) and an increase among persons experiencing job loss (16 of 206 [8%] vs 41 of 264 [16%]; P = .01) from 2019 to 2020 were observed. Among individuals who died of overdose and were Medicaid beneficiaries, the proportions of those aged 50 to 59 years with anxiety (11 of 121 [9%] vs 29 of 150 [19%]; P = .03), men with depression (27 of 121 [22%] vs 57 of 150 [38%]; P = .008), and men with anxiety (28 of 121 [23%] vs 55 of 150 [37%]; P = .02) increased during 2020 compared with 2019. Conclusions and Relevance: In this cohort study, during the first 8 months of 2020, the rate of deaths from overdose increased in Rhode Island compared with the same period in 2019, and several emerging characteristics of deaths from drug overdose during the first year of the COVID-19 pandemic were identified. These findings may inform interventions that address macroenvironmental changes associated with the pandemic.

History of Methadone and Buprenorphine Opioid Agonist Therapy Among People Who Died of an Accidental Opioid-Involved Overdose: Rhode Island, January 1, 2018-June 30, 2020.

To guide intervention efforts, we identified the proportion of individuals previously engaged in opioid agonist therapy among people who died of an accidental opioid-involved overdose. Most individuals (60.9%) had never received any prior buprenorphine or methadone treatment. Individuals who died of an overdose in 2020 had a similar demographic profile and treatment history compared with prior years. To prevent additional accidental opioid-involved overdose deaths, efforts should be directed toward linking individuals to care.