Overdose-Related Cardiac Arrests Observed by Emergency Medical Services During the US COVID-19 Epidemic | Emergency Medicine | JAMA Psychiatry | JAMA Network
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Figure.  Changes in Emergency Medical Services (EMS)–Observed Overdose Incidents, Cardiac Arrests, and Mobility During the US Coronavirus Disease 2019 (COVID-19) Epidemic
Changes in Emergency Medical Services (EMS)–Observed Overdose Incidents, Cardiac Arrests, and Mobility During the US Coronavirus Disease 2019 (COVID-19) Epidemic

A, Overdose-related cardiac arrests per 100 000 EMS calls for 2018 through August 2020. The average of 2018 and 2019 values is treated as a baseline trend and is shown as a dotted black line. B, Excess in overdose-related cardiac arrests (elevation in 2020 over baseline values) as well as the excess in all overdose-related EMS calls alongside changes in mobility (a measure of social distancing, obtained from the Institute for Health Metrics and Evaluation). The vertical dashed line marks the week of March 16, 2020, the first week in which mobility markedly decreased nationally in the US.

Table.  Characteristics of the National EMS Information System Database, 2018-2020
Characteristics of the National EMS Information System Database, 2018-2020
1.
Katz  J, Goodnough  A, Sanger-Katz  M. In shadow of pandemic, U.S. drug overdose deaths resurge to record. New York Times. July 15, 2020. Accessed September 6, 2020. https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html
2.
Wakeman  SE, Green  TC, Rich  J.  An overdose surge will compound the COVID-19 pandemic if urgent action is not taken.   Nat Med. 2020;26(6):819-820. doi:10.1038/s41591-020-0898-0PubMedGoogle ScholarCrossref
3.
Blanco  C, Compton  WM, Volkow  ND.  Opportunities for research on the treatment of substance use disorders in the context of COVID-19.   JAMA Psychiatry. Published online September 1, 2020. doi:10.1001/jamapsychiatry.2020.3177PubMedGoogle Scholar
4.
Lai  PH, Lancet  EA, Weiden  MD,  et al.  Characteristics associated with out-of-hospital cardiac arrests and resuscitations during the novel coronavirus disease 2019 pandemic in New York City.   JAMA Cardiol. 2020;5(10):1154-1163. doi:10.1001/jamacardio.2020.2488PubMedGoogle ScholarCrossref
5.
Lerner  EB, Newgard  CD, Mann  NC.  Effect of the coronavirus disease 2019 (COVID-19) pandemic on the U.S. emergency medical services system: a preliminary report.   Acad Emerg Med. Published online June 17, 2020. doi:10.1111/acem.14051PubMedGoogle Scholar
6.
Reiner  RC, Barber  RM, Collins  JK,  et al.  Modeling COVID-19 scenarios for the United States.   Nat Med. Published online October 23, 2020. doi:10.1038/s41591-020-1132-9Google Scholar
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    2 Comments for this article
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    Overdose Cardiac Arrests and Emergency Medicine During COVID-19
    Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
    The research conducted by medical and health science experts highlights the heavy duties placed on emergency medical services that are faced with the demanding combination of an overdose crisis and the COVID-19 pandemic.

    Flattening both the overdose mortality curve and the COVID-19 confirmed cases and mortality curves simultaneously is a monumental task, especially in view of the causal effect that is accelerating from COVID-19 to overdose mortality.

    The empirical analysis of overdoses was based on comparing 2020 values for weeks 1-10, to accommodate potential decreases in overdose call volumes, with weekly averages in the 2018 and 2019 values, for adults aged 61
    years and older.

    For healthcare policy purposes, it would be informative to compare the changes in overdose mortality during the initial months of the pandemic, which was double in May 2020 and around 50% higher overall than the averages from 2018 and 2019, with the second wave in COVID-19 confirmed cases and mortality from mid-November 2020.

    Considering the number of patients who are likely to be younger than 61 years of age, examining overdose cardiac arrests requiring emergency medical services by age cohorts would also provide important information to healthcare providers, especially as overdose risk has not been mitigated during the pandemic.

    The connection between overdose mortality and mental health issues by age cohort, data permitting, would also be invaluable for front line healthcare workers and patients who need them most.
    CONFLICT OF INTEREST: None Reported
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    Split by states with strict social distancing measures vs states with milder restrictions
    Hristos Dagres, MD, MPH | self-employed
    Besides the possible explanations proposed by the investigators for this disproportional increase of overdose-related cardiac arrests, I'd like to propose some more explanations that could also contribute. So, many cardiac arrests may be due to increased frequency of drug use and/or increased average quantity of drugs per use; also, some of them may be related to first time users, who are inexperienced and, thus, are vulnerable to complications because of overdose.

    Additionally, I'd like to kindly suggest whether the investigators could roughly estimate the absolute number of excess death events after the cutoff date for decreased mobility.
    />Finally, it would be very interesting if the investigator could split the excess cardiac arrests in two groups, the increase in states with strict social distancing measures and the increase in states with mild or no restrictions.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    December 3, 2020

    Overdose-Related Cardiac Arrests Observed by Emergency Medical Services During the US COVID-19 Epidemic

    Author Affiliations
    • 1Medical Scientist Training Program, University of California, Los Angeles
    • 2Department of Health Sciences, Health in Justice Action Lab, Northeastern University School of Law, Boston, Massachusetts
    • 3Department of Emergency Medicine, University of California, Los Angeles
    JAMA Psychiatry. 2021;78(5):562-564. doi:10.1001/jamapsychiatry.2020.4218

    The coronavirus disease 2019 (COVID-19) pandemic took grip of the US 2 decades into an accelerating overdose crisis that caused more than 70 000 deaths in 2019 alone.1 Front-line health care professionals and officials have sounded the alarm that the social and economic fallout from the COVID-19 pandemic may impede efforts to flatten the overdose curve.1,2 However, the state databases tracking overdose mortality often have long lags that stymie timely analysis and response.3 Emergency medical services (EMS) data provide a novel source of near-real-time information to track epidemiological trends during the COVID-19 pandemic.4,5 We leverage a large, national EMS database to characterize emergent trends in overdose mortality fueled by the pandemic.

    Methods

    We conducted a retrospective observational analysis using the National EMS Information System (NEMSIS), a large registry of more than 10 000 EMS agencies in 47 states, which contribute data in near real time and represent more than 80% of EMS activations nationally in 2020.5 We calculated weekly overdose-related cardiac arrests (determined on-site) and overdose-related EMS activations (determined by dispatch). In line with prior studies using NEMSIS data, we measured outcomes per EMS activations to adjust for call volume increases as new agencies join the system.5 We compared 2020 values with a baseline, defined as the weekly average of 2018 and 2019 values. Excess values for 2020 were compared temporally with a cell phone–based mobility score—a measure of social distancing.6 To account for potential pandemic-related decreases in call volume (the outcome denominator), we separately assessed trends using the average call volume for weeks 1 to 10 of 2020 (eMethods in the Supplement). This study was deemed exempt from review and informed consent by the UCLA Institutional Review Board.

    Results

    The 2020 NEMSIS database represents 25.9 million EMS activations, 50.5% from female patients and 50.2% from patients 61 years or older (Table). Overdose-related cardiac arrests rose sharply during April 2020, reaching 74.1 per 100 000 EMS activations (123.4% above baseline) by May 4 (Figure). Overdose-related cardiac arrests subsequently decreased but remained elevated, reaching 48.7 per 100 000 EMS activations (53.7% above baseline) by July 27. Overall, through August 1, overdose-related cardiac arrests in 2020 totaled 49.5 per 100 000 EMS activations (48.5% above baseline). These trends corresponded temporally with a sharp drop in mobility beginning March 16, reaching a minimum of −51.8% of baseline by April 13 and slowly increasing to −24.3% by July 27. Weekly rates of overdose-related EMS activations were elevated in 2020; however, values were largely similar before and during reductions in mobility, with 1635.2 per 100 000 EMS activations before March 16 and 1760.7 per 100 000 EMS activations after March 16 (18.5% and 16.7%, respectively, relative to baseline).

    Discussion

    We describe a large-magnitude, national surge in overdose-related cardiac arrest during the initial months of the COVID-19 epidemic in the US. Peak rates in May 2020 were more than double the baseline from 2018 and 2019, and overall 2020 values were elevated by approximately 50%. The temporal similarities to decreased mobility suggest that the fallout from the COVID-19 pandemic—perhaps especially social isolation—is sharply accelerating fatal overdose trends. The lack of a commensurate sharp increase in total (fatal and nonfatal) overdose incidents could indicate a rising overdose case fatality rate in a context of more stable, albeit elevated, overdose rates. Many of the trends predicted by public health experts at the outset of the pandemic, such as an increased proportion of individuals using substances alone, increased toxification of the drug supply, and reduced access to treatment, could increase the lethality of each overdose incident.2

    These findings are limited, as they reflect a large cohort of EMS agencies for which geographic identifiers below census division are not available that may not capture all nuances of recent epidemiological trends in the US.5 Additionally, shifts in the proportion of overdoses observed nationally by EMS could bias our results up or down. Confirmatory results should be sought as detailed vital registration data become available. Nevertheless, shifts observed here suggest that measures to address the pandemic have largely failed to mitigate overdose risk. These trends implicate investments in substance use treatment, harm reduction, and structural drivers of overdose as core elements of COVID-19 response.

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    Article Information

    Accepted for Publication: November 12, 2020.

    Published Online: December 3, 2020. doi:10.1001/jamapsychiatry.2020.4218

    Corresponding Author: Joseph Friedman, MPH, Medical Scientist Training Program, University of California, Los Angeles, B7-435, UCLA Semel Institute, PO Box 951759, Los Angeles, CA 90095 (josephfriedman@mednet.ucla.edu).

    Author Contributions: Mr Friedman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Friedman, Schriger.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Friedman, Beletsky.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Friedman, Schriger.

    Administrative, technical, or material support: Friedman.

    Study supervision: All authors.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Mr Friedman received support from the UCLA Medical Scientist Training Program (National Institute of General Medical Sciences training grant GM008042).

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Katz  J, Goodnough  A, Sanger-Katz  M. In shadow of pandemic, U.S. drug overdose deaths resurge to record. New York Times. July 15, 2020. Accessed September 6, 2020. https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html
    2.
    Wakeman  SE, Green  TC, Rich  J.  An overdose surge will compound the COVID-19 pandemic if urgent action is not taken.   Nat Med. 2020;26(6):819-820. doi:10.1038/s41591-020-0898-0PubMedGoogle ScholarCrossref
    3.
    Blanco  C, Compton  WM, Volkow  ND.  Opportunities for research on the treatment of substance use disorders in the context of COVID-19.   JAMA Psychiatry. Published online September 1, 2020. doi:10.1001/jamapsychiatry.2020.3177PubMedGoogle Scholar
    4.
    Lai  PH, Lancet  EA, Weiden  MD,  et al.  Characteristics associated with out-of-hospital cardiac arrests and resuscitations during the novel coronavirus disease 2019 pandemic in New York City.   JAMA Cardiol. 2020;5(10):1154-1163. doi:10.1001/jamacardio.2020.2488PubMedGoogle ScholarCrossref
    5.
    Lerner  EB, Newgard  CD, Mann  NC.  Effect of the coronavirus disease 2019 (COVID-19) pandemic on the U.S. emergency medical services system: a preliminary report.   Acad Emerg Med. Published online June 17, 2020. doi:10.1111/acem.14051PubMedGoogle Scholar
    6.
    Reiner  RC, Barber  RM, Collins  JK,  et al.  Modeling COVID-19 scenarios for the United States.   Nat Med. Published online October 23, 2020. doi:10.1038/s41591-020-1132-9Google Scholar
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